1. Transitions in Care Program
Mary Bittner, RN, MPA, CENP, DNP(c)
Vice President, Nursing

2. What is a Transitions Coach?
They encourage patients to take a more active role in care
They don’t fix problems or provide skilled care
They do model and facilitate new behaviors and communication skills
They desire for patients to effectively manage care after discharge and independently manage issues
Bond, Christinia Pavett; Coleman, Eric. Reducing Readmissions, A Blueprint for Improving Care Transitions.(Chapter 5, pg )

3. Goals for Effective Coaching
Patient Empowerment
Improved Self-Management Skills
Enhanced Patient to Practitioner Communication
Strengthened ability to recognize early signs of potential problems
Picture of Coaches here
Possibly could add picture of the Transition Coaches to this slide.

4. Dynamic Patient-Centered Approach Medication Self-Management
The Four Pillars
Dynamic Patient-Centered Approach
Medication Self-Management
Physician Follow-up
Red Flags
Would be cool to find a graphic of four columns or pillars then enter the bullets into each one on this slide.

5. Program Operations Transition Coach staffing Tuesday-Saturday
Initial patient contact prior to hospital discharge
Phone contact within 24 hours of discharge
Face to face visit within hours of discharge

6. Phase One Target Population
CHF (Congestive Heart Failure)
PNA (Pneumonia)
DVT (Deep Vein Thrombosis)
Reasons: - Chronic Disease in our vulnerable elderly population. - Core Measure focus. - CMS no longer paying for readmissions within days for CHF & PNA.

7. Target Population Subsequent Program Phases
Newly diagnosed chronic disease patients
Patients with frequent acute hospital re-admissions and/or multiple E.D. visits
Patients with compliance issues and psycho-social challenges

8. Patient Personal Health Record
Health & Symptoms
Upcoming Provider Appointments & Recent Admissions
Questions for Medical Providers
Medication List
Self Monitoring

9. Patient Personal Health Record
Medical History
Red Flags
Goals
Advanced Directives
Important Phone Numbers

10. PNA Zone Tool

11. CHF Zone Tool

12. DVT Zone Tool

13. Patient Progress Tool

14. Monitoring Our Progress
Patient contact tracking tool
Metrics of measurement for 30 days
Correlation to Utilization Management Committee readmissions data
Evaluation of NRC Picker scores with patient perception of communication and answering questions
Please move this slide to the end of the series

15. Questions?