II 

111TH CONGRESS 

1ST SESSION S. 1295 

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 program. 

IN THE SENATE OF THE UNITED STATES 

JUNE 18, 2009 

Mrs. SHAHEEN (for herself, Ms. COLLINS, and Mrs. LINCOLN) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

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 program. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Transitional 

5 Care Act of 2009’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 

8 (1) More than 20 percent of older Americans 

9 suffer from five or more chronic conditions and 


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1 these older adults typically require health care serv2 ices from numerous providers across several care 

3 settings each year. 

4 (2) Insufficient communication among older 

5 adults, family caregivers, and health care providers 

6 contributes to poor continuity of care, inadequate 

7 management of complex health care needs, and pre8 ventable hospital admissions. 

9 (3) Research suggests that family caregivers 

10 often lack the knowledge, skills, and resources to ef11 fectively address the complex needs of older adults 

12 coping with multiple coexisting conditions. 

13 (4) In 2005, health care services for Medicare 

14 beneficiaries with five or more chronic conditions ac15 counted for 75 percent of total Medicare spending. 

16 The vast majority of these costs were due to high 

17 rates of hospital admission and readmission. 

18 (5) According to Medicare claims data from 

19 2003–2004, almost one-fifth (19.6 percent) of the 

20 11,855,702 Medicare beneficiaries who had been dis21 charged from a hospital were rehospitalized within 

22 30 days, and 34.0 percent were rehospitalized within 

23 90 days. 


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1 (6) A New England Journal of Medicine study 

2 estimates that the cost to Medicare of unplanned re3 hospitalizations in 2004 was $17.4 billion. 

4 (7) The MetLife Caregiving Cost Study dem5 onstrates that American businesses lose an esti6 mated $34 billion each year due to employees’ need 

7 to care for loved ones. 

8 (8) The Transitional Care Model, developed by 

9 the University of Pennsylvania, is a care manage10 ment strategy that identifies patients’ health goals, 

11 coordinates care throughout acute episodes of illness, 

12 develops a streamlined plan of care to prevent future 

13 hospitalizations, and prepares the beneficiary and 

14 family caregivers to implement this care plan. 

15 (9) The major goal of the Transitional Care 

16 Model is to interrupt cycles of avoidable hospitaliza17 tions and promote longer-term positive health out18 comes. 

19 (10) The Transitional Care Model has shown 

20 through multiple randomized clinical trials to 

21 produce significant health outcome improvements, 

22 reductions in health care costs among at-risk and 

23 chronically ill older adults, and increased patient 

24 satisfaction. 


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1 (11) Preliminary results from a clinical trial of 

2 the Guided Care Model (based on a Medical Home 

3 which includes transitional care) demonstrated re4 ductions in hospital days, skilled nursing facility 

5 days, and home health episodes, as well as prelimi6 nary findings of net savings. 

7 (12) A clinical trial of the Care Transitions 

8 Intervention demonstrated lower rehospitalization 

9 rates and lower hospital costs per patient. 

10 SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE. 

11 Title XVIII of the Social Security Act is amended by 

12 adding at the end the following new section: 

13 ‘‘COVERAGE OF TRANSITIONAL CARE SERVICES FOR

14 QUALIFIED INDIVIDUALS

15 ‘‘SEC. 1899. (a) COVERAGE UNDER PART B.— 

16 ‘‘(1) IN GENERAL.—In the case of a qualified 

17 individual (as defined in subsection (b)), the Sec18 retary shall provide under part B for benefits for 

19 transitional care services (as defined in subsection 

20 (c)) furnished by a transitional care clinician (as de21 fined in subsection (d)) acting as an employee of (or 

22 pursuant to a contract with) a qualified transitional 

23 care entity (as defined in paragraph (3)(A)) in ac24 cordance with this section during the transitional 

25 care period (as defined in paragraph (3)(B)) for the 

26 qualified individual. 


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1 ‘‘(2) INITIAL IMPLEMENTATION.—The Sec2 retary shall first implement this section for services 

3 furnished on or after January 1, 2010. 

