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WHATFunding opportunities for community-based organizations partnering with acute-care hospitals to decrease preventable complications during patient transition from one care setting to another.
WHYTo improve care transitions from the hospital to other settings and reduce readmissions for high-risk Medicare beneficiaries.
WHEREThe Center for Medicare and Medicaid Services (CMS)
The Affordable Care Act.

Program Description

Through the “Community-Based Care Transitions” Program health care facilities, skilled nursing facilities, nursing care homes, hospitals and other health care providers can all work to help reduce patient readmissions in the following manner:

-Start care transition services no later than 24 hours prior to discharge
-Provide timely, culturally, and linguistically competent post-discharge education regarding symptoms that may indicate additional health problems or a warning signs of a deteriorating condition
-Help to ensure timely and productive appointments and interactions between patients, doctors, post-acute and outpatient providers
-Help educate on patient-centered self-management support and relevant information specific to a health condition
-Medication review and management (including, if appropriate, counseling and self-management support)

Hospitals have traditionally served to reduce readmissions by focusing on issues such as quality of care during hospitalization and the discharge planning process. However, there are many factors along the care continuum that can effect hospital readmissions. The “Community-Based Care Transitions” Program aims to identify these factors and encourage all organizations involved to work together to improve quality of care and reduce health care costs. The program is a part of the “Partnership for Patients,” which aims to reduce preventative errors in hospitals and reduce hospital readmissions.

Partners of the “Community-Based Care Transitions” Program include:

    Akron/Canton, Ohio Area Agency on Aging (A/C AAA) (Ohio)
    Atlanta Community-Based Care Transitions Program (Atlanta CCTP) (Georgia)
    Council for Jewish Elderly (“CJE SeniorLife”) in Chicago, IL (Illinois)
    Maricopa County, Arizona: The Area Agency on Aging, Region One (Arizona)
    Elder Services of the Merrimack Valley, Inc. (Massachusetts & New Hampshire)
    The Southern Maine Agency on Aging/Aging and Disability Resource Center (SMAA/ADRC) (Maine)
    The Southwest Ohio Community Care Transitions Collaborative (Ohio)
    Advance Care Transitions (ACT), Marin County, California (California)
    AgeOptions (Illinois)
    Brooklyn Care Transition Coalition (New York)
    Care Connection Aging and Disability Resource Center (Care Connection) (Texas)
    CareLink (Arkansas)
    Carondelet Chronic Care Navigation Program (Arizona)
    Delaware County Office of Services for the Aging (Delaware)
    Elder Services of Berkshire County (Massachusetts)
    Elder Services of Worcester, Massachusetts (Massachusetts)
    El Paso, Texas Aging and Disability Resource Center (Texas)
    Greater New Haven Coalition for Safe Transitions (Connecticut)
    Lifespan of Greater Rochester Inc. (New York)
    Michigan Area Agency on Aging 1-B (Michigan)
    North Philadelphia Safety Net Partnership (Pennsylvania)
    Ohio AAA Region 8 (Ohio)
    P2 Collaborative of Western New York, Inc. (New York)
   Pierce County, Washington Community Connections’ Aging and Disability Resources (Washington)
    Southeast Washington Aging and Long Term Care (Washington)
    St. John Providence Health System (Michigan)
    Senior Alliance, Area Agency on Aging 1-C (Michigan)
    Tompkins County, New York Office for the Aging (New York)
    UniNet Healthcare Network (Nebraska)
    Western Pennsylvania Community Care Transition Program
    Allegheny County Department of Human Services Area Agency on Aging (Pennsylvania)
   Catholic Charities of the Archdiocese of Chicago (Illinois)
    Connecticut Community Care, Inc. (CCCI) (Connecticut)
    Eddy Visiting Nurse Association (New York)
    Elder Options (Florida)
    Greater Miami Coalition to Prevent Unnecessary Rehospitalizations (Florida)
    Los Angeles Mid-City Integrated Care Collaborative (California)
    Lower Rio Grande Valley Development Council (Texas)
    Metropolitan Area Agency on Aging (Minnesota)
    Mt. Sinai Hospital (New York)
    New York Methodist Hospital (New York)
    Northwest Triad Care Transitions Community Program (NTCTCP) (North Carolina)
    Oceola-St. Cloud Community-based Care Transitions Coalition (Florida)
    San Francisco Transitional Care Program (SFTCP) (California)
    Somerville-Cambridge Elder Services (Massachusetts)
    Visiting Nurse Service of Schenectady & Saratoga Counties, Inc. (VNS) (New York)
    Whatcom Alliance for Healthcare Access (Washington)

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