Official NTOCC Comments

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Posted on 1/30/2017 by NTOCC ®

New Transitions of Care Pathway for Patients with Idiopathic Pulmonary Fibrosis

                   IMPACT NEWSLETTER                     
                   JANUARY 2017                   

New Transitions of Care Pathway for Patients with Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic disease of unknown cause characterized by progressive formation of scar tissue in the lungs. Despite therapeutic advances, IPF remains incurable and carries a poor prognosis. The complexity of the diagnosis and management of IPF, together with its incurable and progressive nature, necessitate comprehensive support and smooth transitions as patients move from one site of care to another. However, for many patients with IPF and their caregivers, the journey to diagnosis and appropriate management is often riddled with gaps in care coordination and interprofessional collaborative practice.

Although general resources are available to support care teams in promoting safe and effective transitions of care (TOC), tools are needed that address the specific challenges in TOC for patients with complex pulmonary diseases such as IPF. To help address this need, the NTOCC partnered with the Case Management Society of America (CMSA), and PRIME Education, LLC (PRIME®) to develop a new IPF TOC Pathway that aims to break down barriers to smooth care transitions and improve education and awareness of IPF. Development of the IPF TOC Pathway was guided by an interprofessional steering committee with representation from physicians, pharmacists, nurses, case managers, and IPF caregivers.

Designed for system leaders and care team members working in diverse practice settings, the IPF TOC Pathway provides guidance and tools to support transition planning, medication management, and bi-directional transfer of essential patient health information. Essential care transition interventions—including guidance for effective follow-up care and enhancing the TOC process through shared accountability—provide a framework for ensuring holistic care transitions throughout the IPF care continuum. Furthermore, approaches for IPF patient and family/caregiver engagement, as well as important considerations for advance care planning, are addressed. Tools provided within the IPF TOC Pathway are intended to facilitate clear and timely communication of the care plan across care transitions and to ensure continuity of care.  

The IPF TOC Pathway can be downloaded at and is approved for 2 hours of ACCME, ACPE, ANCC, and CCM credits. Essential elements of the IPF Pathway will also be presented in an upcoming live webinar on January 31st, at 2:00pm EST and again on February 16th, at 2:00pm EST, which offers an additional 1 hour of ACCME, ACPE, ANCC, and CCM credits. During the webinar, Executive Director of the NTOCC, Cheri Lattimer, RN, BSN, and IPF expert Lieutenant Christopher Lettieri, MD, FCCP, FAASM, will bring awareness to the gaps and challenges in IPF care and discuss team-based strategies that can improve effective care transitions and patient engagement. To register for the webinar, please visit There is no fee for these activities as they are sponsored by PRIME® through an independent educational grant from Genentech.    

NTOCC Policy & Advocacy Corner

2016 has been an interesting year for NTOCC! While much of the country was preoccupied with a very partisan election, NTOCC was able to make some great, bipartisan progress in Congress and the White House.  

In Congress, NTOCC worked with the Senate Finance Committee Chronic Care Wo
rking Group to introduce legislative provisions for improving care coordination in senior adults and advocated for the inclusion of a study on improving medication synchronization for people with multiple medication schedules in the Working Group’s legislative options.  NTOCC also applauded the passage of the 21st Century Cures Initiative, which included provisions to improve patient access to medical records and encourage better interoperability between healthcare providers.

Furthermore, 2016 has seen CMS extremely active on the regulatory front, and care transitions are playing an increasingly important role as the government shifts from paying for volume to paying for value.  This summer, CMS released details about the new physician pay model, MACRA.  While NTOCC initially expressed some concerns about the rule, we were ultimately pleased to see that care coordination plays a significant role.  NTOCC also commented on CMS’s Advancing Care Coordination rule, advocating for CMS to continue to recognize the importance of care transitions under value-based payment models and emphasizing the importance of medication access to successful transitions of care. It will be interesting to see how President-elect Trump and his new Health and Human Services Secretary continue to implement CMS’s goal of paying for quality.

With a new President in the White House and a new Secretary at HHS, 2017 will be a year to watch in healthcare.  NTOCC encourages individuals to reach out to their elected officials to advocate for improved care transitions in Medicare and Medicaid.



Dear NTOCC Community,

We are almost at the end of January 2017 a New Year and I believe one of many changes for most of us.  NTOCC continues to work in building tools and resources for providers, patients, family caregivers, legislators and regulatory agencies that support improving care coordination and transitions.  Our mission has not changed.

In 2016 NTOCC developed with PRIME Inc. and CMSA, two pathways for improving transitions of care with patients and families dealing with Pulmonary Arterial Hypertension (PAH) and Idiopathic Pulmonary Fibrosis (IPF).  

These pathways are developed through educational grants with various partners supporting the need for better transitions of care.  Each of these pathways helps to improve care coordination and transitions and can be used as a useful patient engagement resource to improve communication and coordination of care.

 In 2017 we hope to develop several additional pathways and to bring those to the NTOCC community.  If you have not reviewed these resources be sure to visit the NTOCC website at and click on the Knowledge and Resource Center.  

(As a note you may find the website down for a couple days in early February as we make some content changes.)

NTOCC also provided a significant amount of comment and interaction with regulatory and legislative entities in 2016 as describe by Venn strategies throughout the many alerts in 2016.  A huge thank you to Venn Strategies for a job well done and the many accomplishments and recognition they have built with various legislators and regulatory agencies over the last several years.  Through their work NTOCC has achieved recognition as a strong networking partner with vital expertise and knowledge in improving coordination and transitions of care for providers, patients and family caregivers.

As we move now into 2017 NTOCC will continue to build new tools and resources for the Community and to keep a careful watch on new legislative and regulatory changes.  We definitely have work cut out for us in educating and building awareness of NTOCC with a new administration and legislators but we also have returning supporters of the work we provide to the healthcare community.  

No matter where you stand within the politics of our process, the one thing that should unite us is our patients and family caregivers for whom we provide the communication and support to bring about a positive change in care coordination and transitions.  Although we want to see and will work towards appropriate financial and legislative support for these changes we also know this needs to happen regardless.  

NTOCC is a Coalition of national healthcare stakeholders who provide this care everyday can continued to unite our voices help to achieve a positive outcome and experience for providers, patients and family caregivers.  

NTOCC will need your support and feedback to accomplish this in 2017 and I look forward to working with each of you in the coming year.



Cheri Signature.jpg                                                                                                                                                                                                                                              Cheri Lattimer

Executive Director


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