Care Transitions (Coleman)
Eric Coleman, M.D., M.P.H.
The Division of Health Care Policy and Research
13611 East Colfax Avenue, Suite 100
Aurora, CO 80045-5701
Office: (303) 724-2523
Fax: (303) 724-2486
Care Transitions Website
OVERALL SNAPSHOT OF CAREGIVER INTERVENTION/PROGRAM:
The overriding goal of the Care Transitions ProgramSM is to improve care transitions by providing patients and their caregivers with tools and support to encourage them to more actively participate in the transition from hospital to home. The program aims to support patients and families; increase skills among healthcare providers; enhance the ability of health information technology to promote health information exchange across care settings; implement system level interventions to improve quality and safety; develop performance measures and public reporting mechanisms; and influence health policy at the national level. During this 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a “Transition Coach,” to learn self-management skills that will ensure their needs are met during the transition from hospital to home. The intervention focuses on four conceptual areas, referred to as pillars, based on the domains that emerged from focus groups:
1) Medication self-management: Patient is knowledgeable about medications and has a
medication management system.
2) Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The PHR is managed by the patient or informal caregiver.
3) Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions.
4) Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.
The four pillars are operationalized through two mechanisms: 1) a Personal Health Record (PHR) and 2) a series of structured visits and phone calls with a Transition Coach. Both of these mechanisms are designed to empower and educate older patients to meet their health care needs and ensure continuity of care in the transition(s) following discharge from a hospital.
Evidence supporting this program has shown that individuals who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five-months after the end of the one-month intervention. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends. Anticipated cost savings for 350 chronically ill adults with an initial hospitalization over 12 months is $295,594. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.
BRIEF BACKGROUND RELATED TO THE DEVELOPMENT OF THE INTERVENTION:
Older adults moving between different health care settings are particularly vulnerable to receiving fragmented care. Delivery of health care is often divided into discrete aspects of care that often function in isolation of one another. A number of barriers including financial, regulatory, and professional barriers serve to further reinforce separation of care such that care coordination across settings is lacking. When practitioners in different settings function independently with no common plan of care, older adult patients may be adversely affected (Coleman et al., 2004).
The development of the Care Transitions ProgramSM grew out of this need to reduce fragmented care and to assist older patients and their family members in making smooth transitions. Because patients and their caregivers are often the only common factor moving across sites of care, they represent agents of change for an intervention program designed to improve care transitions. The program was designed to encourage older patients and their caregivers to assert a more active role in their care transitions to reduce subsequent use of hospital and emergency services.
TARGETED CAREGIVER POPULATION (AGE, ETHNICITY, CONDITION/DISEASE):
The primary targeted caregiver population studied has been with adult patients with at least one of nine diagnoses chosen because of their high likelihood for requiring post-hospital skilled nursing facility (SNF) or home health care. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes mellitus, stroke, medical and surgical back conditions, hip fracture, peripheral vascular disease, and cardiac arrhythmias. Patients in which the intervention was tested on had to reside in the community (e.g., not in a long-term care institution) before and after hospitalization. To date, the evidence supporting the efficacy of this intervention has been with predominantly Caucasian older adult patients. As this intervention has been adopted across the country, the intervention developers have found that at least ¾ Medicare beneficiaries cab be coached. These patients represent great diversity with respect to education level, health literacy, primary language, race/ethnicity, and presence of family caregiver.
A comprehensive description of program materials can be found on the Care Transitions
website. The website consists of a descriptive training and implementation toolkit which includes a training DVD, manual, Personal Health Record (PHR), tools for coaches, performance measures (NQF endorsed Care Transitions Measure or CTM), business plan, and case studies. The intervention developers request that interested individuals visit their website to view detailed information regarding the intervention materials.
MANUAL OF PROCEDURES
: This printer friendly, detailed version can be viewed and downloaded. The manual provides a very thorough guideline for implementing the intervention as well as forms/tools.
: Outcome measures that have been used to evaluate the efficacy of the intervention in a randomized controlled trial (RCT) of the intervention are described in brief below. The intervention developers have created several intervention-specific measures and request that interested individuals refer to the Care Transitions website for more information regarding the measures as well as costs. Lastly, individuals are encouraged to revisit the website on a continual basis to check for any updates.
