Senior Care Facilities Participating in New Community Care Transitions Programs

The Center for Medicare & Medicaid Studies (CMS) has announced 35 new Community-based Care Transitions Program (CCTP) sites in 23 states, five of which feature skilled nursing facilities as participating members.

A five-year program that’s part of the Affordable Care Act, the CCTP now has 82 sites that are testing models to improve care transitions from hospitals to other post-acute care settings, thereby reducing costly, unnecessary readmissions for high-risk Medicare beneficiaries.

About 20% of Medicare beneficiaries, or 2.6 million seniors, are readmitted to hospitals within 30 days of being discharged, according to CMS. This costs the program more than $26 billion every year.


Although hospitals have traditionally been the main player in seeking to reduce readmission by focusing on components leading to rehospitalization that they are responsible for, including the quality of care during the initial hospital visit and the discharge planning process, CMS says it’s “clear” there are multiple factors along the care continuum impacting readmissions. 

Identifying key drivers of rehospitalizations is the first step toward implementing appropriate interventions to reduce or prevent them, causing CMS to create the CCTP program. The initiative’s goal is to “encourage a community to come together and work together to improve quality, reduce cost, and improve patient experience” through sites that coordinate care between various post-acute care providers. 

Skilled nursing facilities and home health agencies are represented in five of the new sites that have recently joined the program, in Colorado, Florida, Mississippi, and New York. The sites including or partnering with senior care organizations include:

  • Denver Regional Council of Governments (Colorado)
  • Catholic Health Care Transitions Services, Inc. (Florida)
  • West Central Florida Area Agency on Aging (Florida)
  • Three Rivers Planning & Development District (Mississippi)
  • Isabella Geriatric Center (New York)

“The presence of these [CCTP site] facilities speaks to the importance of post-acute and skilled nursing centers in the care transitions from hospitals,” says Greg Crist, vice president of public affairs at nursing home trade group the American Health Care Association. “We’ve made reducing rehospitalizations a key quality goal profession-wide. This year is no different.  If we can enhance those successful transitions while keeping the process free of complexities, everyone wins and costs can come down.”

Find out more about each new Community-based Care Transitions Program site. 

Written by Alyssa Gerace