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Project Close Out Information for Practices

When Is CTN Ending?

It has been an incredible four years, but now we must say, “until next time.” As many of you know, the Care Transitions Network program is funded through the Centers for Medicare and Medicaid Innovations’ Transforming Clinical Practice Initiative, a four-year program that runs from October 2015-September 2019. As a result, the Care Transitions Network program will come to a close in September 2019. To ensure clarity on close out timelines and activities, we have prepared the following Q&A for our network members.
Is there anything I need to do as part of project close out?

There are no required actions, but we recommend every provider does the following:

    • If you are not currently in Phase 5 of transformation and anticipate phase progression, complete a final PAT assessment and coaching call with your practice coach by no later than August 30, 2019.
    • Complete our end of project survey so we can incorporate your feedback and successes into our project evaluation.
    • Submit your exemplary practice story to be shared and showcased nationally in CMS’ exemplary practice database.
    • Celebrate with us! Join on August 13 at the DoubleTree Hotel in Tarrytown, NY for the “Care Transitions Network Summit: Sharing and Scaling Four Years of Implementation and Learning.” More details and registration can be accessed here.

When do I need to complete my final Practice Assessment Tool (PAT) assessment and coaching call?

You are eligible for incentive payments each time your practice progresses into a new phase of transformation through the PAT. In order to receive incentive payments for phase progression, all practices must complete their final assessment and coaching call by no later than August 30, 2019.

What will happen to my data?

Care Transition Network will provide all participating practices a participation package that will include key information on PAT progress, technical assistance participation, exemplary practice story (if completed), utilization reports and an excel file of their clinical quality measures data.

Are there any options for continued support?

Although the program is ending, the National Council has a variety of consulting, training and support options for providers that can be shaped to meet your needs. If you are interested in learning more about these opportunities, please contact or your Practice Coach.

General Questions

What is the Care Transitions Network?

The Care Transitions Network for People with Serious Mental Illness supports practice transformation for organizations that serve people with serious mental illness (SMI) in New York State. Funded by the Centers for Medicare and Medicaid Services (CMS), the Care Transitions Network aims to reduce all-cause re-hospitalization rates among people with SMI while, simultaneously, preparing organizations to transition into value-based payment arrangements. The Care Transitions Network is the only CMS-funded Practice Transformation Network specifically designed to support behavioral health and primary care providers who serve people with SMI and other behavioral health disorders, including schizophrenia, bipolar disorder and chronic depression. When your behavioral health organization enrolls, you and your entire workforce will gain access to:

  • Expert faculty who deliver free and individualized coaching, best clinical practice supports, and organizational trainings to support patient and family-centered care, data-driven quality improvement and sustainable business operations
  • A free web-based platform with utilization and financial data to enable enrolled organizations to track progress on key clinical and financial indicators and confidently transition to value-based payment contracts

Who supports Care Transitions Network implementation?

The National Council for Behavioral Health leads the Care Transitions Network in close partnership with Montefiore Health Systems, Northwell Health, the New York State Office of Mental Health, and Netsmart Technologies. It is funded by a four-year grant provided by the Centers for Medicare and Medicaid Services.

How will the Care Transitions Network support the Delivery System Reform Incentive Payment (DSRIP) and other New York state initiatives?

The aims of DSRIP and the Care Transitions Network are closely aligned: they both aim to reduce avoidable hospitalizations and support providers’ transition into payment arrangements that reward value over volume. The Care Transitions Network, and the data and technical assistance it provides enrolled organizations, focuses on service utilization of a specific population – people with serious mental illness. It will provide technical and financial support to meet the aims of both programs.

Enrollment Questions

Who is eligible to join?

Any inpatient or outpatient provider organization that serves people with serious mental illness and bills Medicaid is eligible to join. This includes behavioral health providers (mental health and addictions) and primary care providers.

Enrolled organizations must have at least one of the following clinician types:

  • Physician
  • Physician Assistant
  • Nurse Practitioner
  • Clinical psychologist
  • Licensed clinical social worker

While the Care Transitions Network must track these clinicians for federal reporting purposes, your entire workforce can benefit from the Care Transitions Network learning community, expert consultation, quality improvement platform, coaching and technical assistance.

Who is ineligible to join?

  • Practices that are already participating in another Practice Transformation Network (PTN) are ineligible. An organization with multiple practices may enroll in more than one PTN, but there may be no duplicate enrollment at the practice level.
  • Practices that also participate in a Medicare Shared Savings Program or Pioneer Accountable Care Organization (exception if the enrolled clinician has no patient attribution, such as may be the case for a practice’s behavioral health providers), the CMS Comprehensive Primary Care Initiative or the CMS Multi-payer Advanced Primary Care Practice demonstration.
  • Once the Department of Health launches enrollment for its Comprehensive Primary Care Initiative, organizations will have to choose to participate either in this initiative, or the Care Transitions Network.

What are the benefits of enrollment?

  • Access to a free, web-based platform with utilization and financial data to track progress on key clinical and financial indicators
  • Up to $1,000 incentive payments for each eligible professional
  • Targeted coaching for practice transformation
  • Implementation support to apply best clinical practices for people with serious mental illness
  • Technical support in the transition to value-based payment contracts
  • Free contact hours that contribute to CEUs and CMEs
  • Referrals between participating outpatient and inpatient providers
  • Access to on-demand resources, including clinical and practice modules and training from Network affiliates such as the Center for Practice Innovations, American Medical Association, American Psychiatric Association, and American Association of Nurse Practitioners

[expander title="How does my organization enroll?" color="blue"]
Enrollment is easy!

