Medicare's Transitional Care Payment — A Step toward the Medical Home

Abstract

The Commonwealth Fund, among the first private foundations started by a woman philanthropist-Anna M. Harkness-was established in 1918 with the broad charge to enhance the common good.The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the UnitedStates and other industrialized countries. t h e c o m m o n w e a l t h f u n d c o m m i s s i o n o n a h i g h p e r f o r m a n c e h e a l t h s y s t e m Membership

Physician Visits and 30-Day Hospital Readmissions in Patients Receiving Hemodialysis

“…This could be structured like the transitional care payments enacted by CMS in the 2013 physician-payment rule for primary care providers caring for patients following hospital discharge. 17 Second, 30-day readmissions could be part of a pay-for-performance initiative directed toward physician groups caring for patients undergoing hemodialysis. Following the Hospital Readmissions Reduction Program payfor-performance model recently enacted by CMS for hospital reimbursement, physician groups with excess standardized readmission rates could be penalized with lower reimbursement.…”

Discharge Coordinator Intervention Prevents Hospitalizations in Patients With COPD: A Randomized Controlled Trial

“…22,24 Transitional care management with hospital discharge planning as one of the key steps is recognized as a core element in a highperforming health care system, with maximal quality at reduced costs. 25 Ultimately, we should transform patients with COPD (and their caregivers) from passive recipients into active participants in transition from hospital to home environment and in disease management. In this context, discharge planning appears a promising element in the health care continuum, seeking to bridge the gap between the hospital and home environments.…”

Penn Center for Community Health Workers: Step-by-Step Approach to Sustain an Evidence-Based Community Health Worker Intervention at an Academic Medical Center

“…In 2010, many health outcomes—access to primary care, preventable hospitalizations, patient-reported quality, and chronic disease control—were becoming linked to financial incentives or penalties for the Penn Medicine health care system. 2–5 Researchers at Penn Medicine suspected that low-income communities fared poorly across each of these outcomes, resulting in lost revenue for Penn Medicine.…”