NEWS

"Care Transition Coaches" Trained in Georgia

Twenty-five individuals are now ready to begin "Coaching" after having completed two days of training in the Care Transitions Intervention in Athens, Georgia June 23 and June 24, 2008. The training was provided by Dr. Eric Coleman (developer of the program) and his colleagues from the University of Colorado Health Sciences Center in Denver. Training was funded by a grant from Healthcare Georgia Foundation and sponsored by RCI and its partner CARE-NETs as part of the Georgia Coalition for Caregiver Health.

The Care Transitions Intervention is an evidence-based program designed to empower seniors and their caregivers to effectively manage the challenges of changing care settings. Research has shown that patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. Problems encountered during care transitions (e.g. hospital to home, hospital to nursing home, etc.) include patients being unprepared for their self-management role in the next care setting, receiving conflicting advice regarding illness management, being unable to reach an appropriate health care practitioner with questions and having minimal input into their care plan. Care transitions also result in high rates of medication errors, incomplete or inaccurate information transfer and lack of appropriate follow-up care. The end result is an unacceptable and unnecessary hospital readmission rate in Georgia that is currently near 18%. Because patients and their caregivers are often the only common thread moving across sites of care, together they constitute an important target for an intervention designed to improve quality of care.

The Care Transitions Intervention is designed to address threats to quality during care transitions by providing patients and caregivers with tools and support to allow them to more actively participate in their care. The Care Coach leads the patient to address 4 pillars of care:

1) medication self-management;
2) maintenance of a patient-centered record owned and maintained by the patient,
3) scheduling and rehearsing a timely follow-up with primary or specialty care, and
4) developing and understanding a list of "red flags" indicative of a worsening condition and instructions on how to respond to them.

The Care Transition Coaches recently trained included family caregivers, case managers, nurses and social workers. Over the next few months, this group of Coaches will be actively coaching in the field with the aim of continuing advanced training and receiving designation as "Master Trainers". Once Master Trainers are certified, we will be in a position to develop our own training facility in Georgia to sustain and promote the program.

The aim of this work is to have care-transition coaching widely practiced in Georgia resulting in higher quality of care and reduced hospital readmission.