Coach­ing with care

Pa­tient ad­vo­cates help guide post-hos­pi­tal care in an ef­fort to im­prove out­comes, re­duce read­mis­sions

Modern Healthcare - - Patient Safety -

Dur­ing the course of an av­er­age work­day, Becky Cline sifts through plas­tic shop­ping bags full of med­i­ca­tion bot­tles, re­views lengthy post-dis­charge plans, co­or­di­nates fol­low-up ap­point­ments, and acts out var­i­ous role-play­ing sce­nar­ios with pa­tients in or­der to ed­u­cate them on the red flags of their chronic dis­eases.

Cline is a reg­is­tered nurse and a tran­si­tion coach, em­ployed by Physi­cian Health Part­ners, a man­age­ment-ser­vices or­ga­ni­za­tion based in Den­ver, and she is charged with pro­vid­ing a crit­i­cal bridge be­tween the hos­pi­tal and the home.

She works with roughly 25 pa­tients at a time, all of whom are in var­i­ous stages of the tran­si­tion pro­gram and all of whom have one or more of three chronic con­di­tions: di­a­betes, con­ges­tive heart fail­ure or chronic ob­struc­tive pul­monary dis­ease. She meets with pa­tients briefly in the hos­pi­tal be­fore they are dis­charged, comes to their homes for an hour­long, in-per­son visit and fol­lows up with pe­ri­odic phone calls. The end goal, Cline says, is to em­power pa­tients and their fam­i­lies to take a more ac­tive role in their care, thereby re­duc­ing the rate of hos­pi­tal read­mis­sions.

While pre­ventable re­hos­pi­tal­iza­tions have been a long-stand­ing prob­lem, providers are now scram­bling to find ways to ef­fec­tively ad­dress them, par­tic­u­larly af­ter the pas­sage of the Pa­tient Pro­tec­tion and Af­ford­able Care Act of 2010, which in­cludes a pay­ment penalty in two years for hos­pi­tals with the high­est rates of read­mis­sions.

The star­tling statis­tics re­lated to re­hos­pi­tal­iza­tions are noth­ing new: one out of ev­ery five Medi­care pa­tients dis­charged from the hos­pi­tal is read­mit­ted within 30 days, and nearly 75% of those read­mis­sions are pre­ventable. And the prob­lem is a se­ri­ous, costly one, to­tal­ing more than $17 bil­lion in ad­di­tional Medi­care spend­ing each year, ac­cord­ing to a widely pub­li­cized study pub­lished in the April 2, 2009 is­sue of the New Eng­land

Jour­nal of Medicine.

The prospect of re­duced pay­ments, which are set to take ef­fect in Oc­to­ber 2012, has prompted in­creas­ing num­bers of hos­pi­tals and pay­ers to turn to so­lu­tions that in­cor­po­rate the use of one per­son—a coach or ad­vo­cate—who es­tab­lishes per­sonal re­la­tion­ships, pro­motes self-care and guides pa­tients through the thorny pe­riod fol­low­ing dis­charge from a hos­pi­tal.

“ I’ve had pa­tients who’ve been pre­scribed generic and trade ver­sions of med­i­ca­tions and are tak­ing both of them, and I’ve had di­a­betic pa­tients who don’t even know how to test their blood sugar,” says Cline, who has worked as a coach for three years. “There’s a lot of con­fu­sion so it’s very im­por­tant that pa­tients re­ceive help in an en­vi­ron­ment where they feel com­fort­able ask­ing ques­tions and mak­ing de­ci­sions for them­selves.”

Physi­cian Health Part­ners’ ap­proach is based on the Care Tran­si­tions In­ter­ven­tion model. De­vel­oped 12 years ago by Eric Cole­man, a geri­a­tri­cian and pro­fes­sor of medicine, and his col­leagues at the Uni­ver­sity of Colorado at Den­ver, CTI is a four-week pro­gram aimed at pro­mot­ing self-man­age­ment among high-risk pa­tients. The in­ter­ven­tion is based on four com­po­nents, or “pil­lars”: med­i­ca­tion man­age­ment; fol­low-up care with a pri­mary-care physi­cian or spe­cial­ist; use of a paper-based per­sonal health record; and ed­u­ca­tion about the warn­ing signs that a con­di­tion is wors­en­ing and what to do when they arise.

Mod­els of be­hav­ior

“Coaches don’t fix prob­lems,” Cole­man ex­plains. “They model be­hav­ior on sce­nar­ios such as med­i­ca­tion con­fu­sion, con­flict­ing ad­vice, fol­low-up care and what symp­toms mean. Adults don’t learn by read­ing brochures. They learn by re­hearsal, prac­tice and role-play­ing.”

Cole­man’s model has pretty tight guide­lines. Coaches visit high-risk pa­tients in the hos­pi­tal to es­tab­lish a rap­port, meet with pa­tients in their homes—ide­ally within 72 hours of dis­charge—and then fol­low up with them three times by phone. The re­sult, he says, is a rel­a­tively short, low-cost, low-in­ten­sity in­ter­ven­tion that can be de­ployed in a wide range of set­tings. As of July, 309 sites in 38 states had im­ple­mented the model.

Train­ing is made avail­able to in­ter­ested sites, Cole­man says, and the scope and price tag vary depend­ing on the size of the or­ga­ni­za­tion and the num­ber of coaches they want to use.

In a 2006 ar­ti­cle in the Archives of In­ter­nal Medicine, Cole­man and sev­eral other re­searchers pre­sented the re­sults of a ran­dom­ized con­trolled trial test­ing the Care Tran­si­tions In­ter­ven­tion model. They found lower re­hos­pi­tal­iza­tion rates at 30, 90 and

Brian Jack of Bos­ton Uni­ver­sity’s School of Medicine leads Project Re-En­gi­neered Dis­charge. The pro­gram uses a va­ri­ety of pa­tient-ed­u­ca­tion tools, in­clud­ing a com­put­er­ized “coach” named Louise, who gives post-dis­charge in­struc­tions to pa­tients.

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