Care Transitions Coaching
What is Coaching?
The Care Transition Intervention (CTI), is a formal coaching model developed by Dr. Eric Coleman, MD, Associate Professor of Medicine at the University of Colorado Health Science Center, and is being adopted by several providers in the Quality Insights Care Transition Community Project as an intervention to help reduce un necessary re-admissions. A Coleman CTI training was held May 28 and 29, 2009 for the community participants to prepare them to implement the intervention in July.
The goal of the coaching intervention (CTI) is to improve care transitions by providing patients and primary care givers with tools, support, and to promote knowledge and self management as they journey through all transitions, states Coleman.
The purpose of a care transition coach is to bridge the gaps that exist in the present health care system as patients journey from one setting to another. Coaches assist patients with chronic illness who often require care from multiple settings and often find the systems failed them due to a lack of care coordination and fragmentation of communication between those settings. A care transition occurs anytime a patient moves from one health care setting to another.
When a patient is ready to return home after a hospitalization there needs to be effective and timely communication and coordination between settings and clear instructions for the patient, however, this rarely happens. Patients report they feel frustrated with the repetitious questions and duplication of required documentation.
The coach functions as a facilitator and advocate, not a hands on caregiver. The coach listens to the patient and helps them develop goals while empowering them to evolve from a passive recipient to an active participant in the self-management of their health care plan.
Research conducted by Dr. Eric Coleman from the University of Colorado indicates the CTI:
1. Improves communication
2. Builds cross setting relationships
3. Redesigns workflow
Why we do coaching
Patients generally have not developed a skill set to play an active role in their health care management and often develop a feeling of helplessness and dependency. During an episode of illness, many patients receive health care in a variety of settings putting them at risk for fragmented and poorly executed care transitions. The results often include duplication of services, inappropriate care, medication errors, patient and caregiver distress, higher costs due to re-hospitalization and inappropriate use of emergency services.
Most beneficiaries do not:
- Understand medication management
- Recognize warning signs
- Effectively manage health care needs
- Receive adequate or in many cases any f/u care post discharge
- Manage crisis episodes well and panic or call 911/ED as a resource
- Have confidence to navigate the system
Coaches assist practitioners in the coordination of services as well as develop workflows with providers to involve beneficiaries and caregivers in the process. This process assures appropriate professional involvement, addressing issues effectively and efficiency without duplication and allows for seamless implementation of the care plan and treatment goals. This is of benefit to the beneficiary as it reduces the potential risk for a re-admission while improving the quality of the care they receive.
Coaches facilitate beneficiary activation and self management sessions that contribute to continuity of care during the transition process. This process collaboratively strategizes actions and activities to meet beneficiary goals, provides a contact in case problems arise, and identifies and trouble shoots gaps indentified during the transition process.
CTI works well for beneficiaries with chronic illness who have complex care needs and are involved with a variety of practitioners. These patients often have co-morbidities and frequent exacerbations that are a challenge to manage due to fragmentation of processes and communication between providers and settings. Patients with chronic illness such as CHF/PNE/COPD are often at high risk for re-admission.
Coaches can be either clinical/non-clinical staff trained in coach techniques, principles and concepts of CTI and have an overall understanding of Care Transitions. Both Westmoreland and Southwestern Pennsylvania Area Agencies on Aging are participating in the community based project by providing the coach staff. These agencies see the goals of the project as congruent with their mission statements and will be implementing the intervention in July 2009. They share the goal of reducing unnecessary hospital readmissions for beneficiaries in their community. This is truly a cross setting effort in collaboration with Excela Health Systems and Monongahela Valley Hospital. This unique partnership that highlights Pennsylvania as one of the few pilot states developing this model.
What coaching is not
Not only is it important to understand what the coach role is, understanding what it is not is equally important. In contrast to case management CTI coaches support a self management model and they are not direct hands on caregivers, clinical manager or teachers. They do not "do" for the patient nor do they develop the agenda. Their role is to listen to the patient and support them in meeting their self stated goals. The coach serves as a guide for tasks but does not "take charge".