CMS National Conference on Care Transitions

1. CMS National Conference on Care Transitions December 3, 2010

2. Reducing Re-hospitalization: Coaching Empowers Patients to be the Solution and Improves Health Outcomes Laurie Robinson, RN, CPE, CPUR Director of Quality eQHealth Solutions (225) 248-7035lrobinson@eqhs.org

3. Objectives • To be able to identify barriers to smooth transitions. • To understand the role of the coach and the role of the patient in the coaching relationship.

4. Our Experiences • CMS project: Baton Rouge Community • Collaboration with hospitals. • Process re-design • Partnering with patients and caregivers • Patient tools • Tracking success

5. Drivers of Re-hospitalization • Fragmentation of patient information. • Inappropriate end of life care. • Medication issues. • At-risk patients not properly identified at discharge. • Lack of post-discharge follow-up. • Lack of disease-specific protocols. • Patient adherence to the plan of care. • Patient knowledge deficit. • Lack of community awareness.

6. Coaching Intervention: Strategies to Address Drivers • Fragmentation of patient information. • Portable Health Record. • Medication issues. • Medication reconciliation. • Lack of post-discharge follow-up. • Post discharge follow up appointment. • Patient adherence with the plan of care. • Written plan of care. • Patient knowledge deficit. • Patient education tools.

7. What is Transition Coaching? • Empowering and encouraging the patient on self care. • The Patient and/or the Care Givers are the “Doers”. • The coach reinforces the discharge plan of care as determined by the treatment team. • A series of hospital visits and post discharge telephonic follow ups that focus on the discharge plan of care.

8. The eQHealth Coaching Model • Hospital medicine or case manager refers the patient to the program. • The coach visits the patient in the hospital • The coach completes post discharge telephonic follow ups. • Each interaction with the patient focuses on the post discharge plan of care, medications, post discharge follow up, warning signals, Portable Health Record and a patient centered goal. • Patient tools are used to reinforce teaching.

9. Who is Eligible for the Program? • Medicare fee for service beneficiaries. • Beneficiaries that reside in the designated zip codes. • One of the following diagnosis • AMI • COPD • CHF • Pneumonia • Be able to engage in or have a caregiver that assists with self management.

10. The Coaching Process • Coaching interactions occur with the patients at scheduled intervals: • Hospital visits (begin day 2) • Telephonic post discharge • Day 2 • Day 7 • Day 14 • Day 21 • Day 30

11. Coaching Process cont. • At each interaction the coach focuses on the following: • Post discharge plan of care. • Medications. • Post discharge follow up. • Warning signals. • Portable Health Record. • Patient centered goal.

12. Results March 2009 – October 31, 2010 Community baseline readmission rate 19.6