Transitions in Care Program

Mary Bittner, RN, MPA, CENP, DNP(c)

Vice President, Nursing

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

PNA Zone Tool

CHF Zone Tool

DVT Zone Tool

Patient Progress Tool

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

Questions?