Community-Based Care Transitions Program Implementation and Monitoring

Prepared For

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services

The Medicare Community-Based Care Transitions Program, a major component of the Partnership for Patients Campaign created under the 2010 Patient Protection and Affordable Care Act, provides $500 million in funding over five years to test models for improving care transitions from the hospital to the community for Medicare beneficiaries at high risk of hospital readmission.

Mathematica and its subcontractors are (1) developing and implementing an electronic transmittal system for collecting, validating, reporting, and paying invoices for care transition services submitted by more than 100 participating community-based organizations (CBOs) and their hospital partners; and (2) monitoring and reporting CBOs’ progress toward meeting their performance targets, as well as the impact of the program on federal expenditures. 

Specifically, Mathematica is using Medicare enrollment and claims data and information collected through a patient experience survey to calculate outcome, process, patient experience, and adverse effect measures. Outcome measures include all-cause/all-condition 30-, 60-, and 90-day post-discharge hospital readmission rates at the CBO and hospital levels. Process measures include 7- and 30-day post-discharge physician follow-up visit rates. Participant experience measures include patient information and patient activation scores derived from selected items from the Hospital Consumer Assessment of Healthcare Providers and Systems survey and all items on the Care Transition Measures and the Patient Activation Measure instruments. Adverse event measures include 30-day post-discharge emergency department visit rates, observation bed stay rates, and mortality rates.

To monitor CBO performance over time, Mathematica is generating and reporting monthly participant-level data feeds to the Centers for Medicare & Medicaid Services (CMS) and its technical assistance and evaluation contractors, as well as aggregated CBO-specific quarterly performance reports to CMS and the participating CBOs. CMS and the participating CBOs are using the information to monitor their progress toward meeting the stated goals of the legislation to achieve a 20 percent reduction in the 30-day readmission rate of Medicare fee-for-service discharges across their hospital partners. CMS is also using the information to help determine whether to renew the CBOs’ provider agreements after an initial two-year period of performance.


Related Staff

Karen  Bogen

Karen Bogen

Principal Survey Researcher

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Boyd Gilman

Boyd Gilman

Senior Fellow

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