,i #aacth ,,congress #b;d ,session ,h4 ,r4 #dgfb ,,in ,,the ,,house ,,of ,,representatives ,may #bi1 #bjad ,mr4 ,blumenauer 7for himself and ,mr4 ,petri7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to cover transitional care services to improve the quality and cost effectiveness of care under the ,medicare ,program4 #a4 ,short title ,this ,act may be cited as the ,medicare ,transitional ,care ,act of #bjad4 #b4 ,findings ,congress finds the following3 7#a7 ,there are a number of care models that are designed to enhance coordination during transitions from care settings4 7#b7 ,these care models and others have demonstrated that effective care transitions lead to improvements in overall health care quality and result in savings to patients and the ,united ,states health care system4 #c4 ,medicare coverage of transitional care services 7a7 ,coverage ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended-- 7#a7 in subsection 7s77#b7-- 7,a7 by striking and at the end of subparagraph 7,,ee72 7,b7 by adding and at the end of subparagraph 7,,ff72 and 7,c7 by inserting after subparagraph 7,,ff7 the following new subparagraph3 7,,gg7 transitional care services 7as defined in subsection 7iii77#a772 2 and 7#b7 by adding at the end the following new subsection3 7iii7 ,transitional care services 7#a7 ,the term transitional care services means services described in paragraph 7#b7 furnished to a qualified individual 7described in paragraph 7#c77 by a transitional care clinician 7as defined in paragraph 7#d77 acting as an employee of 7or pursuant to a contract with7 a qualified transitional care entity 7as defined in paragraph 7#e77 during the transitional care period 7as defined in paragraph 7#f77 for the qualified individual4 7#b7 ,the services described in this paragraph are services that support a qualified individual during the transitional care period and include the following3 7,a7 ,a comprehensive assessment of the individual prior to the individual's transition from one care facility to another care facility or home1 including an assessment of the individual's physical and mental condition1 cognitive and functional capacities1 medication regimen and adherence1 social and environmental needs1 and primary caregiver needs and resources4 7,b7 ,development of a comprehensive1 evidenced-based plan of care for the individual developed with the individual and the individual's primary caregiver and other health team members1 identifying potential health risks1 treatment goals1 current therapies1 and future services for both the individual and any primary caregiver4 7,c7 ,development of a comprehensive medications management plan that ensures the safe use of medications and is based on the individual's plan of care4 ,such management plan shall include the following3 7i7 ,identification of individual's medications in use 7including prescription and non-prescription medications74 7ii7 ,assessment and 7if needed7 consultation with key medical providers to ensure medications are necessary1 appropriate1 and free of discrepancies4 7iii7 ,assessment of the individual and family caregiver's health literacy regarding the ability to properly follow medication instructions4 7iv7 ,individual and family education and counseling about medications4 7v7 ,teaching and counseling the individual and the individual's primary caregiver 7as appropriate7 to assure adherence to medications and other therapies and avoid adverse events4 7,d7 ,implementation of a plan to facilitate the safe transition of the individual from one level of care1 care setting1 or provider to another1 which transition plan shall include at least the following3 7i7 ,a process to address the individual's symptoms4 7ii7 ,an established process for the individual and family caregivers to receive timely access to key health care providers during an episode of care as required by the individual's condition4 7iii7 ,an established process for communicating with the individual1 family caregivers1 and other health care providers posttransition from an episode of care4 7iv7 ,a system that ensures ownership1 responsibility1 and accountability for the care of the individual at all times1 including identifying and documenting any family caregiver 7or caregivers7 that exist4 7v7 ,providing information and resources about condition and care choices to adequately prepare the individual and caregivers for informed decisionmaking4 7,e7 ,providing to the qualified individual1 primary caregiver1 and appropriate clinicians and the qualified transitional care entity providing ongoing care at the conclusion of the transitional care period1 a written summary that includes the goals established in the plan of care described in subparagraph 7,b71 progress in achieving such goals1 and remaining treatment needs4 7,f7 ,other services that the ,secretary determines are appropriate4 ,the ,secretary shall determine and update from time to time the services to be included in transitional care services as appropriate1 based on the evidence of their effectiveness in reducing hospital readmissions and improving health outcomes4 7#c7 7,a7 ,in this subsection1 subject to subparagraph 7,c71 the term qualified individual means an individual who-- 7i7 has been admitted to a subsection 7d7 hospital 7as defined for purposes of section #ahhf7 for inpatient hospital services or to a critical care hospital for inpatient critical access hospital services2 and 7ii7 is identified by the ,secretary as being at highest risk for readmission or for a poor transition from