Official NTOCC Comments

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

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Posted on 4/16/2018 by NTOCC ®


                   IMPACT NEWSLETTER                     
                   April 2018                   

Celebrating Transitions of Care Excellence WITH NTOCC in WASHINGTON, D.C. 



An Open Invitation to Attend 

Patients face significant challenges when moving from one health care setting to another.  As currently structured, the United States health and long-term care systems fail to meet the needs of most patients and their family caregivers during transitions between settings.  We have seen improvements in various transitions of care interventions, but to successfully overcome the challenges of complex health tasks, on top of mounting administrative and economic hurdles, patients and their family caregivers require active engagement and assistance in managing their continuity of care.  


With the implementation of the Affordable Care Act, there has been a focused effort on developing transitions of care interventions and programs, and implementing financial incentives and disincentives to reduce hospital readmissions and improve the care quality.  Studies indicate we are improving care transition support, but these studies also report continued barriers like poor integration of transitional care services, services delivered in silos, and low patient and family caregiver engagement contributing to unmet patient needs and lack of physician support and accountability.

NTOCC continues to assess how to best support the health care experience for patients, family caregivers and providers that moves us to seamless and safe transitions of care.  On May 24, NTOCC will provide a day of examining existing transitions of care programs and interacting with industry leaders to discuss the issues of the day and assess what is needed  to build excellent and positive transition services with providers, patients, and their family caregivers.

One of the sessions will focus on improving transitions and achieving fewer readmissions for patients with heart failure.  Several of the interprofessional steering committee members for the paper will review the interdisciplinary guide addressing transition interventions for the heart failure population.  Another session will look at a successful program - the Enhanced Discharge Planning Program - now the Bridge Model, designed to aid in patients’ transition from hospital to home. In this program, transitional care is delivered by masters-prepared social workers who provide telephonic follow-up and short-term care coordination for recently discharged adults.

NTOCC has invited several Congressional Leaders to join us for a session focused on healthcare legislation and concerns facing us today.  We are asking for their perspective on next steps in addressing services for patients, caregivers, and providers. Additional sessions addressing issues with mental health services and services needed for coordinating care for our military, veterans, and the general population are also planned.  

The final session of the day will bring our attendees up to date on the healthcare issues and concerns facing congressional and regulatory leaders bringing forward new bills to enhance the delivery of health care services.  Please join us on Thursday, May 24, 2018, at the National Union Building and interact with today’s healthcare leaders working to address Transitions and Care Coordination.

Registration, conference & hotel information and the full agenda can be found by clicking here.

Find the complete NTOCC Care Transitions Bundle here

NTOCC Care Transition Bundle
Seven Essential Intervention Categories
By Dr James Lett, NTOCC President

All of us are committed to improving transitions of care. Often, however, due to fiscal and other issues we are unable to institute a formal program and the associated infrastructure. An alternative approach is to sequentially implement individual steps, or even a selected bundle of initiatives, to strengthen the care-transition process. The question then becomes, what are those critical elements to be addressed. Fortunately, NTOCC completed a project to determine the seven crucial elements that are involved in every quality transition program.

The “Seven Essential Intervention Categories” as designated by NTOCC are:

1. Medication Management

Three main components are involved with safer medication management.

First, assess all medications that the patient uses. Evaluate prescription drugs, as well as over-the counter medications, herbal supplements and vitamins; determine medication allergies, and potential drug interactions. Seek out high-risk medications and identify polypharmacy.

Next, use the “teach-back” method to establish the patient's and the family's understanding of the medication plan. Emphasize any changes in the drug regimen. Review each medication's purpose, how to take each medication correctly, and important (red flag) side effects that should be watched for by patients and families.

Third, perform reconciliation of the current drug regimen with prior ones to establish a “correct medication list.” Create the medication plan considering the patient's financial, cognitive and transportation status. Partner with other clinicians, especially the pharmacist, for assistance.

