Staffing

Transitions Coaches can be nurses, social workers, occupational therapists or other professionals who have the experience and competence in helping patients advocate and care for themselves. As a conservative estimate, each Transitions Coach can provide care for 24 to 28 recently discharged patients at a time, or approximately 300 per year. The caseload is determined more by the geographic spread of patient’s residences rather than the skills of the Transitions Coach.

Skills needed

Thoughtful selection of the Transitions Coach is essential to the success of the intervention. A good Transitions Coach will have a demonstrated patient-centered focus and excellent communication skills. The person should be an experienced, empowered health professional comfortable with home visits and open to learning the role. Because this is a new role for most health professionals, training by the Care Transitions Program is essential. In training, new coaches learn to identify the difference between their prior “doer/educator” roles and the new coaching role of skill transfer (Coleman 2007).

Sample costs

At the time of the research in 2003, total annual costs to support one advanced practice nurse were $74,310. The primary expense was salary and benefits ($70,980), cell phone and pager ($650), mileage reimbursement ($2,500) and photocopying of the PHRs and other supplies ($180). As noted earlier, the potential savings appear to exceed these costs by a significant amount.

Case studies

The CTI has been successfully implemented in both rural and urban areas. Payers include Medicare, Medicaid, and private health plans. Patients coached represent great diversity with respect to education level, health literacy, primary language, race/ethnicity, and presence of a family caregiver. Health care organizations implementing the CTI include, but are not limited to health plans, accountable care organizations, Area Agencies on Aging, home health agencies, hospitals, independent practice associations, quality improvement organizations, and state agencies. Following are two case studies we will use to demonstrate how the CTI model works. They are a combination of our experience and do not represent specific individuals.

Case study #1

Miss R is a 76-year-old teacher who lives alone in an urban high rise apartment. She has a niece who lives in the city, about 10 miles away. Miss R has a history of HF. She is a 20-year breast cancer survivor, is hypertensive, and will soon be discharged from the hospital following an acute MI.

Hospital visit

The nurse on the cardiac unit noted that Miss R meets the screening criteria for the CTI. She notified the Transitions Coach of Miss R’s admission. Several days later, the nurse called the Transitions Coach with Miss R’s tentative discharge date.

The Coach met with Miss R and explained the intervention. Miss R was exhausted but intrigued. There was a pile of teaching sheets accumulating on her bedside stand, but she had been too tired to read them. The resident physician mentioned that she’d be starting a new medication that morning. He left before she could ask any questions. Miss R welcomed the support of the Coach and agreed to the CTI. The Coach gave Miss R her bright green PHR with the Coach’s name and phone number on it. They reviewed the PHR together. The Coach pointed out the Discharge Checklist and encouraged her to talk with her inpatient care team about these topics, including questions about her new medication. Miss R mentioned that her doctor told her she would be discharged home on Tuesday. They agreed the Coach would come and see her in her home on Thursday at 11:00 AM.

Home visit

After calling to confirm a good time to meet, the Transitions Coach arrived at Miss R’s apartment. As they moved toward the kitchen table, the Coach asked Miss R to gather all of her medications (prescribed and OTC) and any paperwork she got from the hospital. Sitting down to talk, the Coach explained that this would be a different kind of visit from the others Miss R has had, such as those from the Visiting Nurse. The focus of their time together was to help Miss R be better prepared to take care of her health conditions so she would not have to go back to the hospital. Miss R and the Coach would work together to review the medications, prepare her for her next doctor’s visit, and help her to better understand her health conditions.

Miss R located her PHR and handed it to the Coach. The Coach reminded Miss R the PHR belongs to her and handed it back. The Coach asked Miss R to identify one goal she would like to achieve as they work together for the next 30 days. Miss R was stumped. The Coach inquired if there was an activity she enjoyed doing before she went into the hospital. Miss R said she would love to get back to meeting her friends for coffee in the apartment building coffee shop on Wednesday mornings. Miss R wrote down that goal in her PHR. Now she had something positive to work toward. Together they discussed small steps Miss R could take to achieve this goal. Miss R listed these steps under her goal in her PHR. Miss R was uncertain how much walking she should do. She wrote this question in her PHR to discuss with her doctor.

