other risk factors, such as cognitive impairment, de-
pression, or a history of multiple hospitalizations. 
‘‘(2) SECOND PHASE OF IMPLEMENTATION.— 
After submitting to Congress the evaluation under 
subsection (i)(2) and considering any cost-savings 
and quality improvements from the prior implemen-
tation of this section, the Secretary may expand eli-
gibility of qualified individuals to include moderate- 
risk and lower-risk individuals, as determined in ac-
cordance with eligibility criteria specified by the Sec-
retary. In expanding eligibility, the Secretary may 
modify or scale transitional care services to meet the 
specific needs of moderate- and lower-risk individ-
uals. 
‘‘(3) AVOIDING DUPLICATION OF SERVICES.— 
The Secretary shall ensure that qualified individuals 
receiving transitional care services are not receiving 
duplicative services under this title. 
‘‘(c) TRANSITIONAL CARE SERVICES DEFINED.—In 
this section, the term ‘transitional care services’ means 
services that support a qualified individual during the 
transitional care period and includes the following: 
‘‘(1) A comprehensive assessment prior to dis-
charge including an assessment of the individual’s 
physical and mental condition, cognitive and func-
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tional capacities, medication regimen and adherence, 
social and environmental needs, and primary care-
giver needs and resources. 
‘‘(2) Development of a comprehensive, evi-
denced-based plan of transitional care for the indi-
vidual developed with the individual and the individ-
ual’s primary caregiver and other health team mem-
bers, identifying potential health risks, treatment 
goals, current therapies, and future services for both 
the individual and any primary caregiver. 
‘‘(3) A visit at the care setting within 24 hours 
after discharge from the hospital or critical access 
hospital. 
‘‘(4) Home visits to implement the plan of care. 
‘‘(5) Implementation of the plan of care, includ-
ing— 
‘‘(A) addressing symptoms; 
‘‘(B) teaching and promoting self-manage-
ment skills for the individual and any primary 
caregiver; 
‘‘(C) teaching and counseling the indi-
vidual and the individual’s primary caregiver 
(as appropriate) to assure adherence to medica-
tions and other therapies and avoid adverse 
events; 
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‘‘(D) promoting individual access to pri-
mary care and community-based services; 
‘‘(E) coordinating services provided by 
other health team members and community 
caregivers; and 
‘‘(F) facilitating transitions to palliative or 
hospice care, where appropriate. 
‘‘(6) Accompanying the individual to follow-up 
physician visits, as appropriate. 
‘‘(7) Providing information and resources about 
conditions and care. 
‘‘(8) Educating and assisting the individual and 
the individual’s primary caregiver to arrange and co-
ordinate clinician visits and health care services. 
‘‘(9) Informing providers of services and sup-
pliers of those items and services that have been or-
dered for and received by the individual from other 
providers. 
‘‘(10) Working with providers of services and 
suppliers to assure appropriate referrals to special-
ists, tests, and other services. 
‘‘(11) Educating and assisting the individual 
and the individual’s primary caregiver with arrang-
ing and coordinating community resources and sup-
port services (such as medical equipment, meals, 
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homemaker services, assistance with daily activities, 
shopping, and transportation). 
‘‘(12) Providing to the qualified individual, pri-
mary caregiver, and appropriate clinicians and quali-
fied transitional care entity providing ongoing care 
at the conclusion of the transitional care period a 
written summary that includes the goals established 
in the plan of care described in paragraph (2), 
progress in achieving such goals, and remaining 
treatment needs. 
‘‘(13) Other services that the Secretary deter-
mines are appropriate. 
The Secretary shall determine and update the services to 
be included in transitional care services as appropriate, 
based on the evidence of their effectiveness in reducing 
hospital readmissions and improving health outcomes. 
‘‘(d) TRANSITIONAL CARE CLINICIANS.— 
‘‘(1) IN GENERAL.—In this section, the term 
‘transitional care clinician’ means, with respect to a 
qualified individual, a nurse or other health profes-
sional who— 
‘‘(A) has received specialized training in 
the clinical care of people with multiple chronic 
conditions (including medication management) 
and communication and coordination with mul-
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tiple providers of services, suppliers, patients, 
and their primary caregivers; 
‘‘(B) is supported by an interdisciplinary 
team in a manner that assures continuity of 
care throughout a transitional care period and 
across care settings (including the residences of 
qualified individuals); 
‘‘(C) is employed by (or has a contract 
with) with a qualified transitional care entity 
for the furnishing of transitional care services; 
and 
‘‘(D) meets such participation criteria as 
the Secretary may specify consistent with this 
subsection. 
‘‘(2) PARTICIPATION CRITERIA.—In establishing 
participation criteria under paragraph (1)(C), the 
Secretary shall assure that transitional care clini-
cians meet relevant experience and training require-
ments and have the ability to meet the individual 
needs of qualified individuals. 
‘‘(3) ENCOURAGEMENT OF HIT.—The Secretary 
may provide for an additional payment to encourage 
transitional care clinicians and qualified transitional 
care entities to use health information technology in 
the provision of transitional care services. 
