May 172011

The national commitment to improving care transitions is a remarkable opportunity for geriatrics and palliative care to make a mark (and even to get paid for doing it right!).  HHS has set a goal of reducing readmissions nationwide by 20% within three years .  The Affordable Care Act (Section 3026) put in place a $500million initiative for Community-Based Care Transitions, providing funding for community-based organizations to take the lead in assuring smooth transitions among settings in health care.  The Partnership for Patients adds substantial funding and organization to that initiative, and the upcoming QIO contracts provide some help to communities trying to get work underway .  Hospitals are up against serious penalties for high rehospitalization rates in three years, under Section 3025 of the ACA.

What is especially important for geriatrics and palliative care is that most of what one needs to do to move patients safely from one setting to another is also at the core of our competencies – having a good care plan, making sure the medications are right, motivating patients and families to take an active role in treatment, coordinating social and medical services, providing supportive care, enabling patients to live at home through death, standardizing procedures across multiple providers, and getting information to the right place at the right time.  So – we can work toward care plans that reflect the medical and social situation and continue across time and settings, without having to take on the distortions of those who focus only on living wills.  We can work on community-based supportive services without apology to those who focus upon aggressive interventions.  There is even a strong role for supporting family caregivers.

Hospitals and health plans are taking the incentives and penalties seriously, creating an opening for good comprehensive care for our sickest and most disabled patients.  Often, we know the community-based organizations that could take the lead in seeking funding for the Community-Based Care Transitions program.  We can also take a strong hand in shaping these initiatives.  Right now, the quality measures for the Accountable Care Organizations are up for comment. The measures proposed start on about p.19569 at .  You will note that there is no specific measure of the quality of the care plan or its continuity across settings (and you might comment to ask that this be developed and added asap!). You might also note that measure #9 is quite misleading and should not be used (having a physician visit before readmission or within 30 days of hospital discharge).  Another clear target is the oppressive antitrust rule, which mostly bars progression to ACO for most geographically-based organization of services.  This is much more complicated, but probably deserves at least a push-back on behalf of our patients (for whom the distribution of the “market” for surgeries and other interventional treatments is not determinative of good policy.  The instructions on how to submit a comment is on the first page of the proposed regulations .

So – what should you do – First, spread the word that Care Transitions is quite an opportunity for real growth in the quality and reliability of care that we can provide.  Second, check on whether your community might propose a Community Based Care Transitions program.  You can find lots of information at and Third, write comments on the ACO regulations and watch for other opportunities.  Fourth, sign up for Twitter, and follow @medicaring – we’ll aim to keep you informed painlessly.  Fifth, get to know your federal and state representatives – have them come visit your place, or meet with them when they have office hours in the home district.  They will listen to you so much better if they have met you before and heard what you are trying to do.  Finally, help the American Geriatrics Society and others mount ever-stronger voices to shape the care of the elderly and those facing long-term serious illnesses – and back their engagement with letters, calls, and comments.

Keywords: geriatrics, palliative care, care transitions

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