transitions in care program mary bittner, rn, mpa, cenp, dnp(c) vice president, nursing
TRANSCRIPT
What is a Transitions Coach?
• They encourage patients to take a more active role in care
• They don’t fix problems or provide skilled care• They do model and facilitate new behaviors and
communication skills• They desire for patients to effectively manage
care after discharge and independently manage issues
Bond, Christinia Pavett; Coleman, Eric. Reducing Readmissions, A Blueprint for Improving Care Transitions.(Chapter 5, pg. 55-58)
Goals for Effective Coaching
• Patient Empowerment
• Improved Self-Management Skills
• Enhanced Patient to Practitioner Communication
• Strengthened ability to recognize early signs of potential problems
The Four Pillars
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Program Operations
• Transition Coach staffing Tuesday-Saturday
• Initial patient contact prior to hospital discharge
• Phone contact within 24 hours of discharge
• Face to face visit within 48-72 hours of discharge
Phase One Target Population
• CHF (Congestive Heart Failure)
• PNA (Pneumonia)
• DVT (Deep Vein Thrombosis)
Reasons: - Chronic Disease in our vulnerable elderly population. - Core Measure focus. - CMS no longer paying for readmissions within
30 days for CHF & PNA.
Target PopulationSubsequent Program Phases
• Newly diagnosed chronic disease patients
• Patients with frequent acute hospital re-admissions and/or multiple E.D. visits
• Patients with compliance issues and psycho-social challenges
http://www.caretransitions.org/structure.asp
Patient Personal Health Record
• Health & Symptoms
• Upcoming Provider Appointments & Recent Admissions
• Questions for Medical Providers
• Medication List
• Self Monitoring
Patient Personal Health Record
• Medical History
• Red Flags
• Goals
• Advanced Directives
• Important Phone Numbers
Monitoring Our Progress
• Patient contact tracking tool
• Metrics of measurement for 30 days
• Correlation to Utilization Management Committee readmissions data
• Evaluation of NRC Picker scores with patient perception of communication and answering questions