Our collective efforts contributed to multiple provisions of the ACA focused on improving care transitions, including the CMS (Centers for Medicare and Medicaid Services) Innovation Center allocating $500 million to foster community-based care transition programs. This initiative is explicitly designed to highlight the importance of establishing partnerships between hospitals and community partners to meet the health needs of diverse chronically ill patient populations. These programs help hospitalized patients with complex chronic conditions—often the most vulnerable—transfer in a safe and timely manner from one level of care to another or from one type of care setting to another.

In a systematic review, Naylor and colleagues summarized 21 randomized clinical trials of transitional care interventions targeting chronically ill adults. They identified nine interventions that demonstrated positive effects on measures related to hospital readmissions—a key focus of health reform. Most of the interventions led to reductions in readmissions through at least 30 days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, they recommended several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

In addition to the “carrots” resulting in substantial investments in local health systems, the ACA also incorporates “sticks.” On the one hand, the message is to take advantage of innovation opportunities to redesign the care system; on the other hand, disincentives also were included in the ACA to prevent avoidable rehospitalizations for common health problems such as pneumonia. Together, this combination has stimulated massive changes, including embracing evidence-based transitional care as a central component of health system transformation. Transitional care is now ubiquitous because services that promote more seamless care for vulnerable patients during high-stress transitions are now recognized as central to high-value care.

Transitional care billing codes, 99495 and 99496, are now reimbursable under Medicare only once within the 30 days after hospital discharge.

Results from studies of TCM consistently demonstrate significant improvements in patient safety and health care outcomes, enhancements in quality of life and satisfaction with care, and reductions in overall health care costs.