such a hospital to a posthospital site of care4 7,b7 ,the identification under subparagraph 7,a77ii7 shall be based on achieving a minimum hierarchical condition category score 7specified by the ,secretary7 in order to target eligibility benefits under this subsection to individuals with multiple chronic conditions and other risk factors1 such as cognitive impairment1 depression1 or a history of multiple hospitalizations4 7,c7 ,after submitting to ,congress the evaluation under section #b7;d7 of the ,medicare ,transitional ,care ,act of #bjad and considering any cost savings and quality improvements from the prior implementation of transitional care services under this title1 the ,secretary may expand eligibility of qualified individuals to include moderate-risk and lower-risk individuals1 as determined in accordance with eligibility criteria specified by the ,secretary4 ,in expanding eligibility1 the ,secretary may modify or scale transitional care services to meet the specific needs of moderate-risk and lower-risk individuals4 7,d7 ,the ,secretary shall ensure that qualified individuals receiving transitional care services are not receiving duplicative services under this title4 7#d7 7,a7 ,the term transitional care clinician means1 with respect to a qualified individual1 a nurse1 case manager1 social worker1 physician assistant1 physician1 pharmacist1 or other licensed health professional who-- 7i7 has received specialized training in the clinical care of people with multiple chronic conditions 7including medication management7 and communication and coordination with multiple providers of services1 suppliers1 patients1 and their primary caregivers2 7ii7 is supported by an interdisciplinary team in a manner that assures continuity of care throughout a transitional care period and across care settings 7including the residences of qualified individuals72 7iii7 is employed by 7or has a contract with7 a qualified transitional care entity for the furnishing of transitional care services2 and 7iv7 meets such participation criteria as the ,secretary may specify consistent with this subsection4 7,b7 ,in establishing participation criteria under subparagraph 7,a77iv71 the ,secretary shall assure that transitional care clinicians meet relevant scope of practice and training requirements and have the ability to meet the individual needs of qualified individuals4 7#e7 ,the term qualified transitional care entity means-- 7,a7 a hospital or a critical care hospital2 7,b7 a home health agency2 7,c7 a primary care practice2 7,d7 a federally qualified health center or rural health clinic2 7,e7 a long-term care facility2 7,f7 a medical home2 7,g7 an appropriate community-based organization described in section #cjbf7;b77#a77;,b7 of the ,patient ,protection and ,affordable ,care ,act 7#db ,u4,s4,c4 #acie;b-#a note72 7,h7 an assisted living center2 7,i7 an accountable care organization2 and 7,j7 another entity approved by the ,secretary for purposes of this subsection4 7#f7 ,the term transitional care period means1 with respect to a qualified individual1 the period-- 7,a7 beginning on the date the individual is admitted to a subsection 7d7 hospital 7as defined for purposes of section #ahhf7 for inpatient hospital services or is admitted to a critical care hospital for inpatient critical access hospital services1 for which payment may be made under this title2 and 7,b7 ending on the last day of the #de-;day period beginning on the date of the individual's discharge from such hospital or critical care hospital4 4 7b7 ,payment and performance measures ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended-- 7#a7 in subsection 7a77#a71 by striking and before 7,z7 and by inserting before the semicolon at the end the following3 1 and 7,,aa7 with respect to transitional care services 7as defined in section #ahfa7;iii77#a771 the amounts paid shall be #ajj percent of the amount determined under subsection 7z72 7#b7 in the first sentence of subsection 7b71 by inserting or transitional care services 7as defined in section #ahfa7;iii77#a77 after 7as defined in section #ahfa7;hh77#a772 and 7#c7 by adding at the end the following new subsection3 7z7 ,payment and performance measures for transitional care services 7#a7 ,payment 7,a7 ,in general ,the ,secretary shall determine the method of payment for transitional care services under this part1 including appropriate risk adjustment that reflects the differences in resources needed to provide transitional care services to individuals with differing characteristics and circumstances and1 when applicable1 the performance measures under paragraph 7#c74 ,the payment amount shall be sufficient to ensure the provision of necessary transitional care services throughout the transitional care period4 ,the payment shall be structured in a manner to explicitly recognize transitional care as an episode of services that crosses multiple care settings1 providers of services1 and suppliers4 ,the payment with respect to transitional care services furnished by a transitional care clinician shall be made1 notwithstanding any other provision of this title1 to the qualified transitional care entity which employs1 or has a contract with1 the clinician for the furnishing of such services4 7,b7 ,,hit incentive payment ,the ,secretary may provide for an additional payment with respect to transitional care services to encourage transitional care clinicians and qualified transitional care entities to use health information technology in the provision of such services4 