2. Transition Planning

Transition planning is the formal process that facilitates safe patient transfer from one site of care and one clinician to another. Identify personnel performing the transition, and coordinating medical services at the next site of care Then communicate patient/families’ needs to that entity.

Transmit a complete, legible, and timely care summary to clinicians at the new site. Give the patient and family the same information in an appropriate format.

Use formal transition-planning tools to ensure the safest possible transition. Examples are available at:, the NTOCC website, and the care transitions website, developed by Eric Coleman, MD, MPH.

3. Patient and Family Engagement

Education and counseling of patients and families are intrinsic components of every transfer to enhance their participation in care and promote informed decision making. Patients and families must be knowledgeable about their disease, including warning signs that should prompt them to contact their physicians. Education and understanding the plan of care facilitates a positive partnership with medical caregivers.

A key activity is teaching self-care skills to better control the disease process. For example, a diabetic utilizing insulin or caregiver should be able to monitor blood sugars, properly administer insulin, and recognize signs of low and high blood sugar.

4. Information Transfer

Sharing important care information among patients, families, caregivers, and health care providers in a timely and effective manner is central to a safe, efficient transition. Standard forms maintained by the patient for information sharing, such as personal health information and medication regimen, are a practical part of quality transitions. Personal health forms can be obtained at the websites indicated earlier.

5. Follow-Up Care

Facilitating the safe transition of patients from one level of care to another, or from one provider to another, involves arranging effective clinical follow-up care at the new site of care. Notify the patient and family of primary care, specialty, and other clinician visits that will be necessary, how soon and aid the patient in arranging those appointments. Include information on what testing is required, the reason, how urgently it should be done, and to whom the results should be transmitted.

Contact the patient by phone on the next business day after leaving the care site. This is a chance to answer questions and reinforce the follow-up plan.

6. Health Care Provider Engagement

Demonstrate ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times. Engage the family/patient in a partnership with their medical caregivers. Guide the patient and family with written transfer instructions to reinforce their involvement. Provide appropriate, timely information to the next site of care, attempting to directly contact it, or be available to respond to questions.

7. Shared Accountability

The transition-of-care process is enhanced through shared accountability by both the sending and receiving health care entities. This ensures responsible oversight of patient care throughout the transition process. The receiving site has the obligation to review the timely and adequate data set from the sending site and then to contact the sender for any questions or gaps in the information.

Any care site has the ability to adopt one, several, or all of these interventions to ultimately build a successful care-transitions program.

Dear NTOCC Community,
As the President of NTOCC, I would like to personally invite you to attend the National Transitions of Care Coalition (NTOCC) conference day in Washington, DC on Thursday, May 24, 2018. The program will cover the issues of the day regarding transitions of care and what we still need to do in order to build excellent and positive clinical programs with providers and patients.  The agenda for the day will include presentations by industry and congressional leaders and the opportunity for dialog with key stakeholders building resources, legislation and programs to improve healthcare coordination.

I look forward to seeing each of you there!
Dr. James Lett
President, NTOCC

NTOCC Policy & Advocacy Corner

Important Legislation Passed by Congress in the 1st Quarter of 2018

Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act
On February 9, 2018, President Donald Trump signed into law the Bipartisan Budget Act of 2018 (BBA 2018; P.L. 115-123). Division E of that law is titled the Advancing Chronic Care, Extenders, and Social Services (ACCESS) Act. You can find more information and the most recent Congressional Research Report (CRS) here 

S. 870: Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017
A bill to amend title XVIII of the Social Security Act to implement Medicare payment policies designed to improve management of chronic disease, streamline care coordination, and improve quality outcomes without adding to the deficit. Status: Enacted Via Other Measures

Provisions of this bill were incorporated into other bills which were enacted, so there will not likely be further activity on this bill.

This bill was incorporated into:

H.R. 1892: Further Extension of Continuing Appropriations Act, 2018; Department of Defense Appropriations Act, 2018; SUSTAIN Care Act of 2018; Honoring Hometown Heroes Act
Enacted — Signed by the President on Feb 9, 2018. 

