Barbra Link, Director of Care Transitions (248) 262-9223
Tina Berry, Care Transitions Supervisor (248) 263-1444
Strategy One: CTI Coaching
Hospital to Home
Strategy Two: CTI Coaching with Behavior Interventions
Hospital to Home
Strategy Three: CTI Coaching with In-Home Services
Hospital to Home
Participant: Mrs. Smith had been a heavy smoker for many years. Her husband and daughter are also
smokers. She had been in and out of the hospital several times in the last months for treatment of her
COPD. She has tried to quit smoking in the past, but had been unsuccessful because of the other
smokers in her home.
Intervention: Kathy, Mrs. Smith's AAA 1-B CT Coach, employed Care Transitions Intervention Coaching,
including a hospital visit, home visit, use of the Personal Health Record (PHR), and follow-up calls. Mrs.
Smith identified during her home visit that weakness and shortness of breath were her red flags and her
personal goal was to breathe better and quit smoking. Kathy processed the next steps towards her
achieving her goal, which included advocating for a smoke-free home to her family.
Outcome: Mrs. Smith did not smoke and did not readmit to the hospital for the full 30 days she worked with
Kathy. Moreover, Mr. Smith and their daughter began only smoking outside the home. Not only did
this help Mrs. Smith to resist the temptation to smoke and minimize the affect of smoking on her COPD,
it helped her to feel cared for and supported.
Participant: Edgar was admitted to the hospital with pneumonia, but his bipolar disorder and depression were
barriers to his independent participation in his recovery process. He'd been in the hospital before with
pneumonia and harbored continuing fear and anxiety about the discomfort and limitations it brought to
his life. His goal was to be able to walk outside, an activity which he very much enjoyed but was fearful
of doing because he believed it would bring his pneumonia back. Beyond the pneumonia, Edgar had
difficulty adhering to the medication regimen recommended by his physician, psychiatrist and the
hospital staff. He expected the hospital staff to have placed all the correct medications in a bag for him
at discharge and did not want to take certain antipsychotic medications which were prescribed. Edgar
had never read discharge instructions from any previous hospital stay.
Intervention: Desiree adapted CTI Coaching to address Edgar's depression, anxiety and bipolar disorder.
During their home visit, significant redirecting was needed for Edgar to be successful completing the
medication review and using the PHR. Desiree's skill and experience with behavioral health diagnoses
and treatment allowed her to coach Edgar successfully. She was able to assist Edgar in determining
which of his questions were best suited to his primary care physician (PCP) or his psychiatrist.
Referrals to community based behavioral health resources and programs were available, should Edgar
need them. For the first time, Edgar read through his complete hospital discharge instructions.
Outcome: Edgar successfully remained out of the hospital for 30 days. He discussed how and when to walk
outside without risking exacerbating his pneumonia. He arranged for the purchase of meds he had not
been taking and discussed with his psychiatrist his reluctance to take certain prescriptions. Edgar
described to Desiree that he found his discharge instructions to be useful and intended to read them for
any future hospital discharges.
Participant: Brigitta Temple was admitted to the hospital related to her diagnosis of CHF. She also has a
seizure disorder which contributes to her anxiety about staying home when she experiences her
condition's red flags. Brigitta's husband speaks minimal English and is not able to provide much
support. Her goal was to walk down the driveway and be outside.
Intervention: Lisa, Brigitta's CTI coach, connected Brigitta with community based services in addition to CTI
coaching. A Personal Emergency Response System (PERS) was provided which gave Brigitta an
increased sense of safety and connectedness to help if she needed it. Home-delivered meals were put
in place. This more nutritious and well-balanced diet, in conjunction with her beginning to do daily
weights, significantly impacted her CHF symptoms.
Outcome: Brigitta was able to avoid readmission for the 30 days of her intervention. She worked with her AAA
1-B Care Transitions Service Coordinator to arrange for the PERS and home-delivered meals to
continue past the 30-day CT program.
