Evaluating the Community-based Care Transitions Program

From 2012 to 2017, Econometrica conducted an evaluation of the Community-based Care Transitions Program (CCTP) on behalf of the Centers for Medicare & Medicaid Services (CMS). As part of the Partnership for Patients 1.0 initiative, which aimed to improve the quality, safety, and affordability of healthcare in the United States, the CCTP supported partnerships between community-based organizations (CBOs) and hospitals to provide transition services to Medicare beneficiaries. The goals of the program included:

  • Decrease readmissions rates among high-risk Medicare beneficiaries.
  • Improve quality of care through the transition.
  • Provide savings to Medicare.

A driving force in the construction of the program as CBO-based partnerships was awareness of the critical role the community (e.g., family, caregivers, primary care physicians, CBOs) can play in improving hospital-to-home transitions and reducing avoidable readmissions.

The evaluation of the CCTP aimed to identify whether (and how) the program was associated with key outcomes, as well as whether program characteristics and care transition service components might have driven favorable key outcome findings. Key outcome measures included 30-day readmissions, expenditures, post-discharge service utilization, emergency department visits, and observation stays. In addition, the evaluation assessed implementation of the program across sites, utilization of community services by participants, and beneficiary and provider participation in the program.

Econometrica implemented three quantitative strategies to analyze the CCTP’s impacts:

  1. A pre-post regression model.
  2. Difference-in-differences regression models at the beneficiary and hospital levels.
  3. A time-series model.

We also conducted qualitative research based on annual telephone interviews with CCTP sites and 10 in-person site visits per year. We used qualitative data to broaden our understanding of program features, the challenges CBO partnerships encountered in implementing the CCTP, the implementation process, contextual and environmental factors influencing implementation and outcomes, successful strategies, and other programs that could confound findings.

We reported the findings of the evaluation in two published reports in 2014 and 2017, including recommendations about program expansion.

About Econometrica:
Founded in 1998, Econometrica is a research and management organization in Bethesda, MD, established to provide public- and private-sector clients with customized program support services. Econometrica works with multiple agencies to provide high-quality, cost-effective analyses, modeling, and economic evaluations. The company consistently receives exceptional scores from its clients and believes in three principles: technical capabilities, happy customers, and business development.

Key outcome measures included 30-day readmissions, expenditures, post-discharge service utilization, emergency department visits, and observation stays.

Read more about Econometrica’s work on the CCTP here.

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