The Care Transitions InterventionSM

1. The Care Transitions InterventionSM Eric Coleman Coaching Model Implementation in Washington State Selena Bolotin, LICSW Care Transitions Project Manager Qualis Health SharonSharon

2. 2 Care Transitions InterventionSM Four-week program � evidence based Goal � Impart self-management skills Coaching paradigm, not education or direct care/treatment Free of cost to patient Comprised of 5 interactions: Visit to patient in the hospital/skilled nursing facility Home visit Three follow-up phone calls

3. 3 Four Pillars Medication self-management and reconciliation Use of a patient-centered health record Timely follow-up with primary care physician and/or specialist within a week post-discharge Red flags � reinforce hospital discharge instructions

4. 4 Referral Criteria Payer-specific � Medicare recipient Geographically specific � Whatcom County resident during four week intervention Patient specific � at risk for readmission, cognitively able to participate, English-speaking Discharging to � home, assisted living facility, adult family home (long term care facilities excluded) Targeted diagnoses � heart failure, heart attack, pneumonia (not limited to these diagnoses), lacking social support

5. 5 Data Collection Number of patients initiating / completing coaching Pre / Post Patient Activation Measure Pre / Post revised Activated Behaviors Assessments Medication Discrepancies Readmission rates & ED utilization

6. 6 Time line September 2008 � hired QIO coach specialist September 2009 to January 2009 -- planning for implementation Referral education & referral processes Consent & EMR access Patient Activation Measure license January 2009 � coaching initiated April 2009 � 39 community agency staff, Parish Nurses, clinic RN�s & volunteers trained

7. 7 Time line May 2009 � community coaching initiated modified coaching implemented by HHA�s and MA Plans AAA case managers, parish nurses and tribal clinic RN incorporate model into their standard work flow First community volunteer becomes independent August 2009 � �inpatient coaching� of the 4 pillars for patients who decline September 2009 � QIO coach specialist becomes certified trainer October 2009 � 2 trainings 12 Community volunteers 7 University psychology majors

8. 8 Time line January 2010 -- per diem QIO staffing added March 2010 - process mapping referral and data collection processes Next Steps / Sustainability Focus Training handbook Social Service and nursing unit partnering & integration to increase consent rate Considering adding modified coaching model (facility visit / post discharge call)

9. 9 Successes & Challenges Successes High volunteer coach loyalty and satisfaction Volunteer Center & University partnerships Coaching stories highlight improved self management and discharge failure learning opportunities Challenges QIO coach not fully integrated into hospital processes � impacts referral & consenting Volunteer coaches require extensive training & support (and take vacations!)

10. Care Transitions Team