  • Complete an Enrollment Agreement, which we will counter-sign and return
  • Provide information regarding specific clinicians within the organization (Physicians, NPs, PAs, PsyDs, LCSWs) within 30 days of receiving your fully executed enrollment agreement
  • Complete CMS’s Practice Assessment Tool within 30 days of enrollment
  • Contact with any questions along the way

What is the Practice Assessment Tool?

Designed by CMS, the Practice Assessment Tool allows each organization to assess and evaluate its readiness for and progress toward value-based service delivery. The Practice Assessment Tool can be completed by a practice manager in less than an hour, and should be completed within 30 days of enrollment, and every six months for the duration of the project.

Your practice’s Practice Assessment Tool score will determine its location along CMS’s five “phases of transformation.” CMS defines the phases of transformation as the change points for a provider organization as it prepares for value-based payment systems. Participating organizations will receive payments of up to $1,000 per enrolled eligible clinician as they move through these phases.

Technical Assistance and Best Clinical Practice Support Services

What type of Technical Assistance does the Care Transitions Network provide?

The Care Transitions Network offers a wide range of technical assistance and best clinical practice support services to enrolled organizations, including:

  • Live, online learning opportunities that offer free CMEs and CEUs for clinical staff
  • In-person events that address the transition from fee-for-service to value-based payments
  • Tele-consultation with subject matter experts
  • Support to assess practice and set individualized goals
  • Implementation support to apply best clinical practices for people with serious mental illness
  • Online presentations

The Care Transitions Network also offers access to free online dashboards, which show Medicaid claims-derived financial and utilization data so enrolled practices can track their progress through the phases of transformation. These dashboards will also enable practices to benchmark their progress against other enrolled practices across New York State.

What if I can’t find the resources I need?

Complete the Technical Assistance form to get one-on-one assistance to support your organization’s practice transformation efforts or email us at Our team can answer your questions, help you locate resources, and connect you with subject matter experts. You will receive a response to your inquiry within two business days.

What is short-term care transition support?

The Care Transitions Network builds the capacity of behavioral health practices to strengthen care transitions and achieve our goal to reduce re-hospitalization rates among people with SMI by at least 50 percent. Short-term Care Transitions Support Services are telephonic care management services provided for roughly 30 days after discharge from an enrolled psychiatric unit. Care managers work with patients to connect them to health homes (or reinforce an existing relationship), remove any barriers to attending outpatient appointments, and follow up with the inpatient units to tell them whether patients were successfully connected to care. Services are conducted in collaboration with affected managed care organizations, health homes, and inpatient units to reduce duplication of effort, reduce client confusion, and improve transitions of care.

What are Best Clinical Practice Support Services?

The Care Transitions Network has two overarching goals: (1) reducing all-cause re-hospitalization rates for people with serious mental illness, and (2) preparing network members for value-based payment arrangements. A central component to achieving both goals is preparing the behavioral health and primary care workforce to implement organized, evidence-based clinical interventions that are proven to be effective in treating people with serious mental illness. Best Clinical Practice Support Services, provided by Care Transitions Network partner Northwell Health, support organizational leaders and clinicians through tele- and in person-consultation to meet current and future goals to improve quality of care and quality of life for patients.

Clinicians from enrolled organizations can email clinical experts via the Care Transitions Network website. Clinicians can also access clinical resources 24/7 on the Care Transitions Network website.

Quality Improvement

What measures does the Care Transitions Network track?

In 2016, the Care Transitions Network will track the following Medicaid claims-based measures:

  1. All-cause 30 day readmission rate following a mental health inpatient discharge
  2. 30-day Mental Health readmission
  3. Follow-Up After Hospitalization for Mental Illness, 7 Days
  4. Follow-Up After Hospitalization for Mental Illness, 30 Days
  5. Use of Antipsychotic Drug Clozapine for Schizophrenia
  6. Use of antipsychotic long acting injectable (LAIs) for schizophrenia
  7. Adherence to antipsychotic medications (PDC) for people with schizophrenia (percent)
  8. Adherence to mood stabilizers for people with bipolar I disorder (percent)
  9. Use of multiple concurrent antipsychotics
  10. Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (percent)
  11. LDL screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (percent)
  12. 14-day initiation and engagement of alcohol and other drug (AOD) dependence treatment (14 days)
  13. 30-day initiation and engagement of AOD dependence treatment

Do enrolled practices need to do data entry?

No. Provider organizations do NOT need to conduct data entry in order to participate in the Care Transitions Network. All Quality Improvement dashboards and evaluation summaries will be based on Medicaid and Medicare claims data.

Incentive Payments for Practice Transformation

What are the Incentive Payments?

The Care Transitions Network will use the Practice Assessment Tool to measure each practice’s progress over time. An initial incentive payment will be distributed upon enrollment; additional incentive payments will be distributed as practices progress through the phases of transformation. Incentive payment amounts are $200 for each eligible clinician from the enrolled practice and for each of the five phases of transformation. For example, if an enrolled organization with 10 eligible clinicians is in Phase 1 at enrollment and then progressed to Phase 2 at its next assessment, the organization would earn $2,000 at enrollment ($200 x Phase 1 status x 10 clinicians) and $2,000 at its next assessment ($200 x 1 phase change from Phase 1 to Phase 2 x 10 clinicians). Enrolled practices are eligible to earn up to $1000 per eligible enrolled clinician throughout the life of the project. “Eligible clinicians” for purposes of the incentive payments are:

  • Physician
  • Nurse Practitioner
  • Physician Assistant
  • Clinical Psychologist
  • Licensed Clinical Social Worker

The Care Transitions Network is made possible by a grant made to the National Council for Behavioral Health by the Centers for Medicare and Medicaid Services, in a partnership between the National Council, Montefiore Medical Center, Northwell Health (formerly North Shore-LIJ Health System), the New York State Office of Mental Health and Netsmart Technologies. Contact us by emailing or calling 202-849-4920. The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.