4 ‘‘(3) GENERAL DEFINITIONS.—In this section: 

5 ‘‘(A) QUALIFIED TRANSITIONAL CARE EN6 TITY.—The term ‘qualified transitional care en7 tity’ means— 

8 ‘‘(i) a hospital or a critical care hos9 pital; 

10 ‘‘(ii) a home health agency; 

11 ‘‘(iii) a primary care practice; 

12 ‘‘(iv) a Federally qualified health cen13 ter; or 

14 ‘‘(v) another entity approved by the 

15 Secretary for purposes of this section. 

16 ‘‘(B) TRANSITIONAL CARE PERIOD.—The 

17 term ‘transitional care period’ means, with re18 spect to a qualified individual, the period— 

19 ‘‘(i) beginning on the date the indi20 vidual is admitted to a subsection (d) hos21 pital (as defined for purposes of section 

22 1886) for inpatient hospital services, or is 

23 admitted to a critical care hospital for in24 patient critical access hospital services, for 


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1 which payment may be made under this 

2 title; and 

3 ‘‘(ii) ending on the last day of the 90- 

4 day period beginning on the date of the in5 dividual’s discharge from such hospital or 

6 critical care hospital. 

7 ‘‘(b) QUALIFIED INDIVIDUALS.— 

8 ‘‘(1) LIMITING FIRST PHASE OF IMPLEMENTA9 TION TO HIGH-RISK INDIVIDUALS.—Except as pro10 vided in this subsection, qualified individuals are 

11 limited to individuals who— 

12 ‘‘(A) have been admitted to a subsection 

13 (d) hospital (as defined for purposes of section 

14 1886) for inpatient hospital services or to a 

15 critical care hospital for inpatient critical access 

16 hospital services; and 

17 ‘‘(B) are identified by the Secretary as 

18 being at highest risk for readmission or for a 

19 poor transition from such a hospital to a post20 hospital site of care. 

21 The identification under subparagraph (B) shall be 

22 based on achieving a minimum hierarchical condition 

23 category score (specified by the Secretary) in order 

24 to target eligibility for benefits under this section to 

25 individuals with multiple chronic conditions and 


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1 other risk factors, such as cognitive impairment, de2 pression, or a history of multiple hospitalizations. 

3 ‘‘(2) SECOND PHASE OF IMPLEMENTATION.— 

4 After submitting to Congress the evaluation under 

5 subsection (i)(2) and considering any cost-savings 

6 and quality improvements from the prior implemen7 tation of this section, the Secretary may expand eli8 gibility of qualified individuals to include moderate9 risk and lower-risk individuals, as determined in ac10 cordance with eligibility criteria specified by the Sec11 retary. In expanding eligibility, the Secretary may 

12 modify or scale transitional care services to meet the 

13 specific needs of moderate- and lower-risk individ14 uals. 

15 ‘‘(3) AVOIDING DUPLICATION OF SERVICES.— 

16 The Secretary shall ensure that qualified individuals 

17 receiving transitional care services are not receiving 

18 duplicative services under this title. 

19 ‘‘(c) TRANSITIONAL CARE SERVICES DEFINED.—In 

20 this section, the term ‘transitional care services’ means 

21 services that support a qualified individual during the 

22 transitional care period and includes the following: 

23 ‘‘(1) A comprehensive assessment prior to dis24 charge including an assessment of the individual’s 

25 physical and mental condition, cognitive and funcVerDate Nov 24 2008 23:38 Jun 18, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1295.IS S1295

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1 tional capacities, medication regimen and adherence, 

2 social and environmental needs, and primary care3 giver needs and resources. 

4 ‘‘(2) Development of a comprehensive, evi5 denced-based plan of transitional care for the indi6 vidual developed with the individual and the individ7 ual’s primary caregiver and other health team mem8 bers, identifying potential health risks, treatment 

9 goals, current therapies, and future services for both 

10 the individual and any primary caregiver. 

11 ‘‘(3) A visit at the care setting within 24 hours 

12 after discharge from the hospital or critical access 

13 hospital. 

14 ‘‘(4) Home visits to implement the plan of care. 

15 ‘‘(5) Implementation of the plan of care, includ16 ing— 

17 ‘‘(A) addressing symptoms; 

18 ‘‘(B) teaching and promoting self-manage19 ment skills for the individual and any primary 

20 caregiver; 

21 ‘‘(C) teaching and counseling the indi22 vidual and the individual’s primary caregiver 

23 (as appropriate) to assure adherence to medica24 tions and other therapies and avoid adverse 

25 events; 


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1 ‘‘(D) promoting individual access to pri2 mary care and community-based services; 

3 ‘‘(E) coordinating services provided by 

4 other health team members and community 

5 caregivers; and 

6 ‘‘(F) facilitating transitions to palliative or 

7 hospice care, where appropriate. 

8 ‘‘(6) Accompanying the individual to follow-up 

9 physician visits, as appropriate. 

