The “Medicare Transitional Care Act” (H.R. 2773), sponsored by Representatives Earl Blumenauer (D-OR) and Charles Boustany (R-LA), has been introduced as in the House of Representatives to provide senior citizens with a new Medicare benefit. This important legislation is designed to eliminate the thousands of preventable hospital readmissions that occur each year by providing high quality transitional care to high-risk Medicare beneficiaries throughout episodes of acute illness. 

Health overhaul bills under development by the Senate Finance and Senate Health, Education, Labor, and Pensions committees also include legislation requiring Medicare pay claims for "transition" services. Bipartisan legislation introduced by Sens. Susan Collins, R-Maine, and Jeanne Shaheen, D-N.H., point to the the Transitional Care Model, a research-based innovation designed and tested by a multidisciplinary team at the University of Pennsylvania School of Nursing, led by Dr. Mary Naylor. The model involves care by advanced practice nurses throughout the elder's acute episode of illness.

Applying transitional care services to Medicare patients with two or more risk factors saved almost $5,000 per patient over the course of the year, Dr. Naylor explained at an April 17 Senate Finance Committee roundtable.

Under the Collins-Shaheen legislation, the benefit would pay a “transitional care clinician” — generally an advanced practice nurse — for such services as: developing a transitional care plan that identifies potential health risks, treatment goals, current therapies, and future services; reviewing medications to avoid adverse drug reactions, and teaching the patient and caregiver how to organize, manage and take medications; monitoring follow-up physician visits by the patient; assuring appropriate referrals to specialists, tests and other services and help with navigation of the health care system; and assisting the patient and caregiver with coordinating support services such as medical equipment, meals, shopping, and transportation.

For more information on Dr. Naylor's model of transitional care, visit Penn Nursing's Transitional Care site.