Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Policy Drivers for Increased Focus on Transitional Care Programs

10/29/2013

There were two Federal Government programs that provided opportunities to expand programs to improve transitional care processes, improve performance, or test new models of delivery and payment that involved LTSS as described above. They include funding under a CMS 3026 Grant for Community-Based Transitions Program and the Hospital Readmission Reduction Program.

CMS Community-Based Care Transitions Program (3026 Program)

The ITCC is currently participating in the CMS funded CCTP. ITCC members -- Aging Care Connections and Health and Medicine Policy Research group -- provide program management support and AgeOptions serves as the central administrator.

The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.10 In the Rush system eligible individuals for the Bridge Program are Medicare beneficiaries who have at least one chronic condition that requires followup care and meet certain risk criteria for rehospitalization (e.g., over 60 years of age, has at least one chronic condition, lives alone and/or goes home with home health or discharged to a SNF participating in the 3026 Program). The Bridge program serves approximately 1,800 patients. The Bridge Model is a core component of the ITCC CMS CCTP contract.

The ITCC plan (separate from the CCTP) is expanding its use and replication the Bridge Model. Expansion and replication of the Bridge Model beyond the Chicago area is also a component of the CCTP. Figure H-2 Identifies the replication sites around the country -- expansion into five sites were related to the CCTP and twelve others were funded by their community or individual hospital resources.

FIGURE H-2. Replication Sites for Bridge Model and Community-Based Care Transition Program Sites

FIGURE H-2. Replication Sites for Bridge Model and Community-Based Care Transition Program Sites

Hospital Remission Reduction Initiatives

Rush has focused on improving the transition of care through various initiatives starting in 2007. As a result of the CMS Hospital Readmission Reduction Initiative,11 Rush began a readmission reduction project in 2012.

Other Emerging Payment Models such as ACOs

Rush is not currently involved in any of the new payment models such as an ACO or bundled payment, however they are exploring new accountable care arrangements. Dr. Julio Silva is a vice president and the CMIO at Rush reported that Rush is applying for a Medicare Shared Savings plan in the Fall 2013. There is a Medical Home Network, the interviews with staff did not indicate that LTSS programs were integrated into the Medical Home Network and services.


  1. See http://innovation.cms.gov/initiatives/CCTP/.

  2. Readmission Reduction Program. CMS Web site: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html (accessed May 20, 2013).

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