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‘‘(e) PAYMENT.— 
‘‘(1) IN GENERAL.—The Secretary shall deter-
mine the method of payment for transitional care 
services under this section, including appropriate 
risk adjustment that reflects the differences in re-
sources needed to provide transitional care services 
to individuals with differing characteristics and cir-
cumstances and, when applicable, the performance 
measures under subsection (f). The payment amount 
shall be sufficient to ensure the provision of nec-
essary transitional care services throughout the tran-
sitional care period. The payment shall be structured 
in a manner to explicitly recognize transitional care 
as an episode of services that crosses multiple care 
settings, providers of services, and suppliers. The 
payment with respect to transitional care services 
furnished by a transitional care clinician shall be 
made, notwithstanding any other provision of this 
title, to the qualified transitional care entity which 
employs, or has a contract with, the clinician for the 
furnishing of such services. 
‘‘(2) NO COST-SHARING.—Notwithstanding sec-
tion 1833, there shall be no deductible or cost-shar-
ing applicable to payment under this section for 
transitional care services. 
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‘‘(f) PERFORMANCE MEASURES.— 
‘‘(1) ACCOUNTABILITY.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish a method whereby qualified transi-
tional care entities responsible for furnishing 
transitional care services would be held account-
able for process and outcome performance 
measures specified by the Secretary from those 
that have been endorsed by the National Qual-
ity Forum. 
‘‘(B) DEVELOPMENT AND ENDORSEMENT 
OF
PERFORMANCE
MEASURE
SET.—For pur-
poses of carrying out subparagraph (A), the 
Secretary shall enter into an arrangement— 
‘‘(i) with the National Quality Forum 
for the evaluation, endorsement, and rec-
ommendation of an appropriate set of per-
formance measures for transitional care 
services and for the identification of gaps 
in available measures; and 
‘‘(ii) with the Agency for Healthcare 
Research and Quality to support measure 
development, to fill gaps in available meas-
ures, and to provide for the ongoing main-
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tenance of the set of performance meas-
ures for transitional care services. 
‘‘(2) PAY
FOR
PERFORMANCE.—As soon as 
practicable after reliable process and outcome per-
formance measures have been endorsed and specified 
under subparagraph (A), the Secretary shall provide 
that the payment amounts under subsection (e) for 
transitional care services shall be linked to perform-
ance on such measures. 
‘‘(3) PUBLIC REPORTING.—The Secretary shall 
establish a mechanism to publicly report on a quali-
fying entity’s transitional care performance on such 
measures, including providing benchmarks to iden-
tify high performers and those practices that con-
tribute to lower hospital readmission rates. 
‘‘(4) DISSEMINATION
OF
INFORMATION
ON 
BEST PRACTICES.—The Secretary shall disseminate 
information on best practices used by transitional 
care clinicians and qualifying transitional care enti-
ties in furnishing transitional care services for pur-
poses of application in other settings, such as in con-
ditions of participation under this title, under the 
Quality Improvement Organization (QIO) Program 
under part B of title XI, and public-private quality 
alliances, such as the Hospital Quality Alliance. 
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‘‘(g) NOTIFICATION OF ELIGIBILITY AND COORDINA-
TION WITH HOSPITAL DISCHARGE PLANNING.—In estab-
lishing standards for discharge planning under section 
1861(ee)(1), the Secretary shall require each subsection 
(d) hospital and each critical care hospital— 
‘‘(1) to identify, as soon as practicable after ad-
mission, those patients who are qualified individuals 
under this section; and 
‘‘(2) to provide to such patients and their pri-
mary caregivers a list of qualified transitional care 
entities available to arrange for the provision of 
transitional care services, a list of transitional serv-
ices provided under this section, and a notice that 
the transitional care service benefit is provided to 
qualified individuals with no deductible or cost-shar-
ing. 
Nothing in this section shall be construed as preventing 
such a hospital from entering into an agreement with a 
qualified transitional care entity or a transitional care cli-
nician for the furnishing of transitional care services to 
the hospital’s patients. 
‘‘(h) PREVENTION OF INAPPROPRIATE STEERING.— 
The Secretary shall promulgate such regulations as the 
Secretary deems necessary to address any protections 
needed, beyond those otherwise provided under law and 
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regulations, to prevent inappropriate steering of qualified 
individuals to providers of services, suppliers, qualified 
transitional care entities, or transitional care clinicians, 
under this section or inappropriate limitations on access 
to needed transitional care services under this section. 
‘‘(i) EVALUATION OF BENEFIT.— 
‘‘(1) IN GENERAL.—The Secretary shall evalu-
ate the performance of the transitional care benefit 
under this section by measuring the following (for 
those receiving transitional care services and those 
not receiving such services): 
‘‘(A) Admission rates to health care facili-
ties. 
‘‘(B) Hospital readmission rates. 
‘‘(C) Cost of transitional care and all other 
health care services. 
‘‘(D) Quality of transitional care experi-
ences. 
‘‘(E) Measures of quality and efficiency. 
‘‘(F) Beneficiary, primary caregiver, and 
provider experience. 
‘‘(G) Health outcomes. 
‘‘(H) Reductions in expenditures under 
this title over time. 
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‘‘(2) REPORT.—The Secretary shall submit a 
report to Congress no later than April 1, 2013, on 
the performance measures achieved by the transi-
tional care benefit in the first 2 years of implemen-
tation. After submitting such report, the Secretary 
may expand the benefit to moderate-risk and lower- 
risk individuals in accordance with subsection 
(b)(2).’’. 
Æ 
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