Better Care Transitions = Better Outcomes

September 22, 2021

The National Readmissions Prevention Conference on Feb 12th drew over 400 attendees. One intriguing session was Dr. Eric Coleman on Improving Care Transitions by Infusing True Person and Family Centered Care. Dr. Coleman of the University of Colorado School of Medicine won a $500,000 MacArthur "genius" fellowship for 2012, rewarding his pioneering work on improving quality and cutting costs by "coaching" patients through transitions from hospital to home. Coleman's work and collaborations around the nation are now a key part of health care reform, trying to prevent expensive hospital readmissions and case complications by empowering patients and then checking on their progress. He leads the Care Transitions Program, whose goal is to improve quality and safety during care handoffs. Here is a summary of his highlights:Challenges:· To create a match between the individual's care needs and his or her care setting.· As healthcare is moving from volume to value, we lack consensus on what the ideal quality metrics are.· We don't have good refined feedback loops. How often do we get good feedback from patient and family?· Did we do a good job prepare them to go home and care for self or loved one?Three questions he suggests be added to the HCAHPS survey:· The hospital staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left the hospital.· When I left the hospital I had a good understanding of the things I was responsible for in managing my health.· When I left the hospital I clearly understood the purpose for taking each of my medications.What Appears to be Working:1. Foster greater patient engagement2. Foster greater family caregiver engagement3. Foster greater physician engagement and accountability4. Building professional competency5. Forging cross-continuum collaborative teams6. Implementing strategies to improve communicationSelf-care support for the "Silent" Care CoordinatorsPatients/family caregivers perform a significant amount of their own care coordination. They do this without skills, tools and confidence to be effective. His organization ( believes transitions coaching is the vehicle to build skills, confidence and provide tools to support self care.· Model behavior for how to handle common problems· Practice or role play next encounter, adult learning, most schools using simulations for learning· Teach patients to fish ... or move in with them!· Fixing problems for patients represents an implied promise that you will be back to fix the problem again should it arise.· Coaching = skill transfer. Very powerful analogy of learning to drive. Doing for patient puts patient in the back seat. Move them to the passenger seat, educate, then to the driver seat with coaching, for safest transitions and improved outcomes. This could provide a significant reduction in readmission, with the coach out of the picture, patient showing sustained effect of coaching with 90 and 180 days reduced readmissions.· One key element is to agree on a common set of teaching materials for patients and have them teach back the information across the continuum to ascertain understanding.· His process when implemented is generating positive outcomes and reduced readmissions.Quotes"We tend not to use the biggest resource in healthcare - the patients themselves. So I'm trying to figure out possible uses for digital technologies like Facebook but also real-life social networks to improve healthcare provision."Lucien Engelen, director of the Radboud REshape Innovation CenterSpeaking and TravelMar. 5-12 Fun in the Sun, Kona, HIMar. 13 Collaborating for Outstanding Outcomes, Healthcare Leadership Program, Phoenix, AZMar. 16 Facilitate healthcare retreat SWOT analysis, Phoenix, AZMar 23 AzHHA Reducing Readmissions Conference, Phoenix, AZ

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