10 ‘‘(7) Providing information and resources about 

11 conditions and care. 

12 ‘‘(8) Educating and assisting the individual and 

13 the individual’s primary caregiver to arrange and co14 ordinate clinician visits and health care services. 

15 ‘‘(9) Informing providers of services and sup16 pliers of those items and services that have been or17 dered for and received by the individual from other 

18 providers. 

19 ‘‘(10) Working with providers of services and 

20 suppliers to assure appropriate referrals to special21 ists, tests, and other services. 

22 ‘‘(11) Educating and assisting the individual 

23 and the individual’s primary caregiver with arrang24 ing and coordinating community resources and sup25 port services (such as medical equipment, meals, 


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1 homemaker services, assistance with daily activities, 

2 shopping, and transportation). 

3 ‘‘(12) Providing to the qualified individual, pri4 mary caregiver, and appropriate clinicians and quali5 fied transitional care entity providing ongoing care 

6 at the conclusion of the transitional care period a 

7 written summary that includes the goals established 

8 in the plan of care described in paragraph (2), 

9 progress in achieving such goals, and remaining 

10 treatment needs. 

11 ‘‘(13) Other services that the Secretary deter12 mines are appropriate. 

13 The Secretary shall determine and update the services to 

14 be included in transitional care services as appropriate, 

15 based on the evidence of their effectiveness in reducing 

16 hospital readmissions and improving health outcomes. 

17 ‘‘(d) TRANSITIONAL CARE CLINICIANS.— 

18 ‘‘(1) IN GENERAL.—In this section, the term 

19 ‘transitional care clinician’ means, with respect to a 

20 qualified individual, a nurse or other health profes21 sional who— 

22 ‘‘(A) has received specialized training in 

23 the clinical care of people with multiple chronic 

24 conditions (including medication management) 

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1 tiple providers of services, suppliers, patients, 

2 and their primary caregivers; 

3 ‘‘(B) is supported by an interdisciplinary 

4 team in a manner that assures continuity of 

5 care throughout a transitional care period and 

6 across care settings (including the residences of 

7 qualified individuals); 

8 ‘‘(C) is employed by (or has a contract 

9 with) with a qualified transitional care entity 

10 for the furnishing of transitional care services; 

11 and 

12 ‘‘(D) meets such participation criteria as 

13 the Secretary may specify consistent with this 

14 subsection. 

15 ‘‘(2) PARTICIPATION CRITERIA.—In establishing 

16 participation criteria under paragraph (1)(C), the 

17 Secretary shall assure that transitional care clini18 cians meet relevant experience and training require19 ments and have the ability to meet the individual 

20 needs of qualified individuals. 

21 ‘‘(3) ENCOURAGEMENT OF HIT.—The Secretary 

22 may provide for an additional payment to encourage 

23 transitional care clinicians and qualified transitional 

24 care entities to use health information technology in 

25 the provision of transitional care services. 


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1 ‘‘(e) PAYMENT.— 

2 ‘‘(1) IN GENERAL.—The Secretary shall deter3 mine the method of payment for transitional care 

4 services under this section, including appropriate 

5 risk adjustment that reflects the differences in re6 sources needed to provide transitional care services 

7 to individuals with differing characteristics and cir8 cumstances and, when applicable, the performance 

9 measures under subsection (f). The payment amount 

10 shall be sufficient to ensure the provision of nec11 essary transitional care services throughout the tran12 sitional care period. The payment shall be structured 

13 in a manner to explicitly recognize transitional care 

14 as an episode of services that crosses multiple care 

15 settings, providers of services, and suppliers. The 

16 payment with respect to transitional care services 

17 furnished by a transitional care clinician shall be 

18 made, notwithstanding any other provision of this 

19 title, to the qualified transitional care entity which 

20 employs, or has a contract with, the clinician for the 

21 furnishing of such services. 

22 ‘‘(2) NO COST-SHARING.—Notwithstanding sec23 tion 1833, there shall be no deductible or cost-shar24 ing applicable to payment under this section for 

25 transitional care services. 


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1 ‘‘(f) PERFORMANCE MEASURES.— 

2 ‘‘(1) ACCOUNTABILITY.— 

3 ‘‘(A) IN GENERAL.—The Secretary shall 

4 establish a method whereby qualified transi5 tional care entities responsible for furnishing 

6 transitional care services would be held account7 able for process and outcome performance 

8 measures specified by the Secretary from those 

9 that have been endorsed by the National Qual10 ity Forum. 

