Transitional Care: How the Affordable Care Act Would Have Helped My Father

By Susan B. Hassmiller, PhD, RN, FAAN, senior adviser for nursing at the Robert Wood Johnson Foundation. This post is also being published at the Robert Wood Johnson Foundation Human Capital blog.

When I heard that the Supreme Court had upheld the Affordable Care Act, I immediately thought of my father. He suffered mightily at the end of his life. Plagued with multiple chronic illnesses, he spent his last year in and out of hospitals. He received good hospital care, but his health deteriorated every time he left the hospital.

He simply couldn’t keep track of a growing list of prescriptions, tests, and doctor visits. He accidentally skipped antibiotics, which led to infections, which landed him back in the hospital. He accidentally skipped blood tests, which landed him back in the hospital. It seemed that every time he came home, he’d land back in the hospital. I lived thousands of miles away and couldn’t be the advocate that he needed.

What he needed was transitional care—he needed a nurse to meet with him during a hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. He needed a nurse to identify reasons for his instability, design a care plan that addressed them, and coordinate various care providers and services. He needed a nurse to check up on him at home. Transitional care would have eased his suffering and allowed him a better life.

One of the best parts about the Affordable Care Act is that it will make transitional care possible for more patients. The transitional care program is one of many provisions in the law that will provide an unprecedented opportunity for nurses to take on greater roles as members of health care teams—they’ll be better able to provide preventive health care services, care coordination, and chronic disease management to patients.  

The Affordable Care Act came too late for my father, but I’m grateful that other patients and their families will be able to avoid the costly and heart-wrenching cycle of repeat hospital visits and unnecessary suffering at the end of life. At least that is my hope.

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Karen July 31, 2012 at 1:10 am

    Transitional care programs developed to provide an infrastructure for merging funds and services for government insurance programs. CMS is merging Medicare and Medicaid funds to provide necessary services for individuals that do not require hospital care. The current Medicare system prevents recipients from receiving non-skilled care for activities of daily living and hygiene. Medicare excludes non-skilled care as a covered service unless other skilled services medically necessary at the time of the service. In contrast, Medicaid authorizes non-skilled services for payment if the services are medically necessary. Transitional care programs are going to break down the barrier between the two systems, which will not only decrease the overall costs associated with care but will allow patients to receive care in a low risk environment. The program established is to promote health and provide preventative services. Transition programs will help patients cope with life experiences in a less restrictive environment. This will promote physical independence and enhance patient’s rights by promoting a patient’s freedom of choice. Transitional care programs are not a trial and error approach to reducing costs and improving patient outcomes. The program is a long overdue desire for beneficiaries and should not appear to be a plan to enhance “government control”. After 15 years of nursing in the home care environment, it has become obvious to me that a bed bath, diaper change, or assistance with ambulation could have prevented a pressure sore, fracture, or other health disparity. If this program established based on popular vote alone by beneficiaries, community care and preventative services would be in better position today.

  2. suki July 14, 2012 at 9:37 pm

    Unfortunately nursing is NOT proactive these days. The older nurses understand what proactive is but not the ones that want to rush people through like an assembly line. Sometimes government does need to come in and make things right. It is for the patient. Healthcare today is being run into the ground by the greed of the mega corporations and their bloodsucking greedy CEOs. Most nurses today really don’t give a hoot about the “big picture” with regards to each patient and what they really need. Too many nurses today are just getting by finishing their “shift” and doing what is absolutely necessary. A few old dinosaurs left that do attempt to look at all the issues the way we were taught and in our earlier years did practice I am constantly shocked by what I see when working today. Most nurses do not care about the “big picture.” I am told by my coworker nurses, “you care too much Suki.”

  3. jm July 13, 2012 at 7:25 am

    Chris, paperwork is definitely a common and legitimate concern among nurses these days in this age of sometimes blind faith in measurement and data. It’s often said, and not always easily done, but the extent to which such concerns are articulated by experienced nurses as such pilot programs are created and refined may be the extent to which they will be both effective and appreciated. Thanks for weighing in.

  4. Map July 12, 2012 at 7:40 pm

    My question is where will the $500 million come from?? In the past, home health was able provide the described services,and they were cut, due to cost!!! No further experimentation, or pilot programs are needed! The programs are already in place!!!!

  5. Chris Tallman Godfrey July 12, 2012 at 7:00 pm

    I worked in home health when one of the Omnibus Reconciliation Acts went through and was supposed to “reduce paperwork”. What was required for Medicare patients became a nightmare. If nursing would be proactive and define its practice more clearly the problem would be solved. I know you know the old term continuum of care. I graduated in 1971 and at that time we knew we had to look where the patient was going when they left the hospital and what they might need. The nearest hospital to me, Allegiance Health in Jackson, MI has had care managers for years. I am just frustrated that the government wants to tell us to do what we know needs to be done. Thanks for the dialogue. Chris

  6. jm July 12, 2012 at 4:12 pm

    Chris, I’ll try to be clearer about what I meant in my previous comment.

    The law has many provisions, and many that, like the transitional care one, are meant to reduce costs and improve the lives of patients. Most of these provisions can by no known definition be understood as a government takeover of anything.

    That’s why I said it’s empty rhetoric to suggest otherwise…or rather, simply inaccurate, if you prefer. Instead, the ACA has set aside some funds to support innovative pilot programs aimed at improving patients’ lives and saving money in the bargain. Despite what you say about nurses already seeing to transitional care, the data shows that many hospitals are not doing enough on transitional care, whether there are existing mechanisms or not in these hospitals and whether or not individual nurses are already doing a great job in seeing to this. It’s a systemic problem, and needs experimentation and innnovation across disciplines. If you click the link provided in Sue Hassmiller’s post, you’ll find the following passage:

    “In three randomized controlled trials of Medicare beneficiaries with multiple chronic illnesses, use of the TCM lengthened the period between hospital discharge and readmission or death and resulted in a reduction in the number of rehospitalizations (Naylor, 1994; Naylor et al., 1999, 2004). The average annual savings was $5,000 per patient……Until now, transitional care has not been covered by Medicare and private insurers. But the Affordable Care Act sets aside $500 million to fund pilot projects on transitional care services for “high-risk” Medicare beneficiaries (such as those with multiple chronic conditions and hospital readmissions) at certain hospitals and community organizations over a 5-year period. The secretary of the Department of Health and Human Services is authorized to remove the pilot status of this program if it demonstrates cost savings.”

    So you may fairly argue that this isn’t actually likely to improve care of reduce costs in the long run, but that’s an entirely different question than whether or not it’s a government takeover of health care. It’s simply not. It’s about empowering nurses to do the best work they can. And we need to innovate to do so.

  7. Chris Tallman Godfrey July 12, 2012 at 3:43 pm

    Jacob, I think nursing is better served if nurses define their roles and not the government. This role and duty already belong to nursing. Your statement is empty and manipulative.

  8. medlaw July 12, 2012 at 2:28 pm

    I was not aware of the transitional care benefit. In the long run, one would think such a program saves the insurers money by promoting the health of the patient outside of the hospital.

  9. jm July 12, 2012 at 10:39 am

    In answer to the comment by Chris: I fail to see how a program promoting innovation in a much-needed nursing role can be read as “government intervention” into nursing. That is just empty and manipulative rhetoric.-Jacob

  10. Chris Tallman Godfrey July 12, 2012 at 10:34 am

    He should have had a case manager. Most hospitals have this option, usually a nurse or social worker who is job to arrange for post hospital care. A home health referral would have prevented this saddness. A transitional care program should not have to be made into a law for it to exist. It IS nursing. As a nurse I have seen what government intrusion has done to our practice.

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