Miss R and her Coach began the medication review. The Coach asked Miss R to show her what medication she takes and how she takes it. As they reviewed each bottle, Miss R recorded in her PHR each medication as she was actually taking it. If there was a discrepancy between the bottle instructions and what she was taking, they stopped and Miss R wrote down a question in her PHR for her care team (doctor, nurse, or pharmacist) about how to resolve this difference. Miss R also wrote down all the non-prescription medications, supplements, and herbs she was taking. Once she completed the list, the Coach and Miss R compared that list with the medications listed on her discharge instructions. They discovered a medication Miss R’s cardiologist started her on in the hospital. She had a prescription for the medication but had not gotten it filled. Miss R usually walks to her pharmacy two blocks away, but does not yet have the stamina to get there. They discussed possible solutions, such as Miss R asking her niece to the medication filled, or Miss R calling the pharmacy to see if they deliver. Miss R decided to try the pharmacy delivery option first and made a note in her PHR to remind her to make the call. Miss R and the Coach also discovered that the discharge instructions had a different dose of her blood pressure medication than she was taking. Miss R made a note in her PHR to discuss this with her primary care doctor.

Miss R’s Coach asked her if she had an appointment with her primary care doctor. Miss R said no; she thought the hospital would be making the appointment for her. Miss R dislikes calling her PCP’s office for an appointment because the clerk usually says she cannot be seen for months. The Coach shared statements that will be more likely to get her an appointment sooner. “I was just in the hospital for a heart attack.” “My medications were changed and I have questions I need to discuss with the doctor.” “I need to be seen next week.” Miss R and the Coach practiced. The Coach also suggested Miss R ask for the office nurse when she calls. Miss R was still nervous about making the call, so they planned to have Miss R make the call before her Coach left for the day.

Miss R noticed the section of the PHR labeled Medical History and Red Flags. The Coach asked Miss R to list her health conditions in her own words in her PHR. Miss R listed breast cancer, bunions, high blood pressure, and heart attack. The Coach asked her to describe how she was feeling before she went into the hospital. Miss R said she thought at the time she had a stomach problem and was a little short of breath. Miss R wanted to better understand what she should watch for and know when to call the doctor. The Coach agreed this was an important question for the doctor and Miss R added this to her list of questions for her follow-up visit.

At the end of the visit, the Coach reminded Miss R that this would be the only time they would meet face-to-face. The Coach said she would call Miss R Friday after her office visit to see how it went: whether she got her questions answered and how she progressed toward her goal. They reviewed the questions Miss R had written down to discuss with her doctor. She promised to take her PHR to the visit and to update it with any changes to her medications. The Coach reminded Miss R her name and number could be found on the front of her PHR and that Miss R could call with any questions or concerns.

Follow-up phone call

The Coach called Miss R at noon on Friday and asked how she was doing. Miss R said she was walking a bit more each day and was feeling stronger. She talked with the doctor at her office visit about increasing her activity. He said walking would be good. He thought her goal of getting back to seeing her friends was great. The Coach asked if she got her other questions answered about what signs to watch for indicating her condition could be getting worse. Miss R said yes, and she now has an action plan about what to do if that occurs. Miss R let the coach know she took her PHR to the visit and it helped her remember to ask about the dosage change for her high blood pressure medication. The Coach asked her to read her PHR to make sure the medication list was current. Miss R also shared that she had called the pharmacy and they agreed to deliver her pills. The Coach celebrated Miss R’s follow through and asked if she had any other questions. They agreed the Coach would call her in a week to see how her walking was progressing and how close she was to getting back to see her friends in the coffee shop. The Coach reminded Miss R that she could call her if she thought of questions or concerns before their next scheduled call.

Case study #2

Mr. T is an 82-year-old tribal elder from northern Wisconsin. He lives with his son and his family, who are fishing guides. Mr. T was also a guide until his health began to decline. He has a history of diabetes, HF, and a total hip replacement. He was recently hospitalized for shortness of breath related to his HF.

Hospital visit

The Transitions Coach, Tom, was notified of Mr. T’s admission by the discharge planner at the local hospital. In addition to identifying patients who are eligible for the Care Transitions program, the discharge planner has agreed to introduce the CTI to eligible patients. When she told Mr. T his Coach’s name, he realized he knew Tom from a community organization in town whose services he used in the past. Tom is someone he can trust. Mr. T is worried about the changes in his medications and how he and his family will manage once he is discharged back home.