11 ‘‘(B) DEVELOPMENT AND ENDORSEMENT

12 OF PERFORMANCE MEASURE SET.—For pur13 poses of carrying out subparagraph (A), the 

14 Secretary shall enter into an arrangement— 

15 ‘‘(i) with the National Quality Forum 

16 for the evaluation, endorsement, and rec17 ommendation of an appropriate set of per18 formance measures for transitional care 

19 services and for the identification of gaps 

20 in available measures; and 

21 ‘‘(ii) with the Agency for Healthcare 

22 Research and Quality to support measure 

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1 tenance of the set of performance meas2 ures for transitional care services. 

3 ‘‘(2) PAY FOR PERFORMANCE.—As soon as 

4 practicable after reliable process and outcome per5 formance measures have been endorsed and specified 

6 under subparagraph (A), the Secretary shall provide 

7 that the payment amounts under subsection (e) for 

8 transitional care services shall be linked to perform9 ance on such measures. 

10 ‘‘(3) PUBLIC REPORTING.—The Secretary shall 

11 establish a mechanism to publicly report on a quali12 fying entity’s transitional care performance on such 

13 measures, including providing benchmarks to iden14 tify high performers and those practices that con15 tribute to lower hospital readmission rates. 

16 ‘‘(4) DISSEMINATION OF INFORMATION ON

17 BEST PRACTICES.—The Secretary shall disseminate 

18 information on best practices used by transitional 

19 care clinicians and qualifying transitional care enti20 ties in furnishing transitional care services for pur21 poses of application in other settings, such as in con22 ditions of participation under this title, under the 

23 Quality Improvement Organization (QIO) Program 

24 under part B of title XI, and public-private quality 

25 alliances, such as the Hospital Quality Alliance. 


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1 ‘‘(g) NOTIFICATION OF ELIGIBILITY AND COORDINA2 TION WITH HOSPITAL DISCHARGE PLANNING.—In estab3 lishing standards for discharge planning under section 

4 1861(ee)(1), the Secretary shall require each subsection 

5 (d) hospital and each critical care hospital— 

6 ‘‘(1) to identify, as soon as practicable after ad7 mission, those patients who are qualified individuals 

8 under this section; and 

9 ‘‘(2) to provide to such patients and their pri10 mary caregivers a list of qualified transitional care 

11 entities available to arrange for the provision of 

12 transitional care services, a list of transitional serv13 ices provided under this section, and a notice that 

14 the transitional care service benefit is provided to 

15 qualified individuals with no deductible or cost-shar16 ing. 

17 Nothing in this section shall be construed as preventing 

18 such a hospital from entering into an agreement with a 

19 qualified transitional care entity or a transitional care cli20 nician for the furnishing of transitional care services to 

21 the hospital’s patients. 

22 ‘‘(h) PREVENTION OF INAPPROPRIATE STEERING.— 

23 The Secretary shall promulgate such regulations as the 

24 Secretary deems necessary to address any protections 

25 needed, beyond those otherwise provided under law and 


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1 regulations, to prevent inappropriate steering of qualified 

2 individuals to providers of services, suppliers, qualified 

3 transitional care entities, or transitional care clinicians, 

4 under this section or inappropriate limitations on access 

5 to needed transitional care services under this section. 

6 ‘‘(i) EVALUATION OF BENEFIT.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall evalu8 ate the performance of the transitional care benefit 

9 under this section by measuring the following (for 

10 those receiving transitional care services and those 

11 not receiving such services): 

12 ‘‘(A) Admission rates to health care facili13 ties. 

14 ‘‘(B) Hospital readmission rates. 

15 ‘‘(C) Cost of transitional care and all other 

16 health care services. 

17 ‘‘(D) Quality of transitional care experi18 ences. 

19 ‘‘(E) Measures of quality and efficiency. 

20 ‘‘(F) Beneficiary, primary caregiver, and 

21 provider experience. 

22 ‘‘(G) Health outcomes. 

23 ‘‘(H) Reductions in expenditures under 

24 this title over time. 


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1 ‘‘(2) REPORT.—The Secretary shall submit a 

2 report to Congress no later than April 1, 2013, on 

3 the performance measures achieved by the transi4 tional care benefit in the first 2 years of implemen5 tation. After submitting such report, the Secretary 

6 may expand the benefit to moderate-risk and lower7 risk individuals in accordance with subsection 

8 (b)(2).’’. 

Æ 


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