Community-Based Care Transitions Program

Project Type: Health

Project Stage: In Progress

The Centers for Medicare and Medicaid Services began a national initiative in 2012 to pilot the Community-Based Care Transition Programs (CCTP) across the country, with the goal of reducing high hospital readmission rates among Medicare patients.  All CCTP sites focus on improving patient care during the highly vulnerable transition period immediately following hospital discharge, but each site has flexibility over the design and implementation of the specific intervention.  Since July of 2012, Catholic Charities of the Archdiocese of Chicago has been operating a CCTP program referred to as the Chicago Southland Coalition for Transitional Care (CSCTC) in partnership with four hospitals serving 70 low-income zip codes in the area. The CSCTC program is unique in that it relies on social workers, rather than medical personnel, to coordinate care for patients during the transition from a hospital stay. Medicare Advantage patients (who on average look just like standard Medicare patients) are not able to utilize the CSCTC program. Consequently, LEO will compare outcomes for standard Medicare patients able to use CSCTC to outcomes for Medicare Advantage program patients unable to use CSCTC. The LEO evaluation will help partners better understand the impact of the CSCTC program on outcomes such as hospital re-admissions and hospital costs.

Research Partner(s): Beth Munnich, Kathryn Wagner

Catholic Charities Chicago

Non-profit Agencies

Franciscan St. James Health

Non-profit Agencies

Ingalls Memorial Hospital

Non-profit Agencies

Little Company of Mary Hospital

Non-profit Agencies

Metro South Medical Center

Non-profit Agencies