Rep. Earl Blumenauer (D-OR)

Federal lawmakers have introduced a bill designed to improve coordination of care and services for Medicare beneficiaries as they move from one setting to another.

In announcing the Medicare Transitional Care Act, Reps. Earl Blumenauer (D-OR) and Tom Petri (R-WI) noted that the bill is intended to “ensure that appropriate follow-up care is provided” during transitions from hospitals to long-term care, home and other settings, when patients are most vulnerable.

The bill includes a “flexible” benefit to support as improved assessment, planning, medications management, movement between care levels, and coordination of support services such as meals and medical equipment. Observers said long-term care and assisted living support and coordination services, such as development of comprehensive care plans and medication management plan assessments, would likely be prospectively covered for 45 days from hospital discharge.

Petri said the bill would provide greater support for Medicare patients, and in turn, “improve their health and quality of life while saving taxpayers’ money.”

Evidence has long shown that poorly coordinated transitions and hospital readmissions are both excessively costly and risky — for beneficiaries and the Medicare program. One expert told McKnight’s that 30-day hospital readmissions have cost the Medicare program an estimated $15 billion annually.

National Transitions of Care Coalition Executive Director Cheri Lattimer said the bill would provide needed structures and incentives to foster care transition interventions, with collaborative team approaches that have proven successful.

“As providers seek to improve patient outcomes through more coordinated care, Congress must continue to look for effective policies that address gaps in care for our most vulnerable patients, and improving transitions between care settings is critical to that effort,” Lattimer noted in the joint news release.

According to the lawmakers’ joint statement, the bill is supported by the Society for Post-Acute and Long-Term Care Medicine, The National Transitions of Care Coalition, American Society of Aging, Caregiver Action Network, Case Management Society of America, Hudson Health Plan, Rush University Medical Center and Sanofi.