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Patient empowered by transitions coaching

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This article was originally published in July 2009.

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Note: To protect privacy, this article does not use the patient's actual name.

For Elizabeth Parker, a 77-year-old grandmother with several chronic health conditions and a complex mix of medications, being admitted to the hospital has become an all-too-frequent activity. And she’s not alone. According to a recent study, nearly one in five people with Medicare coverage who were hospitalized in 2004 were readmitted within 30 days of being discharged.

As part of the Stepping Stones Project in Whatcom County, and funded by the Centers for Medicare & Medicaid Services (CMS), Qualis Health is training coaches to empower Whatcom County, WA residents to better manage their own care after a hospital discharge.

Parker is very pleased to have been one of the project’s first coaching recipients. “Working with [my coach] was great. She gave me something to think about—and to do,” she says.

For example, Qualis Health coach Karla Hall helped Parker develop a list of questions to ask her doctor and role-played how that conversation might go. “That list was so useful,” Parker reports. “The talk with my doctor went very well.”

Hall also encouraged Parker to make the appointment within days of returning home from the hospital, and connected her with a community resource to get transportation to the clinic. For someone recently discharged from the hospital, checking in with the primary care physician is an important, but often missed, step.

In this case, Parker's well-prepared list of questions not only helped her better understand her own treatment, but also prompted her physician to begin considering system changes in the 13-clinic family medicine practice. “The physician told me that seeing the patient’s expanded medication list made her realize that the regimen was too complicated for anyone, and she plans to address this with the practice staff,” Hall said. “The physician also went on to say that the visit made her realize that all patients need better education about red flags [symptoms requiring a call or visit with the doctor].” 

Among the tools proven to improve the safety of care transitions, coaching is a simple approach with long-lasting results. “We chose to use the coaching model as part of our intervention because it makes sense on so many levels,” Selena Bolotin, Qualis Health’s Care Transitions Project Manager, said. “Helping patients and their family caregivers become more engaged in their healthcare not only reduces hospital readmissions, but can also improve their ability to manage a host of care-related issues.”

After Hall’s initial interaction with Parker, Hall admits that she felt discouraged. “There was such complexity in this case. I felt as though there was so much to do and that a few coaching sessions couldn’t possibly make a difference. Thankfully, I was wrong.”

In Parker’s case, coaching certainly appears to have made an impact. She now knows the proper dosage, as well as the intended purpose, of each her medications. Going a step further, she has made a commitment to better manage her diabetes—which wasn’t a trigger for her hospital admission or a focus of her coaching sessions. The intervention has even spread to others, now that Parker’s doctor is actively discussing care transition issues with her practice.

Parker is feeling a lot better, and it’s not just her medical conditions that have improved. She is now more confident about her ability to manage her own health. According to Hall, Parker very quickly went from a “hopeless and helpless” attitude to one of empowerment—a care transition of the very best type. “It was amazing what just a few conversations did,” Hall says.