Coaches help seniors avoid readmissions

SWs and coaches follow patients for 30 days

Seniors who are at risk for readmission to the hospital are getting support that helps them stay healthy at home by Care Transitions coaches at SCAN Health Plan, a Long Beach, CA based health plan that provides coverage for Medicare and Medicaid beneficiaries.

The health plan is in the midst of an in-depth analysis of outcomes from the project, but preliminary information indicates that readmissions have dropped among members in the program, says Jodi Cohn, DrPH, research director of geriatric practice innovations. "We've gotten a lot of positive contacts from patients and family members who appreciate that someone is advocating for them and helping them learn to advocate for themselves," she adds. In a survey of caregivers who had been contracted by Care Transitions coaches, 96% agreed or strongly agreed that they were satisfied with the Care Transitions program, and 94% indicated they knew who to call for help if their condition worsens, Cohn says.

SCAN bases its readmission reduction program on the Coleman Care Transitions intervention model, developed by a team of researchers at the University of Colorado, led by Eric A. Coleman, MD, MPH, a geriatrician who is director of the Care Transitions Program and a professor of Medicine at the University of Colorado School of Medicine, Denver. Coleman also serves on SCAN's Geriatric Advisory Board. SCAN was an early adopter of the Care Transitions model in 2005 and modified it to meet the needs of their members at high risk for rehospitalization. (For more information on the Care Transitions Program, see

Patients are referred to the program from the SCAN Inpatient Case Management department when the health plan is notified that a member is in the hospital. The Care Transitions team also receives referrals from SCAN case managers who are working with patients and family members on an ongoing basis and think they can benefit from an intervention from the Care Transitions team. In addition, patients who are having a planned hospital visit can refer themselves.

Cohn says, "The coaches are all social workers (SWs) or Licensed Vocational Nurses (LVNs) and are very skilled at working through the follow-up that successful transitions require, such as making sure that individuals know what medication to take, how to follow up with their doctor, and the warning signs that indicate worsening conditions."

Hang Le, MSW, care transitions coach, says that coaches follow up with the patients for an average of 30 days after admission. "Contact is made weekly during the inpatient stay and for three to four weeks after they get home," she says.

When the care transition coach receives a referral for the program, she first calls the patient's home to talk with a family member or caregiver who is the authorized representative and will be the main contact person for the patient if the patient cannot speak for himself. "I try to identify one person as my contact person to avoid misunderstandings and make sure the information I receive is consistent. I like to talk to the caregiver or the patient and explain the program early in the hospital stay," Le says.

Le talks with the caregiver about what the patient's options might be, such as whether they are expected to go to a nursing home or rehab facility after discharge, as well as what services they will need if they go home. "I let them know that I am here to answer any questions they have, to work with them to ensure a safe discharge, and to be an active participant in their care," she says.

If a patient agrees to participate in the program, a package of information is sent to their home. The materials include brochures with information about medication, medication logs, refrigerator magnets with phone numbers for SCAN and its 24-hour nurse line, and a Personal Health Record where members can record personal health information such as diagnoses, upcoming doctor visits, and questions for their doctors.

When the patients go home, the Care Transitions coaches telephone them and go over their discharge summary and treatment plan. They help the patients set personal health goals for the next 30 days, help them determine what they need to do to meet the goals, and guide them as they work on the goals. They help them learn to use the Personal Health Record and educate them on what symptoms indicate that they should call their doctor or seek emergent care. Cohn says, "Medication management is a huge issue for these patients. Many are on eight or more medications and don't understand what they are supposed to stop taking and what to start taking."

The coaches determine what medications the patients were prescribed in the hospital and what they were previously taking and encourage the patients to call their doctor if it appears to be duplicates. They also encourage the patient and caregiver to bring all medications to their physician appointments so the physician can review them. When needed, the coaches call in the SCAN pharmacy staff to consult with the patients on how to take their medication or to discuss the possibility of modifying the medication regimen with their physicians.

The coaches make sure patients have follow-up visits with their primary care physician within a week of discharge. Le says, "Often patients ask why they need to see a doctor when they were just in the hospital and don't feel like going. I explain why it's important and help them make an appointment if needed," Le says.

The coaches help members prepare for their primary care visits, guide them through using the Personal Health Record, and encourage them to write down questions for their doctor. They follow up after the visit to see if the patients have any questions. "We suggest that they take someone with them to the visit to help them interpret the doctor's instructions," Le says.