Tom stopped in to see Mr. T in his hospital room and chatted with him about the day center Mr. T used to visit. Tom explained the CTI and showed Mr. T the PHR. Mr. T shared that he was unsure of what he was supposed to do once he got home. There were changes in his medication and his diet. Tom showed Mr. T the Discharge Checklist in the PHR and encouraged him to ask his hospital team to sit down and discuss these items. Mr. T was glad to hear that Tom would visit him at home. They decided on a day and time. Mr. T said his daughter-in-law had been helping with his medications and planned to ask her to be there for Tom’s visit. Tom requested that Mr. T have all of his medications and hospital-related paperwork gathered for them to review at the home visit.

Home visit

When Tom arrived for his home visit with Mr. T and Sally, his daughter-in-law, they settled at the kitchen table where all of Mr. T’s pill bottles and papers were in a big bowl. Tom explained that this visit and their interactions for the next 30 days would be different from the service coordination he provided before. Together they will work to help Mr. T be better prepared to take care of his health conditions so he does not have to go back to the hospital. They would review Mr. T’s medications, prepare Mr. T and Sally for his next doctor’s visit, and help him to better understand his health conditions. Sally told Tom she had been giving Mr. T his medications and taking him to his office visits. She said she was told Mr. T should be weighing himself every day, but Mr. T thinks it’s a waste of time. Tom acknowledged this as an important topic they will address.

First, Tom asked Mr. T if he could share an activity he would like to get back to – something fun he has not been able to do lately. Mr. T looked out the window at the river. Although he could no longer handle the canoe, he would like to fish from the dock. His legs have been too swollen and his breathing too labored to fish since the season opened. Tom encouraged Mr. T to write his goal in his PHR.

Getting back to the daily weight issue, Tom asked Mr. T to talk about how he was feeling before going into the hospital. Mr. T said his feet got increasingly swollen and his breathing got to the point he could only sleep sitting up in his recliner. It was terrifying and Mr. T said he really did not want this to happen again. Tom asked Mr. T to tell him what he understood about his health condition. Mr. T said a nurse talked with him about his HF in the hospital and said that weighing himself every day could give him an important clue about when he was getting into trouble. Tom reminded Mr. T of his goal to go fishing. Mr. T agreed to try the daily weighing. If keeping better track of his health can get him fishing it’s worth it.

Tom, Sally, and Mr. T began the medication review. Mr. T said “Sally takes care of all my pills, talk to her.” Sally confirmed she been giving him his pills for the past year. Tom asked Sally to show him what medications Mr. T was taking and how he took them. As they reviewed each bottle, Sally listed each medication in the PHR and how Mr. T was taking them. If there was a discrepancy between the bottle instructions and what Mr. T was taking, they stopped and Sally wrote down a question in the PHR for Mr. T’s care team about how to resolve this difference. Sally also wrote down all the non-prescription medications, supplements, and herbs Mr. T was taking. Once Sally completed the medication list in the PHR, they compared that list with the medications listed in Mr. T’s discharge instructions. Sally discovered discrepancies in the dosage of Mr. T’s water pill. Tom suggested Sally add that to the questions for the doctor in the PHR.

Mr. T said he likes his doctor, but has so little time with him at the office visits. Tom shared that doctors are busy, but not too busy to answer patient questions. Taking his PHR to the office visit would actually save the doctor time. Mr. T could share his list of medications and have his top three questions listed there too. Tom asked Mr. T if he would feel comfortable when he and Sally went to see his doctor, saying right at the beginning of the visit, “I have three questions I need to ask you before I leave today.” Mr. T said he felt comfortable saying this and asking the questions. Tom asked if they had a follow-up visit scheduled with Mr. T’s primary care doctor. Sally and Mr. T said no. They were planning on calling some time this week. Now that they had discovered the discrepancies in his medications, they would call that afternoon and ask for an appointment that week.

Tom asked if they had any questions. Sally said the discharge instructions listed a low salt diet. She was not sure how to go about this. Mr. T wanted to be part of that discussion because he does not want his food to be bland. Sally and Mr. T added a question to the PHR for the doctor regarding how to learn more about the diet.

