As part of the new healthcare law’s policies to improve the quality of care available to people with Medicare and all Americans, the Centers for Medicare & Medicaid Services (CMS) today announced 23 additional participants in the Community-based Care Transitions Program (CCTP).  These participants will join seven other community-based organizations already working with local hospitals and other health care and social service providers to support Medicare patients who are at high-risk of being readmitted to the hospital while transitioning from hospital stays to their homes, a nursing home, or other care setting. 

“We are very excited to have these 23 sites join our efforts to improve opportunities for patients to continue to make gains after they leave the hospital,” said Marilyn Tavenner, CMS Acting Administrator.  “I’ve seen the very real difference that support from organizations like our partners in the Community-based Care Transitions Program can make to people’s post-hospital care and their health.” 

CCTP is designed specifically to provide support for high-risk Medicare beneficiaries following a hospital discharge.  These 23 sites will work with CMS and local hospitals to provide support for patients as they move from hospitals to new settings, including skilled nursing facilities and home.  Community organizations will help these patients stay in contact with their doctors to ensure their questions are answered and they are taking medications they need to help them stay healthy.  Today’s announcement will support more than 126 local hospitals and help more than 223,000 Medicare beneficiaries in 19 states across the country. 

CCTP is part of the Partnership for Patients, a public-private partnership aiming to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period.   Achieving these goals has the potential to save up to 60,000 lives, prevent millions of injuries and unnecessary complications in patient care, and save up to $50 billion for Medicare over ten years.  To date, more than 8,000 partners have pledged their commitment to the aims of the Partnership for Patients, including more than 3,800 hospitals. 

As part of their two-year agreement with the CMS Innovation Center, each organization will be paid a flat fee for helping to coordinate patient care after a hospital stay for each Medicare beneficiary who is at high risk for readmission to the hospital. 

The 23 sites will join the seven organizations announced in November 2011, bringing the total number of sites to 30. This is the second round of CCTP participants announced since the program was launched in April 2011.   Under the Affordable Care Act, the program may spend up to $500 million over five years.  With this round of agreements, CMS has committed half of the $500 million allocated to CCTP.  The Innovation Center continues to accept applications as long as funding is available.  

More information on the CCTP is available here

More information about the work the Department of Health and Human Services is doing to improve care for Medicare, Medicaid, and CHIP beneficiaries and by extension, all Americans, through the broader Partnership for Patients initiative, is available at

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