Federal Program Monitoring Patients After Hospital Stay Expanded

Ernie Shannon's picture

A program designed to monitor Medicare patients after they leave hospitals is being expanded to 30 communities across the United States according to the Centers for Medicare and Medicaid Services.

The Community-based Care Transitions Program is described as designed to support high-risk Medicare beneficiaries following a hospital discharge. Centers for Medicare and Medicaid Services Acting Administrator Marilyn Tavenner said her organization will work with local hospitals to assist patients as they move from hospitals to new settings including nursing facilities or their homes. Seven community organizations already participate in the program and the new announcement adds another 23 organizations.

The original seven groups include Maricopa County in Arizona, the Atlanta Regional Commission, the Akron/Canton Ohio Area Agency on Aging, the Southwest Ohio Community Care Transitions Collaborative, Merrimack Valley of Massachusetts and Southern New Hampshire, the Southern Maine Agency on Aging/Aging and Disability Resource Center, and the Council for Jewish Elderly in Chicago. The names of the 23 additional organizations were not yet available for release.


Tavenner said the Care Transitions Program tracks Medicare patients who are at high-risk of being readmitted to a hospital. The community groups maintain contact with the patients, their physicians to ensure patient questions are answered and that the patients are taking their medications. The federal agency said the expansion of the program will support 126 local hospitals and assist more than 223,000 Medicare beneficiaries in 19 states.

“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 Tavenner. “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.”

As part of the Affordable Care Act, the program is expected to spend more than $500 million during the next five years. With the latest round of announcements the Centers for Medicare and Medicaid Services has committed half of the one-half billion dollars allocated to the program. Each organization signs a two-year agreement with the Medicare and Medicaid Services and is paid a flat fee to coordinate patient care after a hospital stay in their communities.

Federal officials said they will continue accepting and reviewing applications for the program during the first half of 2012. Those dates are March 27, April 10 and 26, May 10 and 30, and June 11 and 28.