Outcome Measures Related to Patient
Rehospitalization rates. Rates of nonelective rehospitalization at 30, 90, and 180 days after discharge from the index of hospitalization. The rate of rehospitalization for the same health condition that prompted the index of hospitalization. When used to evaluate this program, rehospitalization data was abstracted from the study delivery system’s administrative records.
Intervention/Program Specific Measures
A number of intervention-specific measures can be found on the Care Transitions website.
: Please refer to the Care Transitions website for program materials.
OTHER INTERVENTION RESOURCES:
A Care Transitions Intervention Business Plan
Sample Transition Coach Scripts
TOTAL LENGTH OF INTERVENTION/PROGRAM:
4-weeks; Patients’ post-hospital discharge needs extend from 21 to 28 days. As such, the Transition Coach is involved and available to patients and their caregivers for up to 28 days.
NUMBER OF SESSIONS:
5 sessions total, including an initial contact between the patient and Transition Coach made in the hospital, followed by a home (or SNF) visit shortly after discharge, and three phone calls at 2, 7, and 14 days post-transition. Ideally, the home visit takes place within 24 to 48 hours. However, the visits may be later in the case of scheduling difficulties or patient preference.
LENGTH OF EACH SESSION
: In general, the hospital visit usually takes approximately 45 minutes, which includes time to gather information needed to help complete the PHR and reconcile medications at the home visit, establish rapport and explain the program to the patient and/or caregiver. The home visit usually takes approximately 60 minutes (not including travel time). The follow-up telephone calls range between 5 to 15 minutes each.
DESCRIPTION OF SESSION CONTENT
Overview of Program Structure (Coleman et al., 2004)
The Transition Coach first engages with the patient upon admission to the hospital. He/she works closely with patients and their caregivers to ensure a smooth transition from hospital to home following an acute episode requiring hospitalization. While the Transition Coach may interact with other service providers, the Transition Coach’s role is not that of a service broker or care manager. Rather, the Transition Coach is a source of information and support for the patient, assisting the patient in identifying key questions or concerns and empowering the patient to make contact with health care providers as necessary.
The Transition Coach functions as a facilitator of interdisciplinary collaboration across the transition, coaching the older patient and caregiver to play a central and active role in the formation and execution of the plan of care. Aside from the Transition Coach, no new interdisciplinary team members are introduced: the interdisciplinary teams are already in place in the respective settings (i.e., hospital, skilled nursing facility, home care, and ambulatory care). Rather, the purpose of this model is to focus on the patient’s needs during transition, thereby expanding the purview of the traditional team. The older patient, caregiver and Transition Coach work together to maximize the involvement of interdisciplinary expertise, ensuring that the appropriate professionals are involved, critical issues are addressed, treatment goals are understood, and the care plan is executed correctly. The primary role of the Transition Coach is to encourage self-management and direct communication between the patient/caregiver and primary care provider rather than to function as another health care provider per se. However, if necessary, the Transition Coach may make phone calls and facilitate connections when a critical need is present, coordinating communication with home health nurses, care managers, and primary care physicians involved with the patient’s care.
The PHR is a dynamic record book consisting of the essential elements for facilitating productive interdisciplinary and patient-provider contacts during current and future care transitions. These elements include a record of the patient’s medical history, medications and allergies, a list of red flags, or warning signs, a structured checklist of critical activities that need to take place prior to discharge (such as instructions and dates of follow-up appointments), and space for the patient to record questions and concerns. In contrast to hospital or physician-maintained medical records, the PHR is maintained and updated by the patient and, as necessary, by the Transition Coach. The intent behind the design of the PHR was that it needs to be simple and easily integrated into the paper or electronic medical record formats of practice settings.
Initial contact between the patient and Transition Coach is made in the hospital, and is followed by a home (or skilled nursing facility) visit shortly after discharge, and three phone calls at 2, 7, and 14 days post- transition. Ideally, the home visit takes place within 24 to 48 hours. However, the visits may be later in the case of scheduling difficulties or patient preference.
