primary care practices, in the case of Intermountain, and nurse practitioner/social worker teams in the case of the GRACE program. Each have achieved a significant reduction of hospitalizations and lower costs. Similar gains were also found for high-risk children in PCMH programs. Community Care of North Carolina (McCarthy and Mueller, 2009; Steiner et al., 2008) had nurses provide case management and care coordination services to high-risk Medicaid and SCHIP enrollees, resulting in a 40 percent reduction in hospitalizations for asthma and a 16 percent reduction in emergency room visits and yielding total annual savings of $154–170 million

The Tax Relief and Health Care Act of 2006 directed the Centers for Medicare and Medicaid Services (CMS) to undertake a demonstration program to test the effectiveness of PCMH models for Medicare enrollees and the capacity to achieve both quality outcomes and lower health care spending through such approaches to organize primary care. Provisions in the health reform legislation complement Medicare’s demonstration program, testing different PCMH models and creating a new CMS Innovation Center to support testing new approaches to organizing, delivering and paying for health care services (Chokshi, 2009). Their capacity to achieve real savings, some argue, will depend on the breadth of providers (e.g., primary care, specialists, hospitals) linked to the medical home and the depth of interdisciplinary collaboration and care coordination among them (Fisher, 2008), underscoring the focal role that nursing will play in achieving these outcomes.

Transitional Care

Other innovations in care management also call upon the scope of practice of RNs. Various current and proposed reforms would financially penalize hospitals whose Medicare readmission rates exceeded an established threshold. These provisions come on the heels of a recent study which found that one in five hospitalized Medicare beneficiaries are readmitted within 30 days of discharge, nearly half of whom return without having seen a physician or other health care practitioner in the intervening period (Jencks et al., 2009). Of the $103 billion spent by Medicare on hospital care in the study year, 17 percent was spent on readmissions that were unplanned and potentially avoidable. These findings raise serious questions about the coordination of care and hospital discharge protocols in place where these patients sought care (Epstein, 2009). The financial penalty is intended to serve as a significant incentive to hospitals to adopt evidence-based strategies that will reduce avoidable readmissions.

Co-incident with the release of the readmission study, CMS announced the 14 sites for its newly funded Care Transitions Project. This nationwide pilot program supports partnerships between Medicare’s Quality Improvement Organizations and local providers to develop and implement strategies to manage the transitions of Medicare patients from acute care to post-acute care settings, whether it’s the patient’s home or another health care setting. Transitions between



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