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WHAT To provide patients with help and support from a transition coach as they move from hospital to home, or nursing home to home.
WHYTo prevent seniors from being readmitted to the hospital from not being able to manage their own care. To provide continuity of care, symptom management and recovery.
WHEREThe Division of Health Care Policy and Research University of Colorado Denver.
Aurora, Colorado, USA.
Funded by The John A. Hartford Foundation, 
The Robert Wood Johnson Foundation.

Program Description

"The Transitions Coach is key to encouraging the patient and family caregiver to assume a more active role in their care… they model and facilitate new behaviors and communication skills for patients and families to feel confident that they can successfully respond to common problems that arise during care transitions…"

Leaving the hospital can be a dangerous time for many patients. After hospital discharge, changes in nursing care environment, care providers and medications can result in oversights that jeopardize senior health. Many elderly are readmitted back to the hospital because of complications, or because they were not prepared to manage their own care.

Issues which may cause hospital readmission are:

-Unclear discharge instructions
-Conflicting instructions from different nursing care providers
-Medication errors, including dangerous drug interactions, or duplications

A "Care Transition Coach" can help elderly stay out of the hospital by educating them on; the use of a checklist to empower them before being discharged from the hospital or nursing facility, medication self-management, primary care physician or specialist follow-up, patient empowerment and participation at doctor appointments, signals that a condition is worsening and how to respond.

The "Care Transitions Intervention" training involves a coach empowering elderly, their families and caregivers to push for advocating their own health care. A detalied list of training includes learning about the following issues so that elderly can avoid being readmitted to hospital:

*Patient-centered record or the Personal Health Record (PHR) listing essential care elements
*Discharge Preparation Checklist to empower patients before discharge from the hospital or nursing facility
*Patient self-activation and management session with a Transitions Coach in the hospital to help patients and their caregivers assert their role in managing transitions
*Transitions Coach follow-up visits in the Skilled Nursing Facility (SNF) or in the home and accompanying phone calls  
*Medication self-management so that patient is knowledgeable about medications and has a medication management system
*Primary Care and Specialist Follow-Up - Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant
*Knowledge of Red Flags-Patient is knowledgeable about signs that their condition is worsening and how to respond

Coaches provide follow-up visits and phone calls at home or to the nursing facility during the transition.

Senior patients who participated in the "Care Transitions" Program have shown to be less likely to be readmitted to hospital.

A "Care Transitions" Program training manual and DVD are available to prospective health providers at no charge.

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