Using Coaching to Reduce Readmissions, Costs and Improve Care_eQHealth Solutions
Using Coaching to Reduce Costs and Improve Care Laurie Robinson, RN, CPE, CPUR Director of Care Coordination Services
What will you learn today?• You will learn to identify: – Drivers of re-hospitalization and interventions used to reduce re-hospitalization – The roles of the coach and the patient in the coaching relationship – Patients appropriate for coaching – Differences in roles of the coach and the Care Coordinator.
Why do we do this? Patient Outcome On coach follow up patient Coaching states “It is really Interaction working. I have not smoked and I feel better. During coaching session, Oh and I did get that COPD patient appointment for my lung contemplating smoking doctor to talk about my cessation lung test.” Patient Activation • Reviewed smoking Patient Outcome cessation options and• Patient called MD coached on discussion with MD• Medication added • Patient agreed to discuss at• Patient continues to be follow up appointment and smoke free 50 plus year smoker with severe contracted not to smoke until COPD the appointment Patient Activation • Patient discusses Patient Activation heightened anxiety • Discussed at follow up since he stopped appointment smoking • Chantix ordered • Coached encouraged patient on important • Continues not to messages to relay to smoking MD
What is Driving Re-hospitalization? • Fragmentation of data • 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 • Lack of patient self-management • Lack of community awareness
Designing Interventions to Address Drivers Driver Intervention Fragmented Documentation Coaching, Transfer Documents Inappropriate End of Life Care Coaching, Discharge Risk Assessment Tool Medication Errors Coaching, Personal Health Record High Risk Patients Poorly Identified Discharge Risk Assessment Tool Lack of Post Discharge Follow-up Coaching, Care Coordination, Follow-up Scheduling Lack of Disease Specific Protocols Protocol Improvement Project Poor Patient Self Management Coaching, Care Coordination, Personal Health Record Lack of Community Awareness Community outreach campaign
Transition Coaching• Models – Care Transitions Intervention (Eric Coleman, MD, MPH) – Transitional Care Model (Mary Naylor, PhD, RN) – eQHealth Solutions - Care Coordination/ Transitions Coaching• Focus – Empowering the patient – Patient-centered goals – Tools that focus on the patient – Medication reconciliation – Discharge plan of care – Making follow-up appointments – Recognizing red flags
eQHealth Model Conceptual Framework• Prochaska Stages of Change• Bandura Social Learning Theory/Self Efficacy• Erikson Stages of Development• Miller & Rollnick Motivational Interviewing• Thorndike Laws of Learning• Stewart PITS Model of Education/Patient Literacy
The Patient as the Solution• Moving from provider centered to patient centered care• Handing off to the patient and caregivers• Using tools to support good decision making This is hard and it requires us to think and act differently.
What is Transition Coaching?• Empowering and encouraging the patient on self care• The Patient and/or the Care Givers are the doers
How Does Coaching Differ from Care Coordination?Care Coordination CoachRecommends services as Encourages the patient toappropriate and assist patients discuss options with thewith accessing these services. physician, case manager and treatment team.Assists the patient with access Coaches the patient to scheduleto providers and sets up the follow up appointment andappointments. May attend refers the patient to the plan forappointments and treatments as network questions.appropriate.Assists the patient by setting up Coaches the patient to assesstransportation services and options for transportation andother community resources. empowers the patient to set up their transportation.
eQHealth Solutions Transition Coaching• The coach visits the patient in the hospital• Follow up phone calls at intervals; day 2, 7, 14, 21, 30 and 45 post discharge.• Each session focuses on the post discharge plan of care, medications, post discharge physician visit, warning signals, Personal Health Record and patient centered goal.• Patient Tools are used to reinforce teaching.• RBC; shared knowledge. Personal Goal: “To be able to watch my grandson play soccer from the side of the field and not my car.”
The Hospital Interaction• Patient’s role is expert in self• Coach builds relationship• Coach and patient share knowledge• Motivational Interviewing• Education; PITS Model of delivery• Building on successes• Preparing for treatment plan handoff to the patient or caregiver at discharge• Patient sets personal goal Personal Goal: “I want to be able to get back to church on Sundays.”
Telephonic Follow Up• Coach contacts the patient and focuses on the coaching components: – Education reinforced – Medications – Warning signs – Plan of care – Follow up – Personal Goal
Coaching Tools• Hospital Discharge “To Do List ”• Educational tools and homework• Personal Health Record• Medication Reconciliation• Warning Signals• Plan of Care• Follow up Appointment• Personal Goal
Who is Appropriate for Coaching? • Patients who can participate in self care or who have a willing caregiver
Who is not Appropriate for Coaching? • Nursing home patients • Hospice patients • Patients who need coordination of services by a clinician • Patients or caregivers must be able to activate for themselves
How Does Care Coordination Differ From Coaching? Care Coordination Coach Recommends services as Encourages the patient to appropriate and assist patients discuss options with the with accessing these services physician, case manager and treatment team Assists the patient with access Coaches the patient to schedule to providers and sets up the follow up appointment and appointments. Attends refers the patient to the plan for appointments when needed network questions Assists the patient by setting up Coaches the patient to assess transportation services and options for transportation and other community resources empowers the patient to set up their transportation
Care Coordination; When Coaching is Not Enough• Care coordination is holistic case management approach: – Manages the condition and the co-morbidities – Manages both clinical and psycho-social needs – Manages and monitors based on a comprehensive plan of care – Manages the transitions across care settings – Manages by incorporating elements of coaching to foster behavior change
Matching Services to Meet the Patient’s Need High Acuity Care Coordination Patient and or family High Moderate require coordinator Acuity Care assistance for navigation. Coordination Co-morbidities requiring Patient and or family clinical intervention. navigate for self but Requires assistance with Moderate Acuity require coordinator post discharge needs Coaching assistance. Co- daily or even multiple morbidities requiring times a day. Frequent Navigates for self or exacerbations may be has a caregiver that clinical intervention. Requires assistance prolonged. End stage navigates minimally disease. for patient. Co- with post discharge morbidities stable. needs 3 or more times Low Acuity Requires assistance a week. Frequent Coaching up to 2-5 times a week exacerbations may be with post discharge prolonged. Navigates for self care needs. or has caregiver Exacerbation that navigates expected to resolve minimally for the short term patient. Co- morbidities stable. Independent to minimal assistance with care needs.
Coordinated Care is Safe, Efficient and Cost Effective • Care Coordination results in • Behavior modification long-term sustainability • Provider adoption of evidence based practice guidelines • Reduced cost and increased quality of care for the patient, payor, provider and the community • Population management when supported by technology and customized reporting
Technology Links to Care Coordination• Technology enhances care coordination by providing – Organization – Efficiency – Structure – Process flow – Care Maps – Quality and consistency – Reporting
Things to consider – Common Pitfalls • Staffing • Program design and integration • Information transfer • Real time data availability • Training and operations • Population managementDon’t expect different results if you do the same thing and just call it something different.
“We did the best we could, with what we knew, and when we knew better, we did better.” - Maya Angelou