Many of the patients in the program after hospitalization are debilitated with a lot of care needs. The coaches help them access community resources such as help with caregiving and transportation. "If we feel like they may need additional assistance, we direct them to the appropriate resources," Le says.

The coaches educate patients on the importance of advance directives and offer them information and forms they can use to indicate their wishes. The program provides coaches for only 30 days after discharge, but if the coaches think people need more help, they can refer them to one of SCAN's disease management or case management programs.

"I tell the patients that it's the last time I'm going to call them, but urge them to call me back if they have any questions or concerns in the future," Le says.

Care guides help patients avoid hospital/ED

Non-clinical staff provide support

A pilot study in which non-clinical care guides provided support to patients during and after their primary care visits has resulted in reduced emergency department visits and hospitalizations, and it saved money for Minneapolis-based Allina Hospitals & Clinics.

In the year before the pilot project, the 334 patients who participated had 310 emergency department visits and 188 hospitalizations. In the first year of the care guide program, the numbers decreased to 259 emergency department visits and 166 hospitalizations. The researchers calculated savings of $137,000 the first year by multiplying the average cost of a hospital admission or an emergency department visit by the number of patients who experienced them. The cost for the care guide program was $110,000.

"We clearly saved money by giving our patients extra support," says Richard Adair, MD, a primary care physician and principal investigator for the research project. "In addition, having care guides to help patients learn to navigate the healthcare system and manage their chronic conditions allows the doctors and nurses to do the jobs they were educated to do and work at the top of their licenses. We see this as one tool for our patient-centered medical homes."

Using a grant from the Robina Foundation, a Minneapolis charitable organization, researchers conducted the pilot study at the Abbott Northwestern Medicine Clinic, a primary care clinic staffed by internal medicine residents from Abbott Northwestern Hospital, students at the University of Minnesota medical school, and their professors. The pilot started in April 2009 and was so successful that the program has been expanded to six clinics across the Allina system.

Care guides are recent college graduates with good communication skills who work in cubicles in the primary care clinic waiting areas. They undergo extensive training and are paid an average of $16 an hour. "Care managers are great at helping improve care for patients with chronic diseases and reducing readmission rates, but with tight budgets, we looked for less expensive alternatives to using RNs to support our patients," Adair says. "The idea of this project was to see if we could take young people recently out of college, pay them fairly at $16 an hour, and teach them to do the things that doctors and nurses want to do but often don't have time for."

The initial job description for care guides required at least a two-year degree and good communication skills. Because of the economy, the hospital was able to hire care guides with four-year degrees in a variety of subjects including public health, pre-nursing, and biology.

The care guides undergo two weeks of training from physicians, nurses, and dieticians in the Allina system, including basic information on heart failure, hypertension, and diabetes, the basics of what medications are common with each disease, nutrition basics, and tobacco cessation resources. A psychologist discusses what life is like for patients who have chronic diseases and how to detect if patients are at risk for depression. Care guides have a one-page educational sheet for each condition with information they can use when they talk to patients. They learn how to find community resources, such as transportation and prescription assistance programs. They attend monthly in-service training on topics that include motivational interviewing, communication barriers, and underlying issues that might interfere with the patient's healthcare.

"We designed this program to be affordable and use non-clinical staff who don't command the higher salaries of clinicians," Adair says. "The people we want to reach are more comfortable talking with non-clinical staff."

Kim Radel, MHA, research program manager, reports that an important component of the program is having the patient and care guide meet face-to-face and get to know each other, "Telephonic relationships aren't as strong as when people meet face-to-face," Radel says. "The patient gets to know the care guide and develops trust."

Jessica Taghon, a care guide at Allina Medical Clinic in Faribault, MN, reports that patients often tell her things they won't necessarily tell their physicians. "I have the time to talk to them and get to know them. They feel comfortable talking with me," Taghon says.

For the research study, the investigators chose patients with hypertension, heart failure, and diabetes because they have measurable clinical parameters, Adair says. During the pilot, the participants reduced their gaps in preventative care and other healthcare goals by 28%.

The clinic in the pilot study is located in the inner city and serves a large population of low income patients and recent immigrants who have limited English proficiency. Some of the care guides speak Somali or Spanish, the two most prevalent languages among the patients. Radel says, "Many of our patients have a lot going on in their lives, and their healthcare is disorganized. The care guides help them think about what questions they have for their doctor and organize them ahead of time."

The care guides coach patients about what is important for them to do to manage their diseases. Adair says, "Like all doctors, I have little time to sit down with patients with chronic diseases and coach them on what they should do to manage their condition. The care guides play an important role in educating and supporting the patients."