Quality Talk

Dr. Coleman is professor of medicine in the Division of Health Care Policy and Research at the University of Colorado at Denver and professor of geriatric medicine at its Health Sciences Center. As director of the institution’s Care Transitions Program, Dr. Coleman bridges innovation and practice to improve quality and patient safety. He also is executive director of the Practice Change Fellows Program, a national initiative that builds leadership capacity among health care professionals who are responsible for geriatric programs. All of the 14 Quality Improvement Organizations (QIOs) conducting the CMS Care Transitions project are using Dr. Coleman’s Care Transitions Intervention.

“My advice for health care providers is to focus on the individual needs of the patient and their family as they transition from one care setting to another. Family caregivers are often the unsung heroes and act as the first and last line of defense when it comes to ensuring patient quality and safety between care settings.”

“Patients are uniquely qualified to judge the quality of their care, and by listening and responding to their experiences, we can ensure quality health care for all patients.”

What is a transition of care and what is the goal for every transition of care?

A transition of care or “care transitions” refers to the movement patients make between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness. These settings include hospitals, skilled nursing facilities, outpatient clinics, assisted-living facilities and private residences. Poorly executed transition periods can confound our best attempts to provide person-centered, quality care. Patients are extremely vulnerable during these transitional periods and are too often left to navigate these interims with little guidance from or cooperation between the interdisciplinary care settings.

The goal for every transition of care is to improve quality and safety during “hand-off” times by enhancing the role of patients and family caregivers in managing their own care. This can be achieved by providing patients and their family members with evidence-based tools that promote knowledge and self-management of their condition during these intervals. In addition, health care providers must practice patient-centered care by measuring the quality of care transitions from the perspective of patients and caregivers, implementing system-level practice improvement interventions, and using health information technology to promote safe and effective care transitions.

How did you become aware of readmissions as a quality of care issue?

As a geriatric physician, readmission is a quality of care issue that I’ve witnessed first hand. I believe that as physicians, we have a responsibility to be there for our patients as they adapt to very challenging and sometimes scary changes in health status. I was professionally embarrassed to learn that many of my patients and their families were trying to navigate and endure these difficult transitions alone. 

From a broader perspective, we have extensive data to demonstrate the frequency with which geriatric patients making transitions across care settings will experience another transition in the near future. For most of these individuals, there will be a next time.

In a study I conducted with Steven Jencks and Mark Williams that was published in the April 2009 issue of the New England Journal of Medicine  we found that readmissions are not only very common in the hospital setting, but are also extremely expensive. Hospital readmissions cost the American health system $17.4 billion per year on average. If the Administration is going to do anything about the rising cost of health care, reducing readmission rates is an excellent place to start. It becoming more important that the health care system shift its paradigm to providing patient-centered care that empowers patients and their families with the tools and skills they need to manage their care during periods of transition.

How did you develop the Care Transitions Intervention^SM (CTI)?

The Care Transitions Intervention^SM (CTI) is unique compared to other case management approaches because it is based in self-management. We engaged staff, patients and family caregivers as true partners from the very beginning to develop and help shape the model. We held group discussions with patients, specialists and professional caregivers to identify key self-management skills and tools to assert a more active role in self-care. We also consulted with financial leaders in hospitals and clinics to verify the financial sustainability of the intervention. Based on this input and the results of our research, we developed a model for self-management that focuses on four conceptual pillars: medication self-management, use of a dynamic patient-centered record, primary care and specialist follow-up, and knowledge of red flags.

During a four-week program, patients with complex care needs and their family caregivers receive specific tools and work with a “Transitions Coach” to learn self-management skills that will ensure their needs are met during their transition between care settings. This is a low-cost, low-intensity intervention consisting of a home visit and three phone calls.

The Transitions Coach helps the patient process the information they received at the time of discharge in a way that will resonate with them long after they’ve left the hospital. The coach is not intended to fix the patient’s problem, but rather, to model patient-activated behavior and monitor the patient’s progress across the care settings.

What impact is your care transitions work across the country having on patients?

Imparting self-management skills pays dividends long after the end of the four-week intervention period. Patients who participated in this program were significantly less likely to be readmitted to the hospital, and benefits were sustained for five months after the end of the one-month intervention. For a typical Transitions Coach panel of 350 chronically ill adults with an initial hospitalization, the anticipated cost savings over 12 months are $295,594. Patients who were coached were also more likely to achieve the self-identified goals surrounding symptom management and functional recovery. The CTI is now endorsed by 3,500 organizations in 15 countries.

How have you interacted with the Centers for Medicare & Medicaid Services (CMS) on its Care Transitions theme?

We’ve worked closely with CMS and the Care Transitions Quality Improvement Organization Support Center (QIOSC) over the past couple of years and find our skill sets to be incredibly complementary. Through the partnership, we’ve developed a strong appreciation for the Quality Improvement Organizations’ (QIO) clear strength and ability to convene diverse stakeholders and their thorough understanding of the communities they serve.

What can health care providers do to help patients make a smooth transition from one setting of care to another?

My advice for health care providers is to focus on the individual needs of the patient and their family as they transition from one care setting to another. Family caregivers are often the unsung heroes and act as the first and last line of defense when it comes to ensuring patient quality and safety between care settings. Engage with the patient and their family caregiver to help them identify their personal health goals and ways to achieve these goals through self-managed care. Patients are uniquely qualified to judge the quality of their care, and by listening and responding to their experiences, we can ensure quality health care for all patients.

To learn more about the Care Transitions Program developed by Dr. Coleman, please visit www.caretransitions.org. To learn more about the CMS Care Transitions Theme and the work that QIOs are doing, go to www.cfmc.org/caretransitions.