Tom asked Mr. T and Sally to review the questions they have down in the PHR for the doctor. Tom told them he would call tomorrow to make sure they were able to get the doctor’s appointment. He encouraged Sally and Mr. T to call him if they had any questions or concerns.

Follow-up phone call

Tom called the next day. Mr. T said they were able to talk to the office nurse. She not only made an appointment for next Friday, she arranged for Sally and Mr. T to see a dietician. Tom asked Mr. T if he had had a chance to weigh himself. Mr. T said yes and told Tom he was writing each day’s weight on the wall calendar. That day, he went out on the dock and tomorrow he planned to walk half way to the dock! Tom celebrated Mr. T’s success and said he would call next week to see how the doctor’s appointment went.

Lessons learned

Planning for adoption of the care transitions intervention

If planning to adopt the CTI, explore the web site in depth (www.caretransitions.org) and contact the Care Transitions Program to guide you through the adoption and training process. Engage the support of senior and clinical leadership. Find a champion for this program – someone who is willing to make an investment in patient care. It is also important that this person think beyond the immediate quarter and instead focus on long-term goals.

Create and maintain positive relationships with community-based organizations. Interaction with various health care organizations in the community is a must for this model, so a positive relationship helps to smooth the transition for the patient. Open communication and a less “siloed” community help to reduce barriers to care for patients.

Training and practice

Transitions Coaches must complete an interactive face-to-face training with the Care Transitions Program Team. This training is essential to ensure model fidelity. Successful adoption of the CTI requires a distinct role change for new coaches. Many health care professionals feel they have been coaching throughout their careers. However, they have been educated and rewarded for doing things for patients. The Transitions Coach focuses on skill transfer and modeling of behaviors. The Coach does not perform assessment of skilled services. It takes practice and focused feedback to make the change from “doer” to Coach.

After initial training, Transitions Coaches need time to practice with colleagues and receive focused feedback. Shadowing each other’s home visits and then debriefing has also been very effective.

Model fidelity

To achieve the best outcomes, adopt the model as designed. We have found the home visit is essential for true patient engagement and skill transfer. The focus of the intervention and movement through the four pillars must flow directly from the patient’s goal, not the Coach’s. This is a cultural change for many organizations.

Model execution

It is important to have a set of clearly defined goals and outcome measures which are aligned with the strategic plan for the organization. Criteria for patient targeting and exclusion should be specific and agreed upon by all stakeholders. Include information technology leadership early in the planning process to make sure that data needs (status report parameters and outcomes measurement) are given priority.

Establish an engaged, consistent, and committed stakeholder group. This must include the hospital. The stakeholder group creates the well-defined workflows from the time of admission to the end of the intervention. All stakeholders must agree on the workflows and the timelines. Plan ongoing meetings to discuss results and modifications needed in the workflows. Include both stakeholders and coaches in these meetings. This provides a safe place to problem-solve operation issues and to celebrate successes.

Support to sustain the model

Planning must continue beyond the launch of the program. Early on, identify a contingency plan for staff turnover in the Transitions Coach role and define criteria for program expansion. This plan should include the recruitment and training of additional Transitions Coaches. Continually refine the business case in response to the changing health care environment and plan for how you will communicate your success, both inside and outside your organization.

Summary

The CTI is an evidence-based four week program where patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach to learn self-management skills that will ensure their needs are met during the transition from hospital or skilled nursing facility to home. This is a low-cost, low-intensity, scalable intervention comprised of a hospital visit, home visit, and three phone calls. Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one month intervention. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends.

References

Coleman, E.A., Parry, C., Chalmers, S., et al. (2006) The care transitions intervention: results of a randomized controlled trial. Archives of Internal Medicine, 166, 1822–1828.

Coleman, E.A. (2007) The Care Transitions Intervention: Improving Transitions Across Sites of Care Users Manual. Division of Healthcare Policy and Research, University of Colorado, School of Medicine, Denver, CO. Retrieved at http://www.caretransitions.org.

Coleman, E.A. (2008) Transition coaches reduce readmissions for Medicare patients with complex postdischarge needs. Agency for Healthcare Research and Quality Innovations Exchange, Rockville, MD. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=1833.

Parry, C., Coleman, E., Smith, J., et al. (2003) The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Services Quarterly, 22(3), 1–17.

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