The how tos for starting your own transition coahing program and using health coaches to reduce readmissions, costs and improve patient care.

1. Using Coaching to Reduce Costs
and Improve Care
Laurie Robinson, RN, CPE, CPUR
Director of Care Coordination Services

2. 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.

3. 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

4. MedPAC
Medicare Payment Advisory
Committee

5. 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

6. 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

7. 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

8. Believe in the Power of the Patient

9. 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

10. 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.

11. What is Transition Coaching?
• Empowering and encouraging the patient on
self care
• The Patient and/or the Care Givers are the
doers

12. How Does Coaching Differ from
Care Coordination?
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. May attend refers the patient to the plan for
appointments and treatments as network questions.
appropriate.
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.

13. 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.”

14. 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.”

15. 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

16. 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

18. Who is Appropriate for Coaching?
• Patients who can participate in self care or
who have a willing caregiver

19. 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

20. 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

21. 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

22. 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.

23. 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

24. Technology Links to Care
Coordination
• Technology enhances care coordination by
providing
– Organization
– Efficiency
– Structure
– Process flow
– Care Maps
– Quality and consistency
– Reporting

28. Population Management:
Customized Reporting

29. Things to consider
– Common Pitfalls
• Staffing
• Program design and integration
• Information transfer
• Real time data availability
• Training and operations
• Population management
Don’t expect different results if you do the same
thing and just call it something different.

30. “We did the best we could, with what we knew,
and when we knew better, we did better.”
- Maya Angelou

31. QUESTIONS?
LAURIE ROBINSON, RN, CPE, CPUR
(225) 248-7035
LROBINSON@EQHS.ORG