7,c7 ,no payment for required discharge planning services ,payment shall not be made for transitional care services under this subsection for an entity insofar as such services are otherwise required to be provided through the discharge planning process under section #ahfa7;ee7 or under conditions of participation for the entity under section #ahff4 7#b7 ,performance measures 7,a7 ,accountability 7i7 ,in general ,the ,secretary shall establish a method whereby qualified transitional care entities responsible for furnishing transitional care services are held accountable for process and outcome based on performance measures specified by the ,secretary from those that have been endorsed by the ,national ,quality ,forum or similar standard-setting organization or are otherwise used in other quality programs under this title or title ,,xix4 7ii7 ,development and endorsement of performance measure set ,for purposes of carrying out clause 7i71 the ,secretary shall enter into an arrangement-- 7,i7 with the ,national ,quality ,forum for the evaluation1 endorsement1 and recommendation of additional performance measures for transitional care services and to identify remaining gaps in available measures1 including measures to both the sending and receiving side of the transition2 and 7,,ii7 with the ,agency for ,healthcare ,research and ,quality to support measure development1 to fill gaps in available measures1 to conduct comparative effectiveness research of transitional care models and tools1 and to provide for the ongoing maintenance of the set of performance measures for transitional care services4 7,b7 ,pay for performance ,as soon as practicable after reliable process and outcome performance measures have been endorsed and specified under subparagraph 7,a71 the ,secretary shall provide that the payment amounts under paragraph 7#a7 for transitional care services shall be linked to performance on such measures4 7,c7 ,public reporting ,the ,secretary shall establish a mechanism to publicly report on a qualifying transitional care entity's performance on such measures1 including providing benchmarks to identify high performers and those practices that contribute to lower hospital readmission rates4 7,d7 ,dissemination of information on best practices ,the ,secretary shall disseminate information on best practices used by transitional care clinicians and qualified transitional care entities in furnishing transitional care services for purposes of application in other settings1 such as in conditions of participation under this title1 under the ,quality ,improvement ,organization ,program under part ,b of title ,,xi1 and public-private quality alliances1 such as the ,hospital ,quality ,alliance4 7#c7 ,prevention of inappropriate steering ,the ,secretary shall promulgate such regulations as the ,secretary deems necessary to address any protections needed1 beyond those otherwise provided under law and regulations1 to prevent inappropriate steering of qualified individuals to providers of services1 suppliers1 qualified transitional care entities1 or transitional care clinicians1 under this part or inappropriate limitations on access to needed transitional care services under this part4 4 7c7 ,coordination with hospital discharge planning ,section #ahfa7;ee77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ee77#b77 is amended by adding at the end the following3 7,i7 ,in the case of subsection 7d7 hospitals and critical care hospitals1 the hospital must-- 7i7 identify1 as soon as practicable after admission1 those patients who are qualified individuals described in paragraph 7#c7 of section #ahfa7;iii72 and 7ii7 provide to such patients and their primary caregivers a list of transitional care entities available under such section to arrange for the provision of transitional care services1 a list of transitional care services provided under this part1 and a notice that the transitional care service benefit under such section is provided to qualified individuals with no deductible or cost sharing4 ,nothing in subparagraph 7,i7 shall be construed as preventing a hospital or critical care hospital from entering into an agreement with a qualified transitional care entity or a transitional care clinician for the furnishing of transitional care services to the hospital's patients4 4 7d7 ,evaluation2 report 7#a7 ,in general ,the ,secretary of ,health and ,human ,services shall evaluate the performance of the transitional care benefit under the amendments made by this section by measuring the following1 both for individuals receiving transitional care services and for individuals not receiving such services3 7,a7 ,admission rates to health care facilities4 7,b7 ,hospital readmission rates4 7,c7 ,cost of transitional care and all other health care services4 7,d7 ,quality of transitional care experiences4 7,e7 ,measures of quality and efficiency4 7,f7 ,beneficiary experience4 7,g7 ,health outcomes4 7,h7 ,reductions in expenditures under this title over time4 7#b7 ,report ,the ,secretary shall submit a report to ,congress no later than ,april #a1 #bjah1 on the performance measures achieved by the transitional care benefit in the first #b years of implementation4 ,after submitting such report1 the ,secretary may expand the benefit to moderate-risk and lower-risk individuals under section #ahfa7;iii77#c77;,b7 of the ,social ,security ,act1 as added by subsection 7a74 7e7 ,effective date ,the amendments made by this section shall apply to services furnished on or after ,january #a1 #bjae4