Note: Names and other identifying patient information have been changed to ensure privacy and confidentiality.
Barbra Link, Director of Care Transitions (248) 262-9223
Tina Berry, Care Transitions Supervisor (248) 263-1444
Strategy Four: CTI Coaching with Multiple Interventions & Hospice
Hospital to Home
Strategy Five: Skilled Nursing Facility (SNF) Transitions Coaching
Hospital to SNF to Home
Participant: Elmer was admitted to the hospital with diagnoses of COPD, A-Fib and a cancerous lung mass. He
was recommended for hospice, but refused at discharge. He accepted home care and CT coaching.
Elmer lives alone and has difficulty breathing, necessitating 24-hour oxygen. He was prescribed four
medications upon discharge, but had more than a dozen prescription bottles and was unable to
describe the use or how to take any of them. Elmer threw away a new prescription and the discharge
instructions, saying that he didn't need them and couldn't afford them anyway. When the CT Coach
made the initial home visit, he had yet to be seen by home care.
Intervention: Denise provided Elmer intensive coaching with multiple levels of intervention, including the
following:
 Daily home visits and phone calls for the full 30 days.
 Follow-up with home care to ensure services were provided.
 Ordering a PERS, being at the home to ensure it was set up and review of red flags to ensure
Elmer knew when to activate it.
 In depth medication reconciliation including coordination with the home care nurse to find the
lost prescription and establish a medication management system that Elmer, unable to read
letters, could follow.
 Health literacy and education with Elmer's daughter, strengthening her role as a caregiver.
 Ongoing exploration into why Elmer refused hospice and education around the role of hospice.
Outcome: Elmer was not readmitted to the hospital within the 30 days. After sharing with Denise a story about
the loss of a friend who had been on hospice, Denise coordinated additional education around the
purpose of hospice. Elmer did accept hospice care and Denise was there to make sure he received
services. The PERS remains in place after the CT program ended, Elmer's daughter is a more
competent and confident caregiver and is connected to respite services, and Elmer is satisfied with his
hospice care. In a last phone call with Denise he said, “I know I am stubborn and am just glad you
were a friend enough to stick with me all this time. You are the best buddy I have ever had.”
Participant: Mr. Lincoln was hospitalized for pneumonia and then was transferred to a SNF. As he has
dementia, his wife acted as the primary learner in coaching. While at the SNF, he experienced
significant difficulty swallowing, was placed on a pureed diet, and salivated so much that his speech
was unintelligible. These symptoms were significantly reducing his quality of life. While Mr. Lincoln had
been a resident at this SNF before, he and his wife had not attended a care conference. Mrs. Lincoln
was scheduled for a hip replacement near the time of Mr. Lincoln's anticipated discharge and there
were no other caregivers available, though this had not been communicated to the SNF.
Intervention: Jodi provided CTI coaching to the Lincolns, augmenting the CTI model with education about the
function and services of SNFs. Jodi helped Mrs. Lincoln to understand the purpose and availability of a
family meeting or care conference with the SNF staff as a way of sharing her observations and goals for
her husband. With Jodi's encouragement and some role play, Mrs. Lincoln was able to schedule a care
conference. She used the PHR to organize the information she wanted to share and questions she
wanted to ask.
Outcome: At the care conference, the SNF staff and the Lincolns initiated medication review that resulted in
medication changes and Mr. Lincoln being able to speak more clearly. Plans were put in place around
Mrs. Lincoln’s hip surgery. A swallow test was ordered to explore the cause of Mr. Lincoln’s symptoms.
Mrs. Lincoln expressed feeling more engaged in managing her husband's recovery and felt more heard
by the SNF staff. The swallow test showed an obstruction, and Mr. Lincoln was sent back to the
hospital to remove it. Unfortunately, he passed away during the procedure. Mrs. Lincoln, though
grieving, indicated that she would be able to use the skills she learned during her own recovery
following her hip surgery.
Note: Names and other identifying patient information have been changed to ensure privacy and confidentiality.