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Connecticut Community Care, Inc. Awarded the Centers for Medicare & Medicaid Services (CMS) Community-based Care Transitions Program (CCTP)


BRISTOL, Conn. – Connecticut Community Care, Inc. (CCCI) has received funds made available by Section 3026 of the Affordable Care Act to implement the Centers for Medicare & Medicaid Services’ (CMS) new Community-based Care Transitions Program (CCTP) in the north central and eastern regions of the state. CCCI will be working with nine hospitals and their associated community partners to offer person-centered, high-quality transition experiences and to reduce avoidable readmissions. Community Passport to Care (ComPass2C) is the name of CCCI’s Community-based Care Transitions Program. 

The CCTP is an initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital readmissions by 20 percent over a three-year period. CCTP’s goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program.

CCCI is working with hospitals in north central and eastern, two of the three regions where CCCI provides an array of community care coordination and support services for participants of the Connecticut Home Care and Money Follows the Person programs. In these two regions, CCCI is also designated by the state as an Aging & Disability Resource Center in partnership with the regional area agencies on aging and centers for independent living. The hospitals partnering with CCCI are Bristol Hospital, Hartford Hospital, John Dempsey Hospital at UConn Health Center, Lawrence & Memorial Hospital, MidState Medical Center, Saint Francis Hospital & Medical Center, The Hospital of Central Connecticut, The William W. Backus Hospital and Windham Hospital.

CCCI is exceedingly fortunate to collaborate with community partners throughout the state, including: Connecticut Association for Home Care & Hospice; Connecticut Commission on Aging; Connecticut Hospital Association; Connecticut State Medical Society – IPA, Inc.; eHealth Connecticut; National MS Society, Connecticut Chapter; Qualidigm; and the State of Connecticut, Departments of Public Health and Social Services. ComPass2C will build new networks of collaboration to meet the goals of the Partnership for Patients--better health, better care and lower costs. 

Hospitalizations account for approximately 33 percent of total Medicare expenditures and represent the largest program outlay. The Medicare Payment Advisory Commission estimated Medicare costs of approximately $15 billion due to readmissions, $12 billion of which is for cases considered preventable.

ComPass2C incorporates enhanced assessment during hospitalization, risk stratification, a person-centered care transition plan, enhanced communication across care settings, and continuous quality improvement at the community and system level. The enhanced assessment includes tools from Project Boost, a national initiative led by the Society of Hospital Medicine to improve the care of individuals returning home from the hospital. The assessment also includes focused screening for depressive symptoms and cognitive impairment.

The person-centered plan builds upon two evidence-based models, the Care Transitions Intervention TM developed by Dr. Eric Coleman and the Transitional Care ModelTM developed by Dr. Mary D. Naylor. Individuals and families/supporters are central to transition planning and become active partners with a transition coach or nurse specialist as they work to meet personal goals, take an active role in addressing health and social service needs, and learn more about health conditions and self management. Care transitions coaching gives individuals and their families the tools and skills needed to be more comfortable and confident in their overall care.

The person-centered plan also includes health education, targeted community services and linkage with ongoing community supports. Community and system-level interventions will begin with timely feedback to all community partners regarding transition challenges, quality indicators and root causes of poor outcomes. These actions will enable the community to develop new strategies and services to promote better health and better care.

The target population for ComPass2C is Medicare beneficiaries age 18 or older with one or more admitting diagnoses – cardiac and vascular events (HF, MI, CVA) and/or respiratory conditions (COPD, asthma, pneumonia); Medicare/Medicaid eligible individuals (MMEs) with multiple chronic conditions and a history of multiple readmissions; and persons with depressive symptoms and/or cognitive impairment.


About Centers for Medicare & Medicaid Services – Community-based Care Transitions Program:

 The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measureable savings to the Medicare program. The period of participation will last for two years.  Participation may be extended on an annual basis for the remaining 3 years of the program if performance targets are met.

The CCTP is part of Partnership for Patients, a national patient safety initiative through which the Administration is supporting broad-based efforts to reduce harm caused to patients in hospitals and improve care transitions. 


About Connecticut Community Care, Inc. (CCCI):

CCCI identifies choices and provides services to support people of all ages, abilities and incomes to live in the community setting of their choice. The nonprofit care management organization is an access agency, as defined in state statute, to the Connecticut Home Care (CHCP) and the Money Follows the Person (MFP) programs in 124 towns in north central, northwest and eastern Connecticut. CCCI’s private division, Care Management Associates, serves those individuals statewide who do not qualify for the CHCP or MFP. CCCI, as an access agency, is an Aging and Disability Resource Center (ADRC) in partnership with the area agencies on aging and centers for independent living in the north central and eastern regions of the state. Entitled Community Choices, the ADRC provides trusted and reliable long term care information and assistance, options counseling and person-centered transitional support for CT residents. Through its regional offices located in Wethersfield, Watertown and Franklin and its corporate office in Bristol, CCCI serves more than 13,000 individuals and their families each year. Toll-free: 866-845-2224.

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My mother was a client of CCCI’s for over 10 years. Her health had declined but I finished my walk out basement to make it accessible for her to live in my home. Mom was in and out of various nursing homes over the past few years due to different surgeries. We know, for her, there truly was “no place like home.” We had the same care manager for this entire time and she was wonderful. She was knowledgeable, helpful and willing to do all that she could so that mom’s care and my care giving for her were as supported as possible.
AB, Manchester, CT
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