(CHICAGO) –Rush University Medical Center is among the latest healthcare providers to participate in the federal government’s “Community-based Care Transitions Program,” which is part of the Affordable Care Act. The initiative is a key element in the new healthcare law’s policies to improve the quality of care available to people with Medicare.
The Community-based Care Transitions Program (CCTP) is designed specifically to provide support for high-risk Medicare beneficiaries following a hospital discharge. Rush will work with CMS, other CCTP sites, hospitals and community organizations to provide support for patients as they move from hospitals to new settings.
The 23 new partners were awarded funding by CMS to improve support for Medicare patients who are at high-risk of being readmitted to the hospital while transitioning from hospital stays to their homes, a nursing home or other care setting.
“It is wonderful that Rush is being recognized for the years of work we have put in to improve post-discharge care,” said Robyn Golden, LCSW, director of Rush Health and Aging. “This new partnership is in direct alignment with our long-term philosophy of enhanced discharge planning and our advocacy efforts for a healthcare model that addresses patients from both physical and psychosocial approaches.
Over the years, Rush Health and Aging has created the enhanced discharge planning program, which is a social work-based transitional care model to help patients and families with post-discharge care. This innovative model of care was studied with a randomized control trial to quantify what strategies improved health outcomes, better well-being, and positive patient and caregiver feedback.
The enhanced discharge planning program was augmented by best practices from community sites across Illinois and came to be known as the Bridge Model. Rush started a statewide effort to replicate the Bridge Model with 10 other hospitals in Illinois. The expansion of the program was funded by the Administration on Aging and supported by the Illinois Transitional Care Consortium and the Illinois Department on Aging.
“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.”
Participants in the Community-based Care Transitions Program join for two years and are paid a flat fee to provide care coordination services for high-risk Medicare patients after hospital discharge. The program was created under the Affordable Care Act, which provided $500 million of funding over five years to establish the program.
The 23 sites will join seven organizations that were announced in November 2011, bringing the total number of sites to 30.
More information on the CCTP is available at http://go.cms.gov/caretransitions