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