Purpose-built to Reduce Hospital Readmission Rates

Collaborative Solution Improves Success of Transitional Care of High-Risk Medicare Patients

In 2011, the federal government launched the Community-based Care Transitions Program (CCTP), part of the Affordable Care Act, to reduce the 30-day hospital readmission rate for high-risk Medicare beneficiaries by ensuring a successful transition from hospital care back to the community. CCTP aims to achieve four primary goals: reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program. Under CCTP, community-based organizations (CBOs) provide a range of care services to effectively manage, educate and support consumers during the 30-day transition period. Providing consumers with these tools and education needed to complement traditional supports ultimately results in a successful transition back into community.

Painlessly Operationalize Your Medicare Community Care Transitions Program Grant

Using Harmony for Care Transitions enables CBOs and hospitals to secure available program funds and to collaboratively create, plan, and deliver high-quality transitional care. With Harmony, CBOs are able to create transition care plans and manage and track transitions in a step-by-step collaboration with hospitals. Organizations can then easily report on processes and measure outcomes to monitor the success of transition programs.


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