Using Coaching to Reduce Readmissions, Costs and Improve Care_eQHealth Solutions

Using Coaching to Reduce Costsand Improve Care

Laurie Robinson, RN, CPE, CPURDirector of Care Coordination Services

• 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.

What will you learn today?

Why do we do this?

Coaching Interaction

During coaching session, COPD patient

contemplating smoking cessation

Patient Activation • Reviewed smoking

cessation options and coached on discussion with MD

• Patient agreed to discuss at follow up appointment and contracted not to smoke until the appointment

50 plus year smoker with severe COPD

Patient Activation• Discussed at follow up

appointment

• Chantix ordered

• Continues not to smoking

Patient Activation• Patient discusses

heightened anxiety since he stopped smoking

• Coached encouraged patient on important messages to relay to MD

Patient Outcome• Patient called MD

• Medication added

• Patient continues to be smoke free

Patient OutcomeOn coach follow up patient

states “It is really working. I have not

smoked and I feel better. Oh and I did get that

appointment for my lung doctor to talk about my

lung test.”

MedPAC

Medicare Payment Advisory Committee

• 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

What is Driving Re-hospitalization?

Driver InterventionFragmented 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

Designing Interventions to Address Drivers

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

Believe in the Power of the Patient

• 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

eQHealth Model Conceptual Framework

• Moving from provider centered to patient centered care

• Handing off to the patient and caregivers• Using tools to support good decision making

The Patient as the Solution

This is hard and it requires us to think and act differently.

• Empowering and encouraging the patient on self care

• The Patient and/or the Care Givers are the doers

What is Transition Coaching?

Care Coordination CoachRecommends services as appropriate and assist patients with accessing these services.

Encourages the patient to discuss options with the physician, case manager and treatment team.

Assists the patient with access to providers and sets up appointments. May attend appointments and treatments as appropriate.

Coaches the patient to schedule the follow up appointment and refers the patient to the plan for network questions.

Assists the patient by setting up transportation services and other community resources.

Coaches the patient to assess options for transportation and empowers the patient to set up their transportation.

How Does Coaching Differ from Care Coordination?

• 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.

eQHealth Solutions Transition Coaching

Personal Goal: “To be able to watch my grandson play soccer from the side of the field and not my car.”

• 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

The Hospital Interaction

Personal Goal: “I want to be able to get back to church on Sundays.”

• Coach contacts the patient and focuses on the coaching components:– Education reinforced– Medications– Warning signs– Plan of care– Follow up– Personal Goal

Telephonic Follow Up

• Hospital Discharge “To Do List ”• Educational tools and homework• Personal Health Record• Medication Reconciliation• Warning Signals• Plan of Care• Follow up Appointment• Personal Goal

Coaching Tools

• Patients who can participate in self care or who have a willing caregiver

Who is 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

Who is not Appropriate for Coaching?

Care Coordination CoachRecommends services as appropriate and assist patients with accessing these services

Encourages the patient to discuss options with the physician, case manager and treatment team

Assists the patient with access to providers and sets up appointments. Attends appointments when needed

Coaches the patient to schedule the follow up appointment and refers the patient to the plan for network questions

Assists the patient by setting up transportation services and other community resources

Coaches the patient to assess options for transportation and empowers the patient to set up their transportation

How Does Care Coordination Differ From Coaching?

• 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

Care Coordination; When Coaching is Not Enough

Low Acuity CoachingNavigates for self or has caregiver that navigates minimally for the patient. Co-morbidities stable. Independent to minimal assistance with care needs.

Moderate Acuity CoachingNavigates for self or has a caregiver that navigates minimally for patient. Co-morbidities stable. Requires assistance up to 2-5 times a week with post discharge care needs. Exacerbation expected to resolve short term

High Moderate Acuity Care Coordination Patient and or family navigate for self but require coordinator assistance. Co-morbidities requiring clinical intervention. Requires assistance with post discharge needs 3 or more times a week. Frequent exacerbations may be prolonged.

High Acuity Care CoordinationPatient and or family require coordinator assistance for navigation. Co-morbidities requiring clinical intervention. Requires assistance with post discharge needs daily or even multiple times a day. Frequent exacerbations may be prolonged. End stage disease.

Matching Services to Meet the Patient’s Need

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 enhances care coordination by providing– Organization– Efficiency– Structure– Process flow– Care Maps– Quality and consistency– Reporting

Technology Links to Care Coordination

Population Management: Customized Reporting

– 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.

Things to consider

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

- Maya Angelou

QUESTIONS?

LAURIE ROBINSON, RN, CPE, CPUR(225) 248-7035

[email protected]