Jun 21, 2019

National Care Transitions Awareness Day promotes safe, effective, person-centered care

Dr. Kate Goodrich, M.D.
CMS Center for Clinical Standards & Quality (CCSQ) & CMS Chief Medical Officer

National Care Transitions Awareness Day promotes safe, effective, person-centered care

One of our priorities at CMS is to identify innovative approaches to improving care for our beneficiaries. Too often we’ve heard about the challenges beneficiaries, families, and caregivers face navigating health care, especially when it comes to transitioning between care settings. There is also a growing knowledge gap related to coordination and successful transitions of care that we believe is important to close. Care transitions matter to CMS because it is part of creating a truly safe and effective experience for our beneficiaries.

That’s why, in April, we hosted the first annual National Care Transitions Awareness Day. Our goal was to partner with clinicians, quality improvement experts, patient advocates, and beneficiaries, families, and caregivers to raise awareness about care transitions, address coordination barriers, and develop unique solutions to use across all settings. An equally important focus was empowering beneficiaries to actively participate in their care. When people have access to information through effective coordination and care transitions, they will make the best decisions about their care.

We have taken initial steps through the Patients Over Paperwork initiative to begin reviewing our regulations and programs to ensure that we are removing unnecessary barriers to help enhance care transitions for our beneficiaries. The Meaningful Measures framework has also served as a guide in developing quality measurement and improvement initiatives to address specific priority areas, one of which includes promoting effective communication and coordination of care. We further demonstrated our commitment to a patient-centered healthcare system through our MyHealthEData Initiative. As part of this initiative, we released the Interoperability and Patient Access proposed rule. If finalized, regulated Medicare Advantage plans, Medicaid, CHIP, and health plans sold on the federal exchange would be required to share healthcare claims and other information electronically with their enrollees. This would ensure that an additional 85 million patients have access to their health information in a standardized digital format. In addition, we proposed a new condition of participation that would require hospitals to share event notifications at the moment a patient is admitted, discharged, or transferred. Together these policies would facilitate the exchange of data between healthcare providers and suppliers, including doctors and hospitals, making it easier for providers to have access to health information about their patients when they need it most, regardless of where the patient previously received care.

The National Care Transitions Awareness Day serves as an additional opportunity to work in collaboration with our partners to identify opportunities for improvement, drive change, and reduce burden as it relates to care coordination and care transitions.  

The importance of our work was shared by several Medicare beneficiaries. Richard Knight shared his story of developing Chronic Kidney Disease (CKD), coping with End-Stage Renal Disease (ESRD), and, finally, adapting to changes in his life brought about by a successful kidney transplant. Stories like Mr. Knight’s would not be as successful if it were not for effective care transitions.

During the event, we captured several vital commitments which align closely with our agency-wide strategic initiatives, particularly around unleashing innovation and empowering patients. For example, several of our partners pledged to:

  • Initiate a campaign related to the American Case Management Association care transitions standards, while targeting member associations and 19,000 supporters
  • Increase the use of Medicare’s Chronic Care Management codes and Transitional Care Management codes among clinicians by providing education and a use-business case
  • Empower beneficiaries to use their own data, available to them through patient portals and be active participants in their care

We know that more work remains. Over the next several months, we hope to see an increase in the number of clinicians and organizations that form new community partnerships to increase resources for patients, families, and caregivers. While we are committed to evolving our programs and policies to foster improvements in care transitions including high risk, high needs populations, we encourage our partners – clinicians, quality improvement experts, advocates and others – to continue engaging with us and sharing innovative ideas to enhance the overall experience of care for our beneficiaries. Most importantly, we want our beneficiaries’ voices present to ensure that we are developing creative solutions that are best for them.

For more information, including presentations and shared resources, please visit the CMS NCTA Day Webpage. Here you can learn how to connect with CMS and be in action to improve care transitions in your communities. If you didn’t get a chance to attend NCTA, you can watch the NCTA Day Recap: https://vimeo.com/powellmediaconcepts/download/332305448/7b7cca9568


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