Healthy World, Healthy Nation, Healthy You

The Affordable Care Act and Transitions in Care-The Main Line Health Experience in Changing the Focus in Care Delivery

Grace Wummer, RN, MSN
Director, Patient Care Coordination
Main Line Health
Bryn Mawr, PA


GraceGrace Wummer has 30 years of professional experience including medical-surgical, rehabilitation and home care nursing. She earned her Master’s in Nursing Health Administration at Villanova University, and her undergraduate Bachelor of Science in Nursing from Seton Hall University. Since November, 2012, Grace is in a new role as Director, Patient Care Coordination for Main Line Health. In this role she provides oversight, direction and facilitation for of all aspects of collaboration with acute care hospitals, primary care physicians and post acute care providers in managing avoidable hospital readmissions.


One of the areas of interest in health care reform is to decrease the times a patient is admitted to the hospital for the same condition. It has been common for patients with heart disease for example to be re-admitted multiple times for symptoms such as shortness of breath or swelling of ankles, or perhaps inability to sleep. Such hospitalizations are stressful for the patient and family as well as very costly. Since the payers for healthcare want to decrease avoidable costs, hospitals will be penalized if such patients are re-admitted rather than cared for in a coordinated way that can substantially decrease such re-admissions. The challenge is how to get doctors and hospitals to behave differently and take needed steps to make the transition from hospital to home more coordinated so that the care that will decrease such complications is provided.

Grace discussed how she is working with key staff at Main Line Health to help staff understand how care needs to be provided in order to reach these goals. Hospitals all over the country are taking similar approaches to changing the delivery of care that will be in the best interests of the patients and help people to achieve their health goals. She specifically discusses:

  1. Why transitions of care are now the focus of many healthcare systems
  2. How healthcare policy is moving the system to a more patient-centered approach to care.
  3. What the healthcare consumer should ask when transferring from one level of care or provider to another

3 Key Points:

  1. The Affordable Care Act includes a section on building a continuum of care where transitions in care have to be managed.
  2. Transitions in care require that costs be managed over a 90 day period.
  3. Consumers are encouraged to ask questions related to their care transitions.

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