The Community-Based Care Transitions Program, a provision of the newly enacted Patient Protection and Affordable Care Act (Section 3026 of HR 3590), provides $500 million to collaborative partnerships between hospitals and community-based organizations designed to meet the goal of implementing evidence-based care transitions services for Medicare beneficiaries at high risk for hospital readmission.

 The provision in the law grew out of a successful translation of the Care Transitions Intervention model into practice settings nationwide. The translation of the model was made possible by funding from the John A. Hartford Foundation, a national funder located in New York City. (The model itself was designed with funding from Hartford and the Robert Wood Johnson Foundation.) Fourteen states, under a Centers for Medicare and Medicaid Services (CMS) contract, have tested the model, and many have experienced significant reductions in hospital readmissions. Eric A. Coleman, a professor of medicine at the University of Colorado Denver, directs the broader Care Transitions Program and has led the model’s development and translation efforts.

This intervention “helps smooth the transition from hospital to home,” explained Amy Berman, a program officer at the Hartford Foundation, in a 23 September 2009 post on the foundation’s blog, Health AGEnda . It works by encouraging older patients to take a more active role in their own care.

The Community-Based Care Transitions Program is on schedule for implementation in early 2011. Eligible hospitals and community-based organizations that forge a partnership committed to implementing evidence-based care transitions services—such as the Care Transitions Intervention described above—may apply to the secretary of the Department of Health and Human Services (HHS) for funding. The program’s success will be assessed through an evaluation of hospital readmission rates for high-risk Medicare beneficiaries receiving services from the program over a five-year period.

The inclusion of the Community-Based Care Transitions Program in the health reform law is important evidence that foundation-funded work is informing the development and implementation of national policy and has the potential to improve the quality of care for older Americans.

To promote the uptake of proven strategies that improve transitions of care, the Commonwealth Fund and the Hartford Foundation partnered with the Health Research and Education Trust (HRET), a subsidiary of the American Hospital Association, to develop the “Health Care Leader Action Guide to Reduce Avoidable Readmissions.” This new resource (which can be downloaded at no charge) outlines approaches to improving quality of care—such as the Care Transitions Intervention. It also addresses issues that lead to costly rehospitalizations, such as lack of appropriate follow-up care, or confusion over medications, which can lead to serious errors and harm.

 For more information on the Care Transitions Program, please visit, including its “Influencing Policy” section.

For more information on the Health Care Leader Action Guide to Reduce Avoidable Readmissions, please visit