A Day for Making Decisions and Planning

on Tuesday, 16 April 2019. All News Items | Case Management | Quality

Putting the Patient First

“I’m late, I’m late! For a very important date! Not time to say ‘hello, goodbye,’ I’m late, I’m late, I’m late!”

  • The White Rabbit in Lewis Carroll’s classic story, Alice in Wonderland

Yesterday, April 16th was National Healthcare Decisions Day and the first National Care Transitions Awareness Day. Although this article is a day later, it is never too late to put the patient first.

April 16th: National Healthcare Decisions Day (NHDD)

NHDD is an initiative of The Conversion Project which is dedicated to helping people talk about their wishes for end-of-life care. According to the NHDD website, this day “exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be.”

Effective January 1, 2016, the CMS began paying for Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). ACP is a face-to-face service between a physician (or other qualified health professional) and the patient discussing advance directives with or without completing relevant legal forms.

The Annual Wellness Visit, Health Risk Assessment and Advance Care Planning

My husband recently had an office visit with his Primary Care Physician and for the first time his Physician discussed advance directives and even sent him home with a blank copy of an advance directive that he could complete. My husband also said that between him and his Physician they filled out what seemed “like a million” forms answering questions about his health history.

While writing this article, I realized this office visit was probably my husband’s Annual Wellness Visit (AWV). Section 4103 of the Affordable Care Act (ACA) established a Medicare Annual Wellness Visit beginning in 2011. An AWV is covered by Medicare once every 12 months and entails the Physician developing or updating a personalized prevention plan, and performing a Health Risk Assessment.

The Health Risk Assessment involves collecting and analyzing health-related data used by health providers to evaluate the health status or health risk of an individual. According to the Centers for Disease Control (CDC)’s A Framework for Patient-Centered Health Risk Assessments, “chronic illnesses account for an estimated 83% of total U.S. health spending and virtually all (99%) of Medicare’s expenditures are for beneficiaries with at least one chronic condition.

One component of the Health Risk Assessment (HRA) is voluntary Advanced Care Planning.  Minimum elements for voluntary ACP services include a discussion about the following:

  • Future care decisions that may need to be made,
  • How the beneficiary can let others know about care preferences,
  • Caregiver identification, and
  • Explanation of advanced directives, which may involve the completion of standard forms.

You can learn more about the Annual Wellness Visit in an MLN Booklet (ICN905706) and more about Advanced Care Planning in an MLN Advance Care Planning Fact Sheet.

April 16, 2019: First National Care Transitions Awareness (NCTA) Day

Even with Annual Wellness Visits and Health Risk Assessments, Medicare patients get admitted to the hospital. Unfortunately, of the approximately 2.6 million Medicare beneficiaries who are discharged from a hospital, one in five are readmitted within 30 days, at a cost of over $26 million every year.¹ 

According to the CMS Effective Care Transitions, Improve Cost Savings Graphic and Fact Sheet:

  • Nationally, inadequate care coordination and care transitions are responsible for $30-54 billion in wasteful spending,
  • 57% of Providers report things fall through the cracks when patients transfer from one facility to another,
  • 50% of Hospital-Related medical errors are attributed to poor communication during transitions of care, and
  • Chronically ill patients will see an average of 16 physicians per year.

Yesterday, April 16, 2019 marked the first National Care Transitions Awareness (NCTA) Day. This day is meant to raise awareness about the importance and value of care transitions and care coordination. In an FAQ Session posted on the CMS Quality Improvement Organization (QIO) website, Jean Moody-Williams and Dr. Adebola Adeleye share the inspiration behind NCTA Day.

“Health care can be very complex, and it requires effective coordination efforts as beneficiaries’ transition from one point of care to another, such as from a hospital to a nursing home. Effective care transitions require a team-based approach that treats people holistically — addressing their socioeconomic circumstances, cultural beliefs and values, as well as their health care needs.

To practice this same holistic approach for the care of our beneficiaries, CMS mobilized a team of individuals across the agency representing the various aspects of our care transitions programs and initiatives to form the CMS CTPAC Affinity Group. This group works to align our care transitions efforts by improving communication and coordination, and eliminating duplication across our programs. 

Early on in our discussions, the CTPAC Affinity Group identified the need to increase awareness and promote action around care transitions and expectations during the process, especially in the beneficiary population. One of our priorities at CMS is to put patients first, and we believe beneficiaries are an essential part of the health care team. If people are well informed about ways to improve their care, they can become more active participants. Ultimately, active patient participation helps us at CMS be more effective in advancing quality care and patient safety as people transition through the health care continuum.”

Staying Connected After NCTA Day

CMS invites you to join their Care Transitions Listserv to receive future communications about upcoming events and opportunities. You can register at https://www.healthcarecommunities.org/NCTA. You can also learn more about Care Transitions from CMS leadership on their YouTube channel.


¹The CMS Community-based Care Transitions Program webpage at: https://innovation.cms.gov/initiatives/CCTP/).

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc.  Beth has over twenty-eight years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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