The State of Transitions of Care: Findings from the 2025 NTOCC National Summit
In September 2025, the National Transitions of Care Coalition (NTOCC) convened a national Working Summit to examine the ongoing challenges affecting transitions of care across the healthcare continuum. Eighty healthcare professionals representing hospitals, post-acute providers, pharmacists, case managers, policy leaders, and care coordination experts from across the country gathered to identify the most pressing barriers, emerging opportunities, and strategic priorities for improving care transitions nationwide. During the Summit, these participants were engaged with live polling, digital response tools, and open discussion to capture real-time insights from professionals working directly within transition processes.
Despite decades of progress in healthcare quality improvement, summit participants consistently described the current state of transitions of care as fragmented, disconnected, and inconsistent across care settings. These systemic gaps continue to place patients—particularly those with chronic illness, behavioral health conditions, or complex care needs—at risk during critical handoff moments between providers.
Participants identified several persistent barriers, including inadequate reimbursement structures, limited interoperability between healthcare systems, incomplete discharge communication, and unclear accountability across care settings. At the same time, participants highlighted significant opportunities to strengthen transitions through improved technology integration, expanded roles for pharmacists and care coordination professionals, and standardized discharge communication protocols.
Notably, summit participants highlighted that enhancing transitions of care necessitates coordinated reforms in both policy and practice. Participants advocated for establishing national standards for discharge communication, updating reimbursement models to better support care coordination, and enhancing collaboration among healthcare systems, payers, and policymakers.
The findings presented in the report reflected the collective insights gathered through live polling, written responses, and facilitated discussions during the Summit. These insights will guide NTOCC’s strategic priorities for 2026 and inform ongoing national conversations about how healthcare systems can better protect patients during one of the most vulnerable points in their care journey.
Why the Summit Was Convened
Transitions of care represent one of the most vulnerable moments in the healthcare system. When patients move between care settings—such as from hospital to home, hospital to skilled nursing facility, or emergency department to outpatient care—the responsibility for treatment, communication, and follow-up shifts between clinicians and organizations.
When these handoffs fail, the consequences can be severe. Poorly coordinated transitions are associated with medication errors, missed follow-up care, avoidable hospital readmissions, increased healthcare costs, and negative patient outcomes.
Recognizing the continued need for improvement, the National Transitions of Care Coalition convened the 2025 Transitions of Care Working Summit to bring together leaders from across the healthcare continuum to examine current realities, identify barriers, and explore solutions for strengthening care transitions nationwide.
Click the link to find the complete report——> Link to full Report
NTOCC invites you to a free online webinar regarding the findings of the report on April 21st at 2:00pm. Individuals can register here.
Cheri Lattimer, NTOCC’s Executive Director will share the findings and discuss several new CMS models that begin to address concerns identified during the Summit by participants. This program is part of the 2026 NTOCC Lunch & Learn Series. NTOCC encourages individuals to send their comments, concerns, suggestions or other thoughts on the article to Cheri.Lattimer@gmail.com
To view the complete press release, click here.
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Opening Keynote:
The Future of Transitions of Care
Shari Ling, MD, CMS Deputy Chief Medical Officer—The Centers for Medicare & Medicaid Services, Washington, DC
The National Transitions of Care Coalition (NTOCC) Working Summit is not your average healthcare conference—it’s a high-impact, solutions-focused event designed to align, activate, and advance the future of transitions of care.
🗓️ Agenda Highlights & Featured Speakers
🔹 8:00 AM — Continental breakfast/Networking
🔹 8:50 AM — Welcome & Opening
Jackie Vance, RNC, BSN, CDONA/LTC, FACDONA, IP-BC, CDP, LBBP, DPN
President, National Transitions of Care Coalition
Kick off the summit with an energizing welcome that sets the tone for collaboration. Attendees will be oriented to the day’s goals and encouraged to actively participate as co-creators of change.
🔹 9:00 AM — Opening Keynote The Future of Transitions of Care
Shari Ling, MD, CMS Deputy Chief Medical Officer— The Centers for Medicare & Medicaid Services, Washington, DC
This action forum will frame the national landscape of care transitions, highlighting current challenges and emerging priorities. Attendees will reflect on how these insights connect to their own work and where immediate innovation is needed.
🔹 9:45 AM — Bridging Gaps Between Acute & Post-Acute Care
Christian Bergman, MD, CMD — Virginia Commonwealth University
Jackie Vance, RNC, BSN, CDONA/LTC, FACDONA, IP-BC, CDP, LBBP, DPN — Mission Health Communities
Instead of simply hearing about the divide, this session will surface real-world barriers and ask participants to discuss what systems-level or workflow solutions could bridge those gaps across settings.
🔹 10:30 AM — Building Standards for Transitions of Care -
CMD - Corresponding Faculty Harvard Medical School
Explore tech-enabled care coordination with a focus on what's working --and what's not. Attendees will workshop with Dr. O'Malley discussing work yet to be done and how this fits into the digital future.
🔹 11:15 AM — WORKING LUNCH
A chance to network, but also to continue the morning’s dialogue through informal peer discussions guided by prompts placed on tables.
🔹 12:15 PM — The Future of Value-Based Care
Steven Buslovich, MD, CMD, MS — Chief Medical Officer, Senior Care, PointClickCare
Tom Haithcoat — President, Ceptor Consulting, LLC
Through interactive discussion, attendees will evaluate the impact of VBC models on transitions of care and propose policy or operational tweaks to improve alignment with patient-centered outcomes.
🔹 1:00 PM — Policy Updates: The Impact of Transitions of Care
Alex Bardakh, MPP, CAE — Senior Director of Advocacy and Strategic Partnerships, Post-Acute and Long-Term Care Medical Association (PALTmed)
This isn’t just a policy briefing. Attendees will assess recent legislative and regulatory changes, then discuss what’s missing and how policy could better support smoother transitions.
🔹 1:45 PM — Pharmacists and Their Impact on TOC
Sara Panella, PharmD, CPh, BCPS, FASHP — Director of Pharmacy, Population Health, Emory Healthcare
Chad Worz, PharmD, BCGP — Chief Executive Officer, ASCP
Panelists will present scalable models, then attendees will examine how pharmacy-based interventions could be adapted or replicated across systems.
🔹 2:30 PM — Break
🔹 2:45 PM — Case Study Presentations: Innovative TOC Models
Norris Turner, PharmD, PhD — Turner Healthcare Quality Consulting, LLC
Cheri Lattimer, RN, BSN — Executive Director, NTOCC
Trisha Cash, PharmD, BCGP, CDCES — Fredrick Integrated Health Networks
Diane Kittle, MSN, RN, CCM — Complex Care Transitions, Mayo Clinic -Arizona
Saswat Kabisatpathy, PharmD — Chief Strategic Officer, Avant Pharmacy & Wellness Center
Each case will be a launchpad for live problem-solving — attendees will be encouraged to ask hard questions, identify success drivers, and brainstorm how to tailor the approach to their own settings.
🔹 3:45 PM — Roadmap to Closing the Gaps
Moderator: Norris Turner, PharmD, PhD —Turner Healthcare Quality Consulting
A facilitated, all-hands dialogue to synthesize insights from the day. Together, participants will help co-author a shared roadmap to address systemic issues and outline next steps for collective action.
🔹 4:30 PM — Closing Remarks
Jackie Vance, RNC, BSN, CDONA/LTC, FACDONA, IP-BC, CDP, LBBP, DPN
Summit leaders will recap the day’s breakthroughs and thank attendees for showing up not just to listen — but to lead.
You can find Exhibitor & Sponsorship information on the
Ntocc website or Download Prospectus here.
A Working Summit with Purpose
As healthcare enters a new era, we’re bringing together leaders from every corner of the system—clinicians, policymakers, patient advocates, academics, and innovators—to move beyond conversation and build coordinated solutions that work.
This summit is:
🔷 Interdisciplinary
🔷 Highly Interactive
🔷 Outcome-Driven
🔷 Collaborative by Design
Through strategic roundtable discussions, live solution mapping, and hands-on working sessions, we will dismantle silos, share insights, and co-create the future of transitions of care.
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Location: Washington, DC the General Gordon R. Sullivan Conference and Event Center hosted by AUSA
Hotel: Hyatt Place Arlington Courthouse Hotel Located at 2401 Wilson Blvd., Arlington, VA
The Hyatt is the AUSA Conference & Event Center partner Hotel and it is attached to the Event Center
Case managers, discharge planners, & care coordinators
Hospital and post-acute care administrators
Physicians & APNs
Pharmacists & Pharmacy Techs Patient advocacy groups
Pharmaceutical and medical technology representatives
Policymakers and government officials (CMS, HHS, state health departments)
Healthcare IT and digital health leaders
Healthcare associations and nonprofit organization