Program focuses on most difficult transition: Going home

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Most hospitals have addressed the transition of patients from one hospital setting to another: emergency room to radiology, radiology to inpatient, etc. These transitions in care, known as handoffs, are areas in which facilities have tried to improve, especially since The Joint Commission (formerly JCAHO) made them part of National Patient Safety Goal #2 in 2006.

However, one of the most significant transitions in care, the transition to the home, has not been paid as much attention.

Care Transitions Intervention (CTI), a program created by Eric Coleman, MD, associate professor of medicine and a geriatrician at the University of Colorado Health Sciences Center in Denver, is helping to bring the transition at discharge into the spotlight. This unique program focuses on coaching patients to care adequately for themselves once they have left the hospital and are living on their own.

CTI has four main pillars:

  • Patient knowledge of medications
  • Patient management of personal health records
  • Patient scheduling of visits to primary care physicians once they leave the hospital
  • Patient awareness of “red flags”—signs that their condition may be deteriorating

To accomplish these pillars, patients enrolled in a CTI program are equipped with the following tools:

A personal health record

A checklist of actions they should have taken part in prior to being discharged

An in-hospital visit from a “transitions coach,” as well as one or more home visits after the patient is discharged and follow-up phone calls for up to four weeks

One of the major reasons to engage in a CTI program is evidence of a reduced readmission rate. In Coleman’s studies of the intervention, published in his paper The Care Transitions Intervention, he found that rehospitalization rates at 30 and 90 days postdischarge were lower for patients who had taken part in the intervention than for those who had not.

Putting the intervention into action

The idea of a transitions coach turns current practice on its head, says Susan Ehrlich, MD, MPP, chief medical officer of San Mateo (CA) Medical Center.

“The Coleman model represents a fundamental paradigm shift in the way the system of medical care works,” says Ehrlich, whose facility is part of a 10-facility grant program funded by the California HealthCare Foundation (CHCF), which began in July 2007. “The way it works now, for the most part, there’s a big chasm between inpatient hospital care and outpatient care.”

Ehrlich says it is even difficult for vertically integrated systems such as that of San Mateo to manage the transition between inpatient hospitalization and outpatient care.

Crouse Hospital in Syracuse, NY, decided to apply for a grant to take part in the CTI program in summer 2007.

After evaluating its senior care and realizing that transitions are the most difficult times for elderly patients during their hospital stays, staff members saw how CTI could help.

“They’re most vulnerable during times of transition—it’s when they kind of fall through the cracks,” says Diane Nanno, RN, a transitions coach for Crouse, a 433-bed facility. Nanno was hired in August 2007 after Crouse won the grant. She is part of the CTI program that began in September 2007, focusing on congestive heart failure (CHF) patients.

As a transitions coach, Nanno is responsible for making the patients feel comfortable with caring for themselves once they leave the hospital. It is easy for patients to become used to nurses and doctors carrying out most day-to-day tasks while in the hospital and, therefore, difficult to learn how to do simple things when moving back home, Nanno says.

“My role is primarily a coaching role; instead of actually making the calls and doing the work, I coach the patients to do it, or a family member if the patient is unable,” Nanno says. “There’s a fair amount of role-playing and me saying, ‘This is what you do, this is how you say it,’ rather than me doing it. The idea behind it is next time when they need to do [a certain task] and I’m not sitting here, they’ll know what to do for their own care.”

Nanno coaches her patients on important tasks, such as making sure they have an appointment set up with their primary care physicians, since staying on top of CHF will lower the chances of being readmitted to the hospital. She also helps with simpler tasks, such as coaching patients on walking to the mailbox or making a bed—seemingly mundane tasks that can be an important part of a patient getting his or her life back together.

“I set a functional goal with the patients and ask them, ‘What is it that you haven’t been able to do that you’d like to be able to do again?’ because if I can tie in the coaching with what their goal is, I find the buy-in is better,” Nanno says.

Prior to discharge, Nanno meets with enrolled patients to discuss anything they should be aware of concerning medications, their conditions, and what to do if they aren’t feeling well. Crouse’s program enrolls patients 65 and older.

Lois Zagha, LMFT, clinical supervisor of the Huntington Senior Resource Center and Huntington Community Options program at Huntington Memorial Hospital (HMH) in Pasadena, CA, is in charge of the facility’s CTI program. Like Crouse Hospital, HMH, a 525-bed facility, focuses on CHF patients. HMH is part of the CHCF grant as well.

Zagha says she has had the most luck with elderly patients who are enrolled in the program.

“We found that when younger clients were referred, there wasn’t as good of a result,” Zagha says. “Often, these people are still working and go back to work, even though they’re very ill, and they wind up back in the hospital. It works best with people [aged] 75–85, and certainly education seems to play a part. Those who understand and see the value in what we’re teaching them seem to benefit most.”

To get physicians on board with the CTI program, Zagha says she and her staff spoke to physicians, explaining the benefits and why they should talk to their patients about the program. In return, some physicians made suggestions about how to tweak the program.

“Our biggest challenge is getting patients to agree to participate,” Zagha says.

The program has referred more than 170 people, but only 43 to date have taken part in the intervention.

“That number is actually not that surprising,” says Zagha. “People are leery. Part of it is a cohort effect; these elderly patients often need the endorsement of their doctors. And even though we’ve publicized it with many primary care physicians on staff here—cardiologists, hospitalists, and nurse managers—the patients haven’t heard about it.”

San Mateo’s program is a little different than the other two in that it has not focused strictly on CHF patients. Also, it is a communitywide effort. San Mateo Medical Center, San Mateo County Health Department, and the Health Plan of San Mateo have been equal partners in implementing the CTI program. Although San Mateo has not focused on CHF patients, Ehrlich says, most are elderly patients with a chronic condition.

“We wanted to be broad in our ability to assign folks,” says Ehrlich. The hospital limited enrollment to adult patients who are members of the San Mateo Health Plan, would benefit from coaching (usually patients with chronic conditions), and would be actively engaged in the program—a key part of any CTI program.

Measuring success

Any new program is going to require buy-in from staff members. Most programs have not yet collected data around the intervention because they are still young and also because it took a couple months to get patients interested and enrolled.

However, staff members seem to have understood and embraced the idea of the CTI program. “It’s a new way for them to interact with the patients, as a coach, but they’re really positive about it,” says Ehrlich. “They see this as an important thing for the patients.”

Zagha says staff members at HMH love having contact with patients at home because it provides a greater opportunity to educate them. Often, patients enrolled in the program are hesitant to ask any questions of the doctor before they are discharged, an issue with which CTI coaches can help.

“Many of our patients don’t want to challenge the doctor. They see him as an authority figure,” Zagha says.

Crouse Hospital is learning as it further develops the program, Nanno says. She has made changes to the original CTI program to better serve patients at her facility. For example, she found that patients performed better with an additional follow-up call during the 30-day postdischarge period. As far as judging how well the program is functioning, Nanno says she looks at rehospitalization rates, emergent care rates, and patient satisfaction. Crouse hired an independent call center to gauge how well the CTI program was functioning.

The original program uses the “Care Transition Measure-3,” a set of three questions that are asked of the patient that are indicative of the quality of the CTI program, as well as recidivism rates.

The questions are:

“Did the hospital listen to my preferences when deciding what care I’d need upon discharge?”

“Did I understand that I was responsible for my own health management upon discharge?”

“Did I understand the reasons for each of my medications?”

Ehrlich says her leadership team’s involvement in the CTI program has been one of the biggest reasons why San Mateo has been able to enroll 30 patients as of March and plans to enroll 100 by June.

“Sometimes with these projects, there are people at the ground level who get very excited about them, but it’s hard to get the attention of the leadership,” says Ehrlich. “But in our case, we’ve got the full buy-in from leadership in all three of the organizations, and that’s made it possible to push through rough spots in implementation. People are thinking creatively throughout the organization, which helps a lot.”

Visit to find out more about the CTI program.

Care Transitions Intervention at a glance

Goal: To better facilitate the transition between receiving care as an inpatient and functioning in the home setting. Bridging that gap should produce lower rehospitalization rates and lower costs for hospitals and patients.

Unique tool: A “transitions coach,” a staff member who meets with the patient prior to discharge, visits the patient in the home and calls patients for follow-up to make sure the desired care plan is on track. The transitions coach focuses on showing patients how to care for themselves instead of doing things for them.

Average case load: 25 patients per coach.

Population of patients: Most are elderly and have chronic conditions.