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The Care Transitions InterventionSM

2. Care Transitions InterventionSM. Four-week program ? evidence basedGoal ? Impart self-management skillsCoaching paradigm, not education or direct care/treatmentFree of cost to patientComprised of 5 interactions: Visit to patient in the hospital/skilled nursing facilityHome visitThree follo

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The Care Transitions InterventionSM

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    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 RNs & volunteers trained

    7. 7 Time line May 2009 community coaching initiated modified coaching implemented by HHAs 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

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