Transitions Coaches support patient self-care after hospitalization

September 15, 2014


Barbara Narduzzi was frightened when she had to be hospitalized at St. Mary Mercy Livonia twice in March due to several health problems, including a heart attack followed weeks later by pulmonary edema. Just one thing upset her more than being in the hospital — the idea of going home. After an episode when she struggled to breathe while hospitalized, Narduzzi, 74, broke into tears as she contemplated how she and her husband would manage her care on their own.

She credits her work with certified Transitions Coach Catherine Ponder with helping in her early days back home from the hospital. A Transitions Coach is a relatively new type of health care professional, often a nurse or social worker. Transitions Coaches complete a branded training program to learn to help patients take care of themselves when they move between care settings, such as returning home after a hospital stay. Ponder, team leader for the hospital's care transition support team, visited Narduzzi while she was still hospitalized to establish rapport and asked to visit Narduzzi at her Livonia, Mich., home to help with the transition.

Transitions Coaches don't tell patients what to do; rather, during the home visit, they ask patients to identify a goal for themselves. In Narduzzi's case, when Ponder visited her at home, Narduzzi said she wanted to get strong enough to return to caring for a 94-year-old she looks after.

Transitions Coaches
Patient Barbara Narduzzi stretches following a session of cardiac rehabilitation. Her Transitions Coach Catherine Ponder from St. Mary Mercy Livonia in Michigan observes in the background.

Ponder gave Narduzzi a paper log where she records her health information and jots notes during medical appointments. They practiced techniques for how Narduzzi could best communicate with her doctors. Using a technique called "show me, tell me," Ponder asked Narduzzi to show how she sets out her pills in a pill box and to demonstrate how she takes the medications, to make sure she was taking the right medications in the right doses at the right time of day.

"I really don't know what I would have done without Cathy, I'll tell you that," Narduzzi said. She is feeling much better, and said that within the last few weeks, she has been able to return to her work caring for the elderly person.

Skill transfer

The relationship between a patient and Transitions Coach at St. Mary Mercy Livonia usually lasts 30 days including one hospital visit and one home visit — ideally within the first few days of a patient's return home — where the coach teaches self-care skills to the patient. The Transitions Coach makes two or three follow-up phone calls to gauge how the patient is faring toward goal attainment, what needs the patient may have, and to help the patient work through how to meet those needs.

St. Mary Mercy Livonia in southeast Michigan, part of CHE Trinity Health's Saint Joseph Mercy Health System, employs Transitions Coaches to work with Medicare patients hospitalized for heart failure, heart attack, pneumonia or chronic obstructive pulmonary disease who are identified as being at risk of a medical relapse requiring a return stay in the hospital within 30 days of discharge. Physicians also refer patients they believe would be helped by working with a Transition Coach.

The hospital says in a program summary that it began transitions coaching in 2010 for five reasons: to allow patients to achieve personal goals and take an active role in their health care; to improve the patient experience post-discharge from the hospital; to reduce avoidable readmissions; to teach patients about self-management of chronic disease; and to help patients stay healthy and functioning in their daily lives.

Carrot and stick
Patients such as Narduzzi report they have found the work with a Transitions Coach valuable in their recovery. Hospitals have a growing financial stake in helping patients avoid unplanned readmissions within 30 days of discharge. Medicare started financially penalizing hospitals in fiscal year 2013 when their unplanned readmission rate for Medicare patients passed a set threshold. The penalty steps up to a maximum of 3 percent of the hospital's Medicare revenues in the next fