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Care Transitions Program (ComPass2C)

What is Community Passport to Care (ComPass2C)?

Connecticut Community Care, Inc (CCCI) was awarded funding by the Centers for Medicare and Medicaid Services to participate in the Community-based Care Transitions Program (CCTP) to implement ComPass2C, a program to improve care transitions for Medicare beneficiaries from the hospital to community and post-acute care settings.  The program is meant to improve quality of care, reduce avoidable readmissions, and document measurable savings to the Medicare Program. 

How does ComPass2C work?

Care transition coaches and nurses employed by CCCI are assigned to specific hospitals to engage eligible beneficiaries in the transition process.  The program is free to participants (and hospitals).  Coaches work with individuals to improve their understanding of how to manage their post discharge care, link them to community resources, build self-efficacy and improve health literacy.  The transition coaches and nurses meet with eligible individuals in the hospital to explain the program, obtain informed consent, assess readmission risk and develop a working relationship. Risk assessment is guided by the Project Boost 8P tool; the General Assessment of Preparedness tool and the Patient Health Questionnaire -2 question depression screener.  Low risk individuals will receive in-hospital coaching and one or more follow-up phone calls.  Moderate risk individuals will receive in-hospital coaching and follow-up home visits based on Dr. Eric A. Coleman's Care Transition Intervention™.  High risk individuals will receive coaching, health education and monitoring using the Transitional Care Model™ developed by Mary D. Naylor, PhD, RN, FAAN.  On a systems level, the program will be able to give feedback to all community partners regarding transition challenges, quality indicators and root causes of poor outcomes.

Who is eligible to participate in ComPass2C?

Medicare A and B beneficiaries age 18 or older with any of the following diagnoses:

  • cardiac/vascular diagnoses (heart failure, myocardial infarction, stroke, transient ischemic attack)
  • respiratory diagnoses (pneumonia, chronic obstructive pulmonary disease, asthma)
  • Medicare/Medicaid beneficiaries with multiple chronic conditions and a history of multiple readmissions.

The program will also provide services to individuals with depressive symptoms, cognitive impairment or persons discharged to nursing homes.

 Who is not eligible to participate in ComPass2C?

  • Individuals who are covered under Medicare Advantage Plans
  • Individuals enrolled in a clinical trial or hospice program
  • Individuals transferred to another hospital within one day or who leave against medical advice
  • Individuals with significant post-acute needs beyond the scope of the program
    such as:
            - major trauma
            - active cancer treatment
            - unstable mental illness
            - active substance abuse
            - long-term hyper-alimentation

What hospitals are participating in ComPass2C?

Nine hospitals in the Eastern and North Central Connecticut are supporting and partnering with CCCI to offer ComPass2C including:  

What are the anticipated benefits of the ComPass2C program?

On an individual level, care transition coaching gives individuals and their families the tools and skills needed to be more comfortable and confident in their overall care.  From a systems perspective, the goal is to improve transition communication and supports between hospitals, post-acute care organizations, primary care providers, specialists and community based organizations.  This should result in improved quality of life for those served, fewer readmissions and measurable savings to the Medicare program.

To read the official press release, please click here.


ComPass2C Logo

Client/Caregiver 2
Our care manager was extremely competent, compassionate, prompt and concerned about all aspects of our case. She followed-up on every detail and checked up on us to make sure things were going well. She is a fine example of professionalism at its best. Without this truly compassionate service we would have had to consider nursing home care.  This would have been awful for her and for our family. It would also have been a very costly option.
SB, Glastonbury, CT
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