The Centers for Medicare & Medicaid Services (CMS) have announced 23 additional participants in the Community-based Care Transitions Program (CCTP) program. They will join seven other community-based organizations, who are participating in the program that partners hospitals and other health care and social service providers to support high-risk Medicare patients who may be readmitted while transitioning from hospital stays to their homes, a nursing home, or other care setting.

 “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,” Marilyn Tavenner, CMS Acting Administrator, said in a statement. “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.”

The program is designed specifically to provide support for high-risk Medicare beneficiaries following a hospital discharge. These 23 sites will work with CMS and local hospitals to provide support for patients as they move from hospitals to new settings such as nursing facilities and home. Community organizations will aim to help these patients stay in contact with their doctors to ensure their questions are answered and they are taking medications they need to help them stay healthy.

Each organization participating will be paid a flat fee for helping to coordinate patient care after a hospital stay for each Medicare beneficiary who is at high risk for readmission to the hospital.  This is the second round of CCTP participants announced since the program was launched in April 2011. Under the Affordable Care Act, the program may spend up to $500 million over five years. With this round of agreements, CMS has committed half of the $500 million allocated to CCTP.