A Medicare initiative designed to improve care transitions for patients moving from a hospital or other healthcare setting back into their homes or communities. CCTP aims to reduce hospital readmissions and improve patient outcomes by facilitating seamless transitions through community-based support and services.
The process of moving a patient from one healthcare setting to another, such as from a hospital to home, with a focus on ensuring continuity of care, patient safety, and optimal health outcomes.
The federal health insurance program primarily for people aged 65 and older, as well as certain younger individuals with disabilities or specific medical conditions. Medicare supports the CCTP initiative to enhance care transitions for eligible beneficiaries.
A healthcare approach that prioritizes the individual needs, preferences, and values of patients, involving them in decision-making and treatment planning to ensure personalized and holistic care.
A collaborative team comprising healthcare professionals from various disciplines, such as physicians, nurses, social workers, pharmacists, and therapists, working together to address the multifaceted needs of patients during care transitions.
Supportive services and interventions provided to patients during the transition from one healthcare setting to another, including medication management, home healthcare, caregiver support, and patient education.
The return of a patient to the hospital within a specified period after discharge, often considered an indicator of gaps or deficiencies in the quality of care transitions and post-discharge support.
The electronic sharing of patient health information among healthcare providers and organizations involved in a patient’s care, facilitating communication, coordination, and continuity of care across different settings.
Non-profit or government organizations operating at the local level to provide a range of social, health-related, and supportive services to individuals and families within the community, collaborating with healthcare providers to deliver comprehensive care transition support.
Systematic efforts to enhance the quality, efficiency, and effectiveness of healthcare services and outcomes, often involving data analysis, performance measurement, best practice implementation, and continuous evaluation and refinement of care delivery processes.
Resources, education, and assistance provided to informal caregivers, such as family members or friends, who assist with the care of a loved one during and after a hospitalization, helping to alleviate caregiver burden and promote patient well-being.
The ability of individuals to obtain, understand, and use health information to make informed decisions about their health and healthcare, emphasizing the importance of clear communication and patient education during care transitions.
An approach to healthcare delivery and management that focuses on improving the health outcomes of entire populations, including identifying at-risk individuals, implementing preventive measures, and coordinating care to address the needs of diverse patient groups within a community.
The use of telecommunications technology to deliver healthcare services remotely, allowing healthcare providers to monitor patients’ health status, provide virtual consultations, and facilitate follow-up care, particularly valuable for patients transitioning to home-based care.
A reimbursement model in healthcare that ties payment to the quality and outcomes of care delivered, incentivizing providers to deliver high-quality, cost-effective care and promoting care coordination, preventive services, and patient engagement.