Transition coaching is based on the Care Transitions Intervention developed by Eric Coleman, MD. The coach supports patients over a four-week period that includes a visit to the patient in the hospital or skilled nursing facility, one home visit, and three follow-up phone calls. Patients with complex care receive specific tools and with the help of the Transition Coach, learn self-management skills to ensure their needs are met during the transition from hospital or facility to home.

Resources:

• Care Transitions Intervention (Coleman model) Overview
  This overview describes the care transitions model in detail and provides resources to learn more.
• The four pillars of care transitions developed by Eric Coleman
  The Care Transition Intervention focuses on four conceptual areas, referred to as pillars. They are: medication self-management, dynamic patient-centered health record, follow-up care, and red flags. Red flags signal the patient’s condition may be getting worse and will prompt the patient to contact their provider.

Contact us to become a coach or refer one of your patients to a Stepping Stones coach. (Our training and coaching services are only available in Whatcom County.)

CARE ToolThe CMS CARE (Continuity Assessment Record and Evaluation) Tool is a standardized patient assessment instrument designed to support clinical excellence, quality measurement, and timely patient care. It is grounded in scientific evidence, and designed to be flexible to accommodate clinical and technological advances and multiple users, while being interoperable across patient care settings.

The CARE Tool has been in several stages of pilot testing and review nationally. It is designed to be used across the hospital and post-acute care settings (nursing homes, home health agencies, and rehabilitation centers). It is oriented toward use at time of admission, in the case of significant changes in patient condition, and discharge. The continued evolution of the tool is to work toward maximum flexibility, continue to develop an instrument that is both useful and responsive to the clinical situation, and provide a standardized data set.

If you are interested in learning more about the CARE Tool please contact us at steppingstones@qualishealth.org.

Teach-back MethodTeach-back is a simple communication tool. After a provider shares new information with the patient and family, the patient is asked to teach-back the information. This allows the provider to correct misunderstanding and provide additional information if necessary. The provider can also assess the patient’s ability and confidence to manage their own care.

• Request a learning session on teach-back by Qualis Health staff.

Medication Self-ManagementEffective management of one’s medications and having a list of all medications in one place and available to all caregivers and providers is important--especially during transitions of care. Medication self-management is one of the four pillars of the Care Transitions Intervention. Furthermore, medication reconciliation (the act of making sure that a patient’s medications are actively reviewed and adjusted throughout episodes of acute care) has been included as a Joint Commission National Patient Safety Goal since 2005. Studies show mismanagement of medications can lead to poor outcomes for patients and helping patients manage their medications can prevent the chance of harm.

• A personal health record is one way to maintain a list of current medications.
• Medication Reconciliation in the Outpatient Setting Sample Toolkit
  This toolkit outlines patient-centered strategies implemented in a community-based initiative to improve the accuracy of the medication list in the outpatient setting.
• Medication Reconciliation in the Inpatient Setting Sample Toolkit
  This tool kit provides detail on where and how to reconcile medications at all transition points of care.
• Institute for Healthcare Improvement’s 5 Million Lives Campaign Medication Reconciliation How-to Guide
  The goal of this guide is to prevent harm from high-alert medications by implementing the changes in care recommended.
• The Medication Discrepancy Tool (MDT©)
  This is a new tool for identifying and characterizing medication discrepancies that arise when patients are making the transition between sites of care.

Personal Health Record A personal health record is a powerful tool that allows patients to share health information during transitions from one setting to another.

• The Shared Care Plan is a free electronic health record that was developed in Whatcom County. It is free, safe, secure, and can be accessed from any computer with internet access. There is also a paper version available.
• The American Academy of Family Medicine on how providers can work with patients to develop a personal health record.

• Ask Me 3™
  Because clear communication is the foundation for patients to be able to understand and act on health information, the Partnership for Clear Health Communications has developed Ask Me 3 as a quick, effective tool designed to improve health communication between patients and providers. Ask Me 3 promotes three simple but essential questions that patients should ask their providers in every healthcare interaction. Providers should always encourage their patients to understand the answers to: What is my main problem? What do I need to do? Why is it important for me to do this?
• Project RED
  Project Re-Engineered Discharge (RED) is a series of randomized controlled trials at Boston University Medical Center. Each phase of Project RED is aimed at improving patient safety by improving the process by which patients leave the hospital. The Project RED intervention is founded on 11 discrete, mutually reinforcing components. A specially trained nurse called a Discharge Advocate introduces the intervention to the RED participant. A toolkit was developed to facilitate the Re-Engineered Hospital Discharge intervention.
• Tools for providers from Care Transitions website
  Care Transition pioneer Eric Coleman, MD, has provided numerous tools for providers to use to ensure safe transitions that include the topics of coaching, medication self-management, discharge checklists, and more.
• The National Transitions of Care Coalition (NTOCC)
  NTOCC, an organization formed to bring together thought leaders and healthcare providers from various care settings to improve care coordination and communication when patients are transferred from one level of care to another, has many tools available for your use.
• Joint Commission Journal on Quality and Safety, Patient Centeredness- Implementing Practical Interventions to Support Chronic Illness Self-Management
  This article outlines a model of self-management support applicable across different chronic illnesses and healthcare systems.
• Using Telephone Support to Manage Chronic Disease