Testimony on Transitional Care Highlights Effectiveness of Nurse-Led Chronic Care Management Teams

On Tuesday, April 21, the Senate Finance Committee held a roundtable hearing, "Reforming America's Health Care Delivery System." A focus of this roundtable included a discussion of a transitional care benefit in the Medicare program.

The goal of this benefit is to support Medicare beneficiaries as they enter the hospital and move from the hospital to home or another setting, such as a skilled nursing facility or a rehabilitation facility. A nurse-led interdisciplinary team assesses the beneficiary (and his or her caregiver) at or close to the time the individual is admitted to the hospital and before hospital discharge. The nurse and other providers, in consultation with the beneficiary and caregiver, develop an individualized plan for appropriate follow-up during and after the transition. This is an evidence-based model that has shown to improve patient outcomes and reduce costs and hospitalizations.

AARP testimony underscored the need for a highly skilled nursing workforce that is prepared to address the needs of those with chronic conditions and long-term care needs and the growing aging population more broadly. Read AARP President Jennie Chin Hansen's thoughts on transitional care in her April 26 New York Times letter-to-the-editor.