Hospital Readmission of patients after discharge is both prevalent and costly. In an attempt to reduce preventative hospital readmissions, the Care Transitions Project supports patients with self-management care goals after discharge with the assistance of a specially trained Health Coach. This project, one of the eleven by Care Compass Network (CCN), has been implemented throughout CCN’s nine-county region in collaboration with five health systems, nine hospitals and fourteen community-based organizations (CBOs).
The Care Transitions Project uses an evidenced based approach with a foundation in the Four Pillars® for coordinated care. These pillars are intended to prepare the patient for a successful transition to home and follow through by encouraging self-management and direct communication with their medical team. The support given by the Health Coach for each of the pillars empowers the patient and their families to learn new behaviors, skills and communication strategies that create success after hospitalizations.
The patient’s hospital care team prepares the patient for the next level of care ensuring each of the pillars are understood and the patient receives a “warm handoff” to their Health Coach prior to discharge. During this initial in-hospital visit, the Health Coach introduces themselves, explains their role and describes the support that will be provided. The Health coach reviews the discharge summary with the patient with an emphasis on the four pillars. The goal of this initial visit is to establish a comfort level between Health Coach and patient while they work together to assess unmet needs and begin to plan for the coming 30-days.
At the patient’s direction, ideally within 3 business days of discharge, the Health Coach performs an in-home visit. With a focus on the four pillars, the Health Coach uses a method known as Teach Back to validate the patient’s understanding of the pillars and their plan of care, and to uncover areas where they are able to assist the patient. The patient’s medication list is revisited to making sure there are no discrepancies and any further questions the patient may have are identified. If questions are raised, the patient is reminded to list them in their Personal Health Record to discuss at their follow-up appointment unless a quicker resolution is required, in which case the patient is directed to call their provider sooner. The patient is encouraged to bring their patient-centered health record with them to all appointments. This ensures continuity of care across providers as well as helping the patient be more confident in managing their self-care. Symptoms and side effects of worsening conditions are again discussed so that the patient knows how to respond, who to contact from their medical team and when.
Following the in-home visit, the Health Coach contacts the patient with three follow-up phone calls, generally a week apart. These calls are meant to support the patient and give the Health Coach the ability to assess what care needs remain for the patient. It also gives the patient the opportunity to ask any questions relating to their recovery. The Health Coach can again check in to make sure they patient has attended any follow-up visits, discuss the outcome of the visits and any next steps. Referrals for patients to other care providers or community-based programs such as Meals on Wheels, or assistance with transportation, housing, etc., that would complement their self-management goals are also made. During the phone calls the red flag indicators are reinforced by the Health Coach, confirming the patient knows who to contact should any problems arise. This is emphasized so that the condition can be caught early, decreasing the probability of an avoidable readmission to the hospital or emergency department visit. At the conclusion of the 30-day period the Health Coach submits a written summary to the patient’s primary care provider.
Certified Coleman Trainer, Sue Ellen Stuart, of Visiting Nurse Service of Ithaca and Tompkins County, assisted in building the Care Transitions Health Coach curriculum and provides monthly classes for Health Coaches. Health Coaches attend n 8-hour class once per month, reviewing the Four Pillars® as well as training on Teach Back and Motivational Interviewing. They also receive training on other community resources that can provide continued support for the patient during and beyond the 30-day program. The project has trained over 100 Health Coaches from different disciplines including social workers, home health aides, and respiratory therapists.
The most important takeaway that Stuart has for the Health Coaches she trains is the understanding that they “are doing something that can make a big difference. Each pillar is important, it will make an impact and make a difference.” She cites one case where a patient was given two copies of discharge papers and thought that meant they needed to take double meds. Because the Health Coach met with the patient within the 72-hour post-hospitalization window, they were able to clarify the appropriate medication amount with the patient.
Aside from managing the condition that the patient was hospitalized for, Health Coaches are also able to identify and address any barriers they may face post discharge. While creating a relationship with the patient the Health Coach can assess social determinants and what, if any, support systems exist. They also learn in their training about the community resources available so that they are better able to connect patients to organizations that can assist them in overcoming any potential barriers.
Health Coaches also teach the patient coping mechanisms for their health conditions and work with other family members to support the patient. Jena Stickler, a Health Coach with the Family and Children’s Society, described a home visit with a woman who had been hospitalized for mental health concerns. As Jena and her patient were creating a list of activities and helpful homework the patient’s husband jumped in and started making suggestions. “I think that was helpful,” Stickler says. “Because the patient’s husband now also had buy-in and understood how this list was helping his wife heal.”
One another visit Stickler met with an elderly patient who had undergone surgery for a large tumor and was having follow up chemotherapy. Through her conversations with the patient she realized that the patient provided care for her husband who had a disability. The couple was hoping to have home care but were unsure of how to initiate it. Stickler walked them through the process so that when chemo began the patient and her husband had everything they needed in place, reducing stress and possibly preventing future hospitalizations of either spouse.
Greg Rittenhouse, Care Compass Network Strategic Advisor, emphasizes the networks and relationships that are developing through this project. “The Care Transitions Project is helping to break down the silos between providers and community-based organizations,” he states. “The sharing has occurred so openly.”
The Care Transitions Project is creating what Rittenhouse describes as “a model that is generalizable and scalable.” Throughout the nine-counties where the program is being implemented resources can be quite different. What works will for an urban area may not work the same for rural counties. The participating organizations are working together to find alternative ways of approaching the specific needs of their communities. “This helps patients receive the best, most appropriate care,” Rittenhouse reports. “The people and organizations working on this common goal, their understanding and commitment, is extraordinary,” he says.
Not only are Health Coaches bridging gaps in care but organizations are understanding who their community partners are and what it is they are doing. The skills and competencies that are being gained are not only beneficial for the Medicaid population that are being served through this project, but they can be transferred to the care of all patients. Juned Mohammed, Care Compass Network Project Manager for the Care Transition Project says “care is best delivered at the community level.” This is evident with the success seen through the Care Transitions Project.