Community Care Transitions Project



Care transitions occur when a patient moves from one health care provider or setting to another. Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—is readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible for, including the quality of care during the hospitalization and the discharge planning process. However, it is clear that there are multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions. The Community Care Transitions Project (CCTP) seeks to correct these deficiencies by encouraging a community to come together and work together to improve quality, reduce cost, and improve patient experience. The CCTP is part of the Partnership for Patients, a nationwide public-private partnership that aims to reduce preventative errors in hospitals by 40 percent and reduce hospital readmissions by 20 percent.

Excerpt taken from: Center for Medicare & Medicaid Innovation.

San Francisco Experience

As of October 2012, 47 organizations have been selected to participate. San Francisco was selected in Round 3, announced this past August. The San Francisco Transitional Care Program, led by the Department of Aging and Adult Services, will utilize health care coaches and care managers working for local Community Based Organizations (CBO’s) to effectively manage Medicare patients' transitions and improve their quality of care. The CBO’s will be paid an all-inclusive rate per eligible discharge by CMS, based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary. San Francisco General Hospital has played a large role in the planning and implementation process. Michelle Schneidermann sits on the governing board and Sharon Kwong, Director of Social Services at SFGH, sits on the steering committee.

For further information, please contact Dr. Michelle Schneidermann.