S. 1028: RAISE Family Caregivers Act
A bill to provide for the establishment and maintenance of a Family Caregiving Strategy, and for other purposes.
Status: Enacted Via Other Measures

Provisions of this bill were incorporated into other bills which were enacted, so there will not likely be further activity on this bill.

This bill was enacted as:

H.R. 3759: RAISE Family Caregivers Act
Enacted — Signed by the President on Jan 22, 2018.

Bills we are currently watching in Congress.............

To amend the Public Health Service Act to facilitate assignment of military trauma care providers to civilian trauma centers in order to maintain military trauma readiness and to support such centers, and for other purposes. 
Status: This bill passed in the House on February 26, 2018 and goes to the Senate next for consideration.

S. 2278: State Offices of Rural Health Re-authorization Act of 2018 
A bill to amend the Public Health Service Act to provide grants to improve health care in rural areas. (The federal budget process occurs in two stages: appropriations, which set overall spending limits by agency or program, and authorizations, which direct how federal funds should (or should not) be used. Appropriation and authorization provisions are typically made for single fiscal years. A reauthorization bill like this one renews the authorizations of an expiring law.)
Status: The committees assigned to this bill sent it to the House or Senate as a whole for consideration on February 28, 2018.

S. 292: Childhood Cancer STAR Act
A bill to maximize discovery, and accelerate development and availability, of promising childhood cancer treatments, and for other purposes.
Status: This bill passed in the Senate on March 22, 2018 and goes to the House next for consideration.



NTOCC Lunch N’ Learn Webinar 

May 1, 2018 12pm-1pm CDT

"Deciding On Going To The Hospital - Informed decision making with families and caregivers.”
Presented by Jacqueline Vance, RNC, BSN, IP-BC, ASCOM, CDP, CDONA, FACDONA, LBBP, DPN
Webinar Information:
For Webinar access go to:
Under "online meetings" at the top of page, go to "join meeting" and enter ID: ntocc
For Audio the Dial-in number is: (515) 739-1513 
Access code:986228      
In many cases the hospital is not the first choice of a chronically or catastrophically ill patient.   During this presentation we will look at a process of communication in which clinicians, patients and family caregivers work together to make shared decisions about their healthcare needs that align with what matters most to patients.  Two-way communication is critical to improving person-centered care.

The objectives for this webinar are:
  • Discuss the risks of hospitalization
  • Discuss the benefits of hospitalization
  • Recognize the term “medical futility”
  • Examine the benefits of palliative/comfort care
  • Review a process of assisting the families and caregivers in making an informed decision to hospitalize or not

     Jacqueline Vance is the Senior Director of Clinical Innovation and Education for Mission Health Communities in Tampa, Florida and the President of Vance LTC Consulting in Ellicott City, Maryland.
Ms. Vance previously was the director of clinical education at Sava Senior Care in Atlanta, Georgia. She has served as a director of development and director of clinical affairs and industry relations for AMDA − The Society for Post-Acute and Long-Term Care Medicine (AMDA).
     She is a certified director of nursing in long-term care, and she is board certified in gerontological nursing and infection prevention (IP-BC). She is a certified Master in Antibiotic Stewardship (ASCOM), a Certified Dementia Practitioner (CDP), and is a Lean Six Sigma Black Belt Professional LBBP). In addition, she has a technical diploma in Personal Nutrition (DPN). Ms. Vance is affiliated with AMDA, the American Association of Directors of Nursing Services (AADNS), National Association of Directors of Nursing Administration in Long-Term Care (NADONA/LTC), and is on the board of the National Transitions of Care Coalition and the American Society of Consultant Pharmacists Foundation.
     She has been an author of more than 50 articles relating to long-term care residents and facilities published in Caring for the Ages magazine, peer-reviewed journals, and other publications, and she has been a frequent presenter at national conferences. She is the author of the award winning blog “The Real Nurse Jackie” hosted by McKnights long term Care.

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