Official NTOCC Comments

Review the official comments, letters and responses from the National Transitions of Care Coalition (NTOCC).

   Visit the Policy Maker information page

National Transitions of Care Coalition Discusses the Importance of Improving Transitions of Care on Capitol Hill

Posted on 10/21/2009 by NTOCC ® in Press Releases

Washington, DC — The National Transitions of Care Coalition (NTOCC) held their second Advisory Task Force Meeting of 2009 in Washington DC on October 20th and 21st. In addition to the Advisory Task Force Business Meeting, appointments had been made for Advisory Task Force members to meet with Senators and Representatives or staffers from their local congressional districts who are at the forefront of healthcare reform in the nation’s Capitol. The purpose of the meetings were to affirm areas of proposed language in House Bills and Senate Bills which line up with the considerations which NTOCC believes are important for better transitions of care.

This includes:

  • Improve communication during transitions between providers, patients, and caregivers;
  • Implement electronic medical records that include standardized medication reconciliation elements;
  • Establish points of accountability for sending and receiving care, particularly for hospitalists, SNFists (physicians practicing in skilled nursing facilities), primary care physicians, and specialists;
  • Increase the use of case management and professional care coordination;
  • Expand the role of the pharmacist in transitions of care;
  • Implement payment systems that align incentives; and
  • Develop performance measures to encourage better transitions of care.

Advisory Task Force members shared specifics which delineate a good transition of care. Personal anecdotes were shared to illustrate the results of transitions that are less than optimal, such as: medication errors, hospital readmissions, miscommunication, unfortunate patient outcomes and patient dissatisfaction. NTOCC has identified communication as the main driver for improving transitions of care which involve six identifiable persons and elements. NTOCC believes a critical component of communication of information is the dialogue between the healthcare provider and the one constant in a transition, the patient and/or their family caregiver. For more information on these components go to

Objectives of the meeting included the review of newly developed patient and family caregiver health care tools, which included Cultural Competence: Essential Ingredient for Successful Transitions of Care and Guidelines for a Hospital Stay for Patient, Family and Caregiver. Also a review of updates to the National Transitions of Cares Implementation and Evaluation Plan were two case scenarios: Improving on Transitions of Care: Emergency Department to Home and Improving Transitions of Care: Hospital to Home.

NTOCC, a coalition of 32 organizations with the common goal of improving the quality of transitions of care encouraged lawmakers to retain transitions of care language through the remaining negotiations leading up to the final version of the healthcare reform bill. Performance measures and payment incentive alignments which insure improved outcomes were stressed. Advisory Task Force members also offered to assist congressional offices with professional healthcare information, experience and data from across the continuum before, and as regulations develop following the adoption of legislation.

NTOCC Advisory Task Force members visited 24 congressional delegates and their staff.

* Transitions of care include situations in which a patient moves from primary care to specialty physicians or moves within the hospital, including moves from the emergency department to other various departments, such as surgery or intensive care; or when a patient is discharged from the hospital and goes home or to an assisted living or skilled nursing facility. Patients, especially older persons, face significant challenges when moving from one level of care or practice setting to another in the healthcare system. During these transitions, lack of communication can result in redundant or conflicting information that often creates serious issues for patients, their caregivers, and their families.


About National Transitions of Care Coalition (NTOCC)
NTOCC was formed in 2006 to address a serious U.S. health care issue: filling the gaps that occur when patients leave one care setting and move to another care setting. These transitions include patients moving from primary care to specialty physicians; moving or transferring patients from the emergency department to intensive care or surgery; or when patients are discharged from the hospital to home, assisted living arrangements, or skilled nursing facilities. The U.S. healthcare system often fails to meet the needs of elderly patient populations during these transitions because care is rushed and responsibility is fragmented with little communication across care settings and multiple providers. These failures lead to undue burdens on patients and their families and negatively impact patient safety, quality of care and outcomes. The focus of NTOCC is to bring together thought leaders and health care experts from various settings to address this critical issue, define solutions and develop tools to address the gaps impacting patient care. Tools and resources developed by NTOCC will be made available to everyone in the health care industry including providers, payers, patients and consumers. NTOCC is chaired and coordinated by the Case Management Society of America in partnership with sanofi-aventis U.S. For more information, visit

The NTOCC Advisory Board has guided the work of the coalition since 2006 and includes the Academy of Managed Care Pharmacy (AMCP), American Association of Homes and Services for the Aging (AAHSA), American College of Healthcare Executives (ACHE), American Geriatrics Society (AGS), American Medical Directors Association (AMDA), American Medical Group Association (AMGA), American Society for Healthcare Risk Management (ASHRM), American Society of Health- System Pharmacists (ASHP), American Society on Aging (ASA), American Society of Consultant Pharmacists (ASCP), AXA Assistance USA Inc., Case Management Society of America (CMSA), Consumers Advancing Patient Safety (CAPS), Health Services Advisory Group (HSAG), Institute for Healthcare Improvement (IHI), Joint Commission International Center for Patient Safety (ICPS) ,Lipitz Center for Integrated Health Care, Mid-America Coalition on Health Care (MACHC), National Association of Directors of Nursing Administration - Long Term Care (NADONA / LTC), National Association of Social Workers (NASW), National Business Coalition on Health (NBCH), National Case Management Network of Canada (NCMN), National Family Caregivers Association (NFCA), National Quality Forum (NQF), Predictive Health, LLC, sanofi-aventis, U.S., Society of Hospital Medicine (SHM), The Joint Commission Disease - Specific Care Certification, United Health Group (UHG) and URAC.

About Case Management Society of America (CMSA)
Established in 1990, the Case Management Society of America is an international non-profit 501(c)(6) multi-disciplinary professional association dedicated to the support and advancement of the case management profession through educational forums, networking opportunities, legislative advocacy, and establishing standards to advance the profession. It is based in Little Rock, AR, and serves more than 20,000 members/subscribers and 70 affiliate and pending chapters. Since its inception, CMSA has been at the forefront of setting professional standards for the industry, which allows for the highest level of efficiency and integrity, as well as developing national and local leaders who are recognized for their practice and professional excellence. For more information on CMSA, call CMSA at (501) 225-2229 or go to

About sanofi-aventis
Sanofi-aventis U.S. is an affiliate of sanofi-aventis, a leading global pharmaceutical company that discovers, develops and distributes therapeutic solutions to help improve the lives of patients. Sanofi-aventis is listed in Paris (EURONEXT: SAN) and in New York (NYSE: SNY). For more information, visit: or