Care Transitions Process Gets Up and Running to Empower Patients

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When Care Compass Network (CCN) conducted a community health assessment in 2014, one of the major issues to emerge was avoidable readmission. Too many Medicaid patients who are discharged from the hospital return within 30 days. Often, they come back needing more care because they haven’t fully followed their discharge instructions—not taking medication correctly, or failing to keep follow-up medical appointments.

Twenty percent of Medicare patients discharged from the hospital in 2010 were readmitted for avoidable reasons, incurring costs of about $17.6 billion, according to Center for Medicare and Medicaid Services (CMS). The problem for Medicaid patients is similar in scale.

That’s why CCN launched the Care Transitions project, a collaboration designed to empower Medicaid patients in our nine-county region to understand and follow their discharge instructions.

“This program gives patients more attention in areas that might send them back to the hospital, such as symptoms they should be aware of and how to understand their medications,” says Josephine Anderson, program manager for New York State DSRIP programs at Guthrie. Anderson is one of nearly 40 subject matter experts who brings a wide variety of perspectives and deep knowledge of the local health care environment to the Care Transitions project team.

That team has developed a standard set of protocols for helping a Medicaid patient during and after discharge. The protocol focuses on four areas, known as the Four Pillars: medication self-management; following up with a primary care provider (PCP) or medical specialist; recognizing “red flag” symptoms that call for medical attention; and keeping a personal health record for use when talking with the PCP.

Support for old woman from her carer

To help with this transition, on discharge a hospital assigns each Medicaid patient a health care coach—a carefully-trained nurse, social worker or other professional drawn from a local community organization. The process starts in the hospital, where coach and patient review the patient’s discharge instructions and discuss any special concerns, such as language barriers or lack of transportation. The coach also discusses how to fill out the personal health record and use it as a tool for taking control of one’s own care.

Over the next 30 days, the coach visits the patient once at home and follows up with three phone calls, to make sure the patient adheres to the discharge instructions.

“With patient consent, we’ll follow that patient into the community to ensure that the patient follows up with the primary care provider, that they have access to their medications, and that they are well-versed in the signs and symptoms that their disease might be growing worse,” says Rochelle Eggleton, MBA, BS, RN, service line administrator at Lourdes at Home and the Hospice at Lourdes, and co-lead of the Care Transitions project. The coach will also encourage the patient to call the PCP with any questions or concerns, using the personal health record as a tool in that discussion.

CCN contracted with one of its partner organizations, Visiting Nurse Service (VNS) of Ithaca and Tompkins County, to develop training for the health coaches. The curriculum is based largely on the care transitions model developed by Dr. Eric A. Coleman of the University of Colorado, but tailored to the needs of patients in our region.  The Care Transitions project team reviewed the curriculum extensively to make sure it would accomplish the goals of the project. VNS also conducts the health coach training sessions.

In part, the team chose VNS for this role because it was already providing health coaches in Tompkins County, using a similar protocol. Based on that experience, VNS became the first of CCN’s community partners to start coaching Medicaid patients under the new Care Transitions program. Serving Medicaid patients discharged from Cayuga Medical Center, VNS has already seen some notable success.

Sue Ellen Stuart, BNS, MS, executive director of VNS, tells of one patient who, on leaving the hospital, received two copies of the discharge instructions rather than one. “They thought that meant they should take double doses of their medication,” she says. “When the health coach made the visit, they clarified the instructions.” With one short conversation, the coach stopped the patient from taking a potentially-harmful overdose.

While elements of the Care Transitions program have been in place at each of our partner hospitals for quite some time, all of those hospitals are gearing up now to implement the full protocol—especially the personal health care record, which is new to most of them.

As hospitals and community partners continue to roll out Care Transitions, the project team also looks forward to applying the protocol to a wider range of patients. “This process has great scalability and can be generalized to patients who are treated and released from emergency departments,” says Greg Rittenhouse, Care Transitions project co-lead at CCN.

Throughout the two and half years leading to implementation, the Care Transitions team has shown terrific commitment to the project and done a remarkable job, Rittenhouse says. “Their work demonstrates how important it is to capitalize on all the resources in our community to achieve a positive outcome.”