During the hospital visit, the Transition Coach introduces herself and the program to the patient and conducts the initial session aimed at imparting skills for greater self-management. The hospital visit is designed to help patients and their caregivers understand and use the PHR and Intervention Activities Checklist, and to prepare patients and caregivers for discharge.
Follow-Up Visits at Home or Skilled Nursing Facility:
The follow-up visits in the skilled nursing facility and/or home, along with the accompanying phone calls, are designed to empower patients to play a more active and informed role in managing their care by expanding upon the information provided in the initial hospital visit and providing continuity across the transition.
While the four conceptual domains, or pillars, are reviewed during each contact, the intervention is tailored to the individual patient’s needs, goals, and priorities at each stage of the transition. Thus, while the overall content of the pillars is revisited and reinforced at each contact between the patient and Transition Coach, the specific format and content of the pillars varies by patient and by visit. For example, during the home visit, the Transition Coach may discover that the patient has already scheduled a follow-up appointment and understands the red flags and warning signs that his or her condition is worsening, but may be confused about which medications and dosages to take. In this case, the primary focus of the visit would be medication management. Ultimately, the patient’s readiness and ability to invest in the content of the pillars dictates the timing and focus on specific content.
The intervention addresses patient empowerment and self-management at a broader level by discussing the care plan with patients, reviewing possible transfer-related problems and creating prevention strategies in areas such as pain management, goal-setting, and lifestyle issues. The Transition Coach also assists patients in developing questions and role-playing interactions with providers. By modeling empowerment and providing patients with information, the intervention has the potential to alter the paradigm within which patients interact with the medical system, rendering them more responsible, aware, and savvy managers of their own health.
The relationship between the four pillars and the specific goals and tasks for each stage of the intervention is illustrated in Table 1.
Table 1. Care Transitions Intervention Activities by Pillar and State of Intervention (Reproduced from: http://www.caretransitions.org/structure.asp and Coleman et al., 2004)
Pillar: Medication Self-Management Dynamic Patient-Centered Record Follow-Up Red Flags
Goal Patient is knowledgeable about medications and has system Patient understands and manages a Personal Health Record (PHR) Patient schedules and completes follow-up visit with Primary Care Provider/Specialist Patient is knowledgeable about indications that condition is worsening and how to respond
Hospital Visit Discuss importance of knowing medications Explain PHR Recommend Primary Care Provider follow-up visit Discuss symptoms and drug reactions
Home Visit Reconcile pre- and post-hospitalization medication lists
Identify and correct any discrepancies Review and update PHR
Review discharge summary
Encourage patient to share PHR with Primary Care Provider and/or Specialist Emphasize importance of the follow-up visit
Practice and role-play questions for the Primary Care Provider Assess condition
Discuss symptoms and side effects of medications
Follow-Up Calls Answer any remaining medication questions Discuss outcome of visit with Primary Care Provider or Specialist Provide advocacy in getting appointment, if necessary Reinforce when/if Primary Care Provider should be called
METHOD OF ADMINISTRATION/DELIVERY:
This program is intended to be delivered in the 1) hospital, 2) home or skilled nursing facility, and 3) over the telephone.
The Investigators have a training program that takes place over 1.5 days and is highly experiential. Individuals interested in training may reach the PI and other program developers via the website or via email:
Carla Parry, PhD, MSW, e-mail: Carla.Parry@uchsc.edu
Susan Rosenbek, RN, MS, e-mail: firstname.lastname@example.org
Eric Coleman, MD, MPH, e-mail: Eric.Coleman@uchsc.edu
The investigators are hoping to explore a train-the-trainer model with their partners to reduce the costs of their teams coming out to train over multiple visits. To date, the Care Transitions Program team has collaborated with 16 leading health care delivery organizations to adapt the model to their unique environments and this number will exceed 50 by September 2007. In addition to the availability of comprehensive training materials on the program website, interested persons can also request a detailed Care Transitions Intervention video in DVD or VHS format to illustrate the intervention as well as the evidence behind the intervention. To request a copy, visit: http://www.caretransitions.org/downloadvideo.asp
COST AND TIME CONSIDERATIONS:
For the latest information regarding the costs associated with intervention materials, training, and/or resources, the intervention developers request that individuals visit the Care Transitions website.
Time for staff training
Master’s level staff recommended
Travel expenditures to hospital and home/skilled nursing facility (e.g., gas, mileage)
Travel time for personnel (e.g., distance)
Telephone call costs
Access to computer to download forms/training materials
VIDEO CLIP OF INTERVENTION/PROGRAM:
A variety of video clips related to the administration of program measures/forms, the requirements for each visit, and patient testimonials, visit: http://www.caretransitions.org/video.asp
In addition to the availability of comprehensive training materials on the program website, interested persons can also request a detailed Care Transitions Intervention video in DVD or VHS format to illustrate the intervention as well as the evidence behind the intervention. To request a copy, visit: http://www.caretransitions.org/downloadvideo.asp
DOWNLOADABLE FACT SHEETS:
Evidence and Adoptions
BRIEF DESCRIPTION OF EVIDENCE:
Evidence has repeatedly shown the sustained benefits of this program. Individuals who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five-months after the end of the one-month intervention. In a randomized controlled trial of 750 community-dwelling adults 65 years or older who were admitted to the study hospital with 1 of 11 selected health condition, patients in the Care Transitions intervention group had lower rehospitalization rates at 30 days and at 90 days than patients in the control (non-treatment) group (Coleman et al., 2006). Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days and at 180 days than controls. The mean hospital costs were lower for intervention patients ($2,546) at 180 days. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends. Anticipated cost savings for 350 chronically ill adults with an initial hospitalization over 12 months is $ 295,594. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery.
Chalmers, S. A., & Coleman, E. A. (2006). Transitional Care in Later Life: Improving the Move. Generations, 86-89.
Chugh, A., Williams, M. V., Grigsby, J., & Coleman, E. A. (2009) Better transitions: Improving comprehension of discharge instructions. Frontiers of Health Services Management, 25(3), 11-32.
Coleman, E. A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51, 549-555.
Coleman, E. A., & Berenson, R. A. (2004). Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine, 141, 533-536.
Coleman, E. A., Mahoney, E., & Parry, C. (2005). Assessing the quality of preparation for post-hospital care from the patient's perspective: The care transitions measure. Medical Care, 43(3), 246-255.
Coleman, E. A., Parry, C., Chalmers, S., Chugh, A., & Mahoney, E. (2007). The central role of performance measurement in improving the quality of transitional care. Home Health Care Services Quarterly, 26(4), 93-104.
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166, 1822-8.
Coleman, E. A., Smith, J. D., Frank, J. C., Min, S., Parry, C., & Kramer, A. M. (2004). Preparing Patients and Caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), 1817-1825.
Coleman, E. A., Smith, J. D., Raha, D., & Min, S. J. (2005). Post-hospital medication discrepancies: prevalence, types and contributing factors. Archives of Internal Medicine, 165(16), 1842-1847.
Coleman, E. A, & Williams, M. V. (2007). Executing high quality of care transitions: A call to do it right. Journal of Hospital Medicine, 2(5), 287-290.
Parry, C., Coleman, E. A., Smith, J. D., Frank, J. C., & Kramer, A. M. (2003). The care transitions intervention: A patient-centered approach to facilitating effective transfers between sites of geriatric care. Home Health Services Quarterly, 22(3), 1-18.
Parry, C., Kramer, H., & Coleman, E. A. (2006). A qualitative exploration of a patient-centered coaching intervention to improve care transitions in chronically ill older adults. Home Health Care Services Quarterly, 25(3-4), 39-53.
Parry, C., Mahoney, E., Chalmers, S., & Coleman, E. A. (2008). Assessing the Quality of Transitional Care: Further Applications of the Care Transitions Measure. Medical Care, 46(3), 317-322.
Smith, J. D., Coleman, E. A, & Min S. (2004). Identifying post-acute medication discrepancies in community dwelling older adults: A new tool. American Journal of Geriatric Pharmacotherapy, 2(2), 141-148.
Care coordination, care transitions, self-management, patient centered care, family caregivers, patient safety, care fragmentation, medical errors, interdisciplinary teams, chronic illness