New payments will be awarded to nurse practitioners, clinical nurse specialists, certified nurse midwives, and other primary care professionals for "transitional care management" services provided within 30 days of a Medicare patient's discharge from a hospital or similar facility.
To qualify for reimbursement, the primary care professional has to contact the patient soon after discharge, conduct an in-person visit, and engage in medical decision-making. They also have to provide care coordination, which includes effectively facilitating health services and information among a continuum of providers, functions, and settings.
Care coordination has long been a major challenge for hospitals. In the 2012 HealthLeaders Media Industry Survey, 30% of CEOs said care coordination is their greatest strategic challenge. By contrast, improving patient experience (including patient flow) was the next most popular choice, cited as the top strategic challenge by only 17% of respondents.
It's easy to see why getting a handle on coordinated care is so critical for executives: Up to 20% of Medicare patients are readmitted to hospitals within 30 days of discharge, says Carlson.