Medicare Advantage Care Transition

The Medicare Advantage (MA) Care Transition Program is the coordination of care after a member is discharged from an inpatient acute care facility. Proactive interventions begin when the member is directly contacted by telephone prior to discharge and continues post discharge during a 34-day period. Blue Cross and Blue Shield of Nebraska (BCBSNE) annually reviews and updates the CT program.  

The primary goals of the Medicare Advantage Care Transition Program are:

• Increase member adherence to treatment plan through education 
• Affect healthy outcomes and member experience  
• Encourage member communication with their practitioner about their health conditions and treatment  
• Assist in coordinating care after discharge, including follow up visits following discharge  
• Provide information about community resources that may be helpful  
• Decrease inappropriate inpatient admissions and emergency room visits  

Care Transition Process  

1. The Care Transition (CT) nurse will receive a notification from the UM nurse when a member is admitted to the hospital for acute care.
2. In order to be proactive, and to ensure a safe and effective discharge, the CT nurse will attempt to contact the member during the inpatient admission to discuss discharge needs and will also work with their discharge planner.  
3. Once the member is discharged, the CT nurse will contact the member to provide education, address gaps in care and medication adherence issues, and coordinate services as needed.  
4. The nurse will also assess the member’s risk for readmission and apply appropriate follow up interventions.  

Care Transition Program Outcomes 
Care Transition Program trends are analyzed and opportunities for improvement are identified through Care Transition and UM reports. The program will used targeted interventions to drive positive and healthy member outcomes, monitor ongoing progress and refer members to the Case Management program as appropriate.