Healthy Transitions

By Nancy Giguere, Star Tribune Sales and Marketing

Last update: December 17, 2007 - 10:08 AM

During today's short hospital stays, there's little time to educate patients before they're discharged. They may be unfamiliar about symptoms to watch for, confused about their medications and without home health services. "As patients move across settings of care, the potential for complications increases," says Mary Deering, manager of Care Management and Chronic Disease Care for HealthEast Care Systems.

A New Model Of Care

To reduce these problems, Dr. Eric Coleman of the University of Colorado has pioneered "transition coaching," a new model of care for persons with complex care needs. Last September, HealthEast began a pilot program using Coleman's model.

The model rests on four pillars:

• A personal health record. A little booklet taken to all appointments. It contains the names of all providers, a list of medications and places to jot down questions and information.

• Medication reconciliation. The list of medications received at the hospital matches what patients are taking at home, and they have a system to manage their medications.

• Knowledge of "red flags." Patients recognize when their condition is worsening and know how to respond.

• Timely follow-up. Patients are able to schedule and keep appointments with physicians after they leave the hospital.

How It Works

Most patients participating in HealthEast's pilot program are frail elders over 80. They suffer from conditions like congestive heart failure, diabetes, lung disease, hip fractures and stroke. Many spend a week or more in a "subacute" or rehab unit before they go home.

Before leaving the hospital, they are visited by the "transition coach," a nurse who explains the program, invites them to enroll and gives them a personal health record.

Within 48 hours after discharge, enrolled patients receive a call from the coach who schedules a home visit. During the visit, the coach works with the patients to ensure they are knowledgeable about their red flag symptoms and coaches them on techniques to make follow-up appointments.

The coach and the patient work together to reconcile medications. This is essential because errors are common when individuals move between settings. "We are noticing medication discrepancies in almost every home visit," Deering says.

In addition, the coach makes sure that other needs - like home care or meals on wheels - are met.

A week later, the coach calls again. During a final call, made two weeks after discharge, the coach verifies that all is going well. If not, the coach refers the patient to a HealthEast care manager for long-term follow-up.

Patients discharged to a nursing facility for rehab before returning home are visited in the facility and then at home.

Rethinking The Nurse's Role

"So far we have only one coach," Deering says. "But we're hoping to expand the program. Patient satisfaction is high, families love it and so does the coach." Deering believes that more nurses will move into transition coaching as the population ages.

Successful transition coaches need geriatric nursing experience and good grounding in pharmacology. A background in home care is helpful. "They must also have skill and a liking for empowering patients to care for themselves," Deering says. "This requires rethinking the nurse's role."

Nancy Giguere is a freelance writer from St. Paul who has written about healthcare since 1995.

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