Care Transitions Intervention
The Coleman Model
Introduction
• ADRC of Eau Claire County– 1st to implement this model
in Wisconsin; evidence based model
• Partner health care facilities: Mayo Clinic Health System,
St. Joseph’s, Sacred Heart Hospital & Dove Healthcare
• Collaborating with ADRC in Chippewa County to serve
patients discharged to Chippewa County
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• Lisa Riley, APSW – Certified Coach (1.0 FTE)
• Miranda Hotter, CSW – Prevention Program Coordinator
(.5 FTE)/Certified Coach (.5 FTE)
• Emily Rogers, CSW- Certified Coach (.75 FTE)
• Jennifer Owen, CSW – Supervisor
Timeline
• Hospitals worked to identify potential root cause(s) for
readmission (Fall 2011)
• Readmission data provided by Metastar (Fall 2011)
• Coalition reviewed the data and intervention options
• Identified the Care Transitions Intervention, Coleman Model,
as the starting point
• ADRCs in Eau Claire and Chippewa Counties are funding the
project in 2012
• Began the intervention in February 2012 with Mayo Clinic
Health System in Eau Claire
• April 2012- expanded to Sacred Heart Hospital in Eau Claire
• May 2012- expanding to St. Joseph’s Hospital and patients
discharge to Chippewa County
The Issue
• When patients are inadequately prepared for the next setting
(hospital to home) they or their caregivers act as default care
coordinators
• This can lead to med errors, postponed care, and re-hospitalization
(which is defined as re-entering within 30 days, regardless of
diagnoses or cause)
• This re-hospitalization is costly in terms of quality of life for
patients, and is financially costly for hospitals and usage of
Medicare dollars
• Hospitals will have financial repercussions from high rehospitalization rates
The Goal
 “The transition coach’s role is
based on teaching the skills,
knowledge, and attitude necessary
to empower patients to manage
their own care.”
Eligibility Criteria
• Patients at high risk of readmission as identified by the
hospital via their risk screening tool
• Discharges to Eau Claire County & Chippewa County
• Medicare beneficiary
• Living independently (not in CBRF or long term SNF)
• Diagnoses: CHF, COPD, coronary artery disease, diabetes,
stroke, spinal stenosis, hip fracture, peripheral vascular
disease, cardiac arrhythmias, pulmonary embolism, DVT, &
individuals with dementia that have an active/able caregiver
• Exclusions: Those on hospice, managed care, primary AODA
or primary psych. diagnosis
• Note: If the patient goes to short term rehab, the
intervention will continue when they leave from the nursing
home and return home
Coaching
Coaching is…
Coaching is not…
T EAC H I N G PAT I E N TS
TO F I S H R AT H E R T H A N
GIVING THEM A FISH
D I R EC T PAT I E N T C A R E
OR
LO N G T E R M C A S E
M A N AG E M E NT
The Four Pillars
• 1. Medication Self-management
• 2. Patient Health Record (PHR)
• 3. Timely Follow up with primary and/or
specialist physician
• 4. Red Flags
Program Structure
5 contacts, designed to be a “catch & release” intervention -30
days
• 1 Hospital visit – introduction of the program to the patient and/or
family, rapport building, providing PHR (Done when patient is
medically stable, prior to time of discharge)
• 1 Home visit – patient engages in med. reconciliation with verbal
cues from coach, encouragement to schedule to f/u appt with
doctor. Patient centered agenda and pace (Ideally done 24-72
hours after d/c)
• 3 Follow up phone calls – follow up regarding patient’s appt. with
physician, discuss any of the 4 pillars that weren’t covered in the
home visit, address needs identified by patient and family (These
calls are done incrementally over the remaining 30 days)
1. Medication Self-Management
• The goal is that the patient is knowledgeable about his/her
medications and has a management system
• The management system has to be realistic and individual to the
person
• Coach is non judgmental and realistic, i.e. Whatever the patient
was doing before the Coach arrives is what they will continue to do
when the Coach leaves
2. Patient Health Record (PHR)
• A record of the patients health conditions, in his or her own words
• List of medications (dose, frequency, & reason) how they actually
take it, not necessarily as prescribed
• Space for the patient’s self-identified goal
• Space for patient’s concerns & questions for follow up visit with
their physician or other provider (RN/PT/Pharmacist)
• Space for Red Flags
It is essential that the patient fill this out or has a consistent person to do it.
The Coach will not be there in the future update it.
3. Patient Follow up with Physician
• Coach will encourage and remind patient to schedule a follow up
with their primary physician once out of the hospital. Many patients
do not realize that their physician may not be aware they were in
the hospital
• Coach can role play this with patient to build skills in effectively
getting a quick appointment, i.e. “I was just in the hospital for my
CHF and have some questions about my medication” may be more
effective than simply “I need an appointment.”
• This follow up appointment is when the physician will look at PHR &
learn about a possible med error or concern
4. Red Flags
• Patients will identify and write down the
indications that their condition is worsening…
i.e. “what were you feeling before you went to
the
hospital?”
• Along with that – they will identify what their
plan is when they experience these red flags
Coaching role
• Coaching is not a replacement of any other current
provider
• It does not attempt to replace discharge planners or
home health nurses
• Coaching is intended to supplement any other service
that a patient receives and enhance the patients
effectiveness in utilizing these services and
communicating with other providers
• Coaching requires flexibility and letting go of rigid
agendas
Transitioning from
this…
To this
How we are we measuring
success?
• Re-hospitalization rates will be monitored (QIO)
• Patient activation scale – self care competencies are measured by
the coach at first contact and after the last phone contact (simple
10 questions). Any positive movement is considered a success.
• Follow up survey at 30, 60, 90, 180 days after intervention
Note: It is to be expected that some patients will not progress in
their skills, it requires a willingness to be empowered
What we have seen so far…
In the first 3 months of the program operating (February-May):
• 140 referrals have been made to the program
• 112 referrals accepted participation in the program (80%)- our
goal is to have a 90%+ acceptance rate but this will take time
• 39 have fully completed the program to date
• Average increase in patient activation assessment score is 2
points
• We are only aware of 2 readmissions that occurred within 30
days of completing the program; 0 readmissions within 60
days of completion
• Medicare claims data will provide us with more concrete
evidence, however, there is about a 3-6 month lag in data
"My Transitions Coach® has helped me to
feel more confident in managing my heart
condition. I feel as though I am in charge
of my health and I am less reliant on
others.“
Contact info
• ADRC of Eau Claire County 715.839.4735
• Lisa Riley 715.839.1870
lisa.riley@co.eau-claire.wi.us
• Miranda Hotter 715.839.7998
miranda.hotter@co.eau-claire.wi.us
• Emily Rogers 715.839.1272
emily.rogers@co.eau-claire.wi.us
• Jennifer Owen 715.839.6713
jennifer.owen@co.eau-claire.wi.us
www.caretransitions.org