CMS National Conference on Care Transitions

December 3, 2010

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Reducing Re-hospitalization: Coaching Empowers Patients to be the Solution and Improves Health Outcomes

Laurie Robinson, RN, CPE, CPURDirector of QualityeQHealth Solutions

(225) 248-7035lrobinson@eqhs.org

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.

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Our Experiences

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

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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.

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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.

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.

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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.

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.

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

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.

Results

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

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Hospital Referrals Coached Re-admission

30 day re-admission rate

Hospital A 739 107 8 7%

Hospital B 345 81 5 7%

Hospital C 187 47 9 19%

Hospital D 52 10 4 40%

Hospital E 45 5 2 40%

Total 1368 250 28 11.2