Download English - AgeOptions

The Affordable Care Act (ACA) and Medicare:
Hospital Care Transitions
The Affordable Care Act (ACA), also known as “health care reform” was signed into law
in March 2010. The law made several changes to health care, including programs to
improve the quality of care that people receive when they leave the hospital. One
program that is designed to do this is the ACA’s Community-Based Care Transitions
Program. “Care transitions” occur when you leave a hospital and move to another place,
such as your home or a skilled nursing facility. The ACA’s Community-Based Care
Transitions Program (CCTP) aims to improve people’s care when they leave the
hospital and to help people manage their health better and avoid going back to the
hospital. If you are leaving the hospital, you may be able to get free help as you
return home – see page 2 of this tip sheet for more information on CCTP services
and participating hospitals in Illinois.
Why Do We Need Care Transitions?
Hospital readmission is a major health care concern. A hospital readmission occurs
when you leave the hospital and then return to the hospital for the same or related care
within 30 days. One in five Medicare beneficiaries who leave the hospital are
readmitted within 30 days. These readmissions cost Medicare more than $26 billion a
year. Hospital readmissions can happen for many reasons, such as poor care
coordination at the hospital or poor community support. The goal of the ACA
Community-Based Care Transition Program is to improve patient care as people leave
the hospital, so that they will not be readmitted.
What is the Community-Based Care Transition Program (CCTP)?
The Community-Based Care Transitions Program (CCTP) was created by the ACA to
improve care transitions and reduce hospital readmissions for high risk Medicare
beneficiaries. A “high risk” Medicare beneficiary is someone who has medical conditions
that are hard for the person to manage. (For example, some people who have
conditions like heart disease or diabetes may have trouble taking care of these
conditions.) In the CCTP, community-based organizations work with hospitals to help
patients have a more positive experience when they leave the hospital. These
organizations begin supporting patients at least 24 hours before they leave the hospital.
Who can get CCTP services?
 Each CCTP program has its own requirements. To qualify, a person must
have original fee-for-service Medicare (Part A and Part B) and may need
to meet other rules, such as being a certain age.
(OVER) 
How much will it cost?
 There is no cost to you for the services.
Benefits you may receive
 Follow up from a social worker or nurse
 Help with managing your medications
 In-home care to help you manage your conditions
 Help developing knowledge, skills, and confidence to manage your
medical conditions at home
CCTP Programs in Illinois
AgeOptions is working with local community-based organizations in suburban Cook
County to help older adults move safely from a hospital to their home or to a skilled
nursing facility. Here are the organizations and hospitals involved in this project:
Community-Based Organizations
Aging Care Connections
Kenneth Young Center
North Shore Senior Center
PLOWS Council on Aging
Rush University Older Adults Programs
Solutions for Care
Hospitals
Adventist La Grange Memorial Hospital
St. Alexius Medical Center
Advocate Lutheran General
Palos Hospital
Rush University Medical Center
MacNeal Hospital
Three other CCTP projects exist in Illinois. Here are the organizations and hospitals
involved in those CCTP Projects:
Hospitals
Lead Organizations
CJE SeniorLife (Chicago and suburban
Cook County)
Catholic Charities of the Archdiocese of
Chicago (Chicago and suburban Cook
County)
Community Research Resource
Information Services for Seniors, Inc.
(Central Illinois)
Northwestern Memorial Hospital
St. Joseph Hospital
St. Francis Hospital
Ingalls Hospital
Little Company of Mary Hospital
Metro South Hospital
St. James Hospital
Carle Foundation Hospital
Provena Covenant Medical Center-Urbana
Provena United Samaritans Medical
Center- Logan
For descriptions of these projects and others in each state visit this website:
http://innovation.cms.gov/initiatives/CCTP/CCTP-Site-Summaries.html