Summer 2009
Medicare and Whatcom County Partners Launch New Care Transitions Project
In late March, Whatcom County consumers were introduced to a new federally-funded initiative that aims to improve healthcare transitions at the annual Caregiver Conference in Bellingham. “Stepping Stones: Bridging Healthcare Gaps” is the Care Transitions Project of Whatcom County, one of only 14 such community projects across the U.S. The project was presented to providers in Whatcom County at a kick-off meeting last November.
The Centers for Medicare & Medicaid Services (CMS) has contracted with Qualis Health, Washington’s quality improvement organization, to engage community partners including providers, patients and families in the project through 2011. Local project co-sponsors are PeaceHealth/St. Joseph Hospital, the Northwest Regional Council and the Critical Junctures Institute.
“The Care Transitions initiative tackles some of the most pervasive and troubling problems facing Medicare beneficiaries as they leave the hospital—medication errors, misunderstandings about the likely course of their condition(s), lack of skills and planning needed in the follow-up period, and other care system shortcomings that end up making far too many Medicare patients come back to the hospital within a few days or weeks,” said Barry M. Straube, MD, CMS Chief Medical Officer and Director of CMS’ Office of Clinical Standards & Quality.
“Collaborating with our partners in Whatcom County to improve care transitions is one of our most exciting projects,” said Jonathan Sugarman, MD, MPH, President and CEO of Qualis Health, “and a perfect fit with our goal to ensure that all patients get the care they need in the right setting and at the right time.” Studies across the county have demonstrated that there are potential gaps in communication and coordination when patients transition from one setting or aspect of care to another, resulting in patient risk and increased costs. The aim of this project is to bridge those gaps and enable safer, more effective transitions.
Nancy Steiger, CEO and Chief Mission Officer for the PeaceHealth Whatcom Region, notes that improving how patients transition from one setting to another cannot be done without engagement and cooperation between organizations and people. “We are committed to working with skilled nursing facilities, community physicians, patient families and others to demonstrate what a community committed to a common vision can accomplish.”
Steiger went on to point out that St. Joseph Hospital is committed to the Stepping Stones project “not because our re-admission rates are particularly high—but because our commitment is to provide excellent medicine and compassionate care to every patient, every time. Our involvement in the Stepping Stones project helps us fulfill this commitment.”
Please visit www.steppingstoneswhatcom.org to learn more. The site offers information about improving care transitions for consumers and healthcare providers, as well as information about how to get involved in the project.
Back to Top
Meet Karla Hall and Rosemary Lea
Care Transitions Coaches at St. Joseph Hospital
St. Joseph Hospital is participating in the new Medicare-funded project called the Stepping Stones Project: Bridging Healthcare Gaps. It is focused on improving communication during care transitions and ultimately reducing unnecessary hospital readmissions in Whatcom County. One component of this project is to provide coaching to patients prior to, and shortly after, hospital discharge. Karla Hall and Rosemary Lea are working onsite at St. Joseph’s as care transitions coaches.
The care transitions coaches are an exciting and visible component of the Stepping Stones Project at St. Joseph Hospital. Karla and Rosemary, Qualis Health employees, and the initial coaches in the project, trained and will be training other coaches in the future. The primary role of the coach is to empower the patient and/or caregiver to take a more active role during healthcare transitions, and to develop lasting self-management skills. The coach supports patients over a four-week period that includes a hospital visit, home visit and follow-up phone calls. In late April, Dr. Eric Coleman, a national leader in care transitions, conducted a two-day seminar in Bellingham to train Whatcom County volunteers to become coaches using the Care Transition InterventionSM (www.caretransitions.org). Read more about this in the Transition Coaching is Growing in Your Community article in this issue.
To learn more about coaching and the Stepping Stones Project, visit www.steppingstoneswhatcom.org.
Back to Top
The Shared Care Plan
Personal Health Record
A Tool to Help You with Safe Care Transitions
A personal health record is a powerful tool that allows patients to organize, store and keep track of health information. Health information that could be stored on a personal health record include: medications, diagnoses, hospitalizations, surgeries, allergies and reactions to medications. You can also store important documents and health indicators such as blood pressure, cholesterol and blood sugars. Sharing this information with family and providers is especially helpful during transitions from one care setting to another.
One of the primary goals of the Stepping Stones project is to encourage everyone to use a personal health record.
The Shared Care Plan is an electronic health record that was developed in Whatcom County. In addition to the information that can be stored mentioned above, the Shared Care Plan can include your health goals, dietary needs, important information that affects your health and advance directives. With the Shared Care Plan, information that is important to your providers and to your family will all be in one place. It is free, safe, secure and can be accessed from any computer with internet access. There is also a paper version available.
You can start using one today by visiting www.sharedcareplan.org.
Back to Top
A Patient’s Perspective
Sue Wright is a caregiver and patient representative on the care transitions team Stepping Stones Project. She shares with us her perspective on care transitions.
You might ask why a patient and caregiver would be interested in and see the importance of participating in the care transitions team. One big reason is that I have a chance to be a voice for many patients and caregivers in Whatcom County who can’t take part in this project.
I believe that healthcare systems in Whatcom county are striving to improve healthcare for all of us and that the Stepping Stones Project is an important part of that.
I want to help increase awareness and provide education so that patients and caregivers have the tools necessary to feel comfortable as they change from one medical setting to another or are going home.
As patients and caregivers, we are the reason for the care and are in the center of what goes on. We all need to use our healthcare dollars as efficiently as possible. We are all responsible for our own health.
I want to get the word out about the importance of the transition coaches—they will become a vital link for all of us in the future of quality healthcare.
We all have a role to play, working together for the future of quality healthcare in Whatcom County.
Back to Top
Transition Coaching is Growing in Your Community
Transition coaching is important for improving care transitions for residents of Whatcom County. Whatcom County currently has two transition coaches—Karla Hall and Rosemary Lea, both Qualis Health employees. To make coaching available to more Whatcom County residents, Qualis Health offered a two-day coach training workshop for volunteer coaches. Forty volunteers from Whatcom County participated in the training. The event took place in Bellingham on April 23 and 24, 2009. A nationally known care transitions team from Colorado, facilitated by care transitions pioneer Eric Coleman, MD, MPH led the volunteer coaches through two days of training in the Care Transitions InterventionSM (CTI).
During the two days, the 40 volunteers participated in dynamic training sessions that included learning about the CTI model, building effective communication skills, role-playing and learning to use CTI tools.
The transition coaches were also taught the “four pillars” model of the CTI to assist patients being discharged from the hospital. These “pillars” are known to positively impact readmissions rates.
The four pillars are:
Medication Self-Management—The coach empowers the patient to take charge of medications and reconcile their home medications with discharge medications.
Red Flags—The coach helps the patient identify an action plan based on knowing when their condition is worsening, knowing what to do when red flags occur, when to contact their provider and understanding the reason for their hospitalization.
Follow-up—The coach encourages the patient to schedule and keep medical appointments, and helps patient feel comfortable and able to communicate effectively with providers, through role play and practice.
Patient-centered Record—The coach facilitates patient use and ownership of a personal health record.
Additionally, the newly trained coaches participated in another Qualis Health sponsored session on June 3rd in Bellingham to refine their knowledge of the Care Transitions tools and to help plan for growing and sustaining transitions coaching in Whatcom County well into the future.
What’s next?
Already new coaches have been deployed in Whatcom County and there are plans to continue to train and deploy more coaches in the coming months and years.
If you are interested in becoming a coach please contact Karla Hall at karlah@qualishealth.org.
Download a PDF version of this issue 
Back to Top
