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Transitions from hospital to home can be complicated and risky, especially for individuals with multiple chronic illnesses. Patients frequently report difficulty remembering clinical instructions, confusion over correct use of medications, and uncertainty over their prognosis. And in cases where multiple providers are involved, patients often get conflicting instructions from different providers.
A study published in April 2009 in the New England Journal of Medicine found that almost one¬ third of Medicare beneficiaries studied who were discharged from a hospital were re-hospitalized within 90 days. Additionally, one-half of the individuals re-hospitalized had not visited a physician since their discharge, indicating a lack of follow-up care
AARP has endorsed The Medicare Transitional Care Act (H.R 2773) which would directly address continuity of care problems by increasing support to patients as they move from the hospital to their new care setting and ensuring that appropriate follow-up care is provided during this vulnerable period. The benefit would be phased-in, initially targeting the most at-risk individuals by providing evidence-based transitional care services tailored to their specific needs. We hope to have a Senate companion bill soon and we urge the Committee to include this transitional benefit in any final health care reform legislation.

Programs to Facilitate Shared Decision Making: The Institute of Medicine identified “patient-centeredness” as one of six attributes of high quality care. In addition, based on its understanding that engaged, activated patients are likely to have better health outcomes, the National Priorities Partners, a broadly representative group of 28 organizations with an interest in improving health care, identified patient and family engagement as one of six national priorities and goals. From a patient’s perspective, the concepts of patient-centered care and patient engagement cannot be fully realized unless patients (or their designated family caregivers) are able to participate as full partners in their health care. This means they must have access to and are able to use information that is relevant, meaningful, applicable, and reliable. Therefore, AARP commends the committee for recognizing the role evidence-based shared decision making tools can play in improving care, and we support opportunities to expand the availability and implementation of such aids that meet specified criteria and that are suitable across the age span, including vulnerable populations and children. Since use of shared decision making tools is a relatively new idea for patients and providers, the idea of establishing resource centers to provide technical assistance to providers to develop and disseminate best practices could accelerate adoption of these tools.

Increasing the Supply of the Health Care Workforce: We applaud the Committee’s leadership in addressing the needs of the health care workforce, including their education and training. Health care services should be provided by a well-trained, fairly compensated workforce who put their patients’ needs above all else and who carry out their responsibilities under rules that permit clinicians to maximize the full scope of their training. The nation must have an adequate workforce trained and prepared to take on the needs of an aging population.

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