New Organizations, Nursing Homes Participating in CMS Medicare Transition Program

The Centers for Medicare & Medicaid Services (CMS) announced 23 new participating organizations in its Community-based Care Transitions Program (CCTP) on Wednesday, March 14, at least three of which will be partnering with skilled nursing facilities. The program seeks to prevent hospital readmission for Medicare patients who are transitioning into post-care settings such as nursing homes or rehabilitation centers.

These new participants will join seven other community-based organizations who are already working with hospitals and other health care and social service providers to support Medicare patients who are at a high risk of rehospitalization.

“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.”


At least three of the organizations, the Care Connection Aging and Disability Resource Center, Michigan Area Agency on Aging 1-B, and Western Pennsylvania Community Care Transition program, will be working with networks that include skilled nursing facilities and nursing homes along with hospitals, home health agencies, hospice agencies, personal care homes, and other care settings.

All 23 sites will work with CMS and local hospitals to provide support for high-risk Medicare beneficiaries following hospital discharges as they move from an acute care setting to other care settings. The community organizations help patients stay in touch with their doctors to make sure their questions can get answered and that they are taking necessary medications to stay healthy—and out of the hospital.

“It’s really designed to keep people from falling off the radar screen once they’re discharged,” a CMS spokesperson told SHN.


The CCTP program is part of a public-private partnership aimed at cutting preventable hospital errors by 40% and reducing preventable hospital readmissions by 20% in a three-year time span, says CMS, and achieving these goals has the potential of saving up to 60,000 lives and more than $50 billion for Medicare during the next 10 years.

There are more than 8,000 partners to date, and part of their two-year agreement with the CMS Innovation Center includes each organization getting paid a flat fee for helping to coordinate patient care after a hospital stay for each Medicare beneficiary who’s at a high risk for hospital readmission.

With this round of new participants, CMS has committed half of the $500 million allocated to the CCTP program through the Affordable Care Act, and will continue to accept applications for more partnerships as long as funding is available.

View the full list of participating organizations here.

Written by Alyssa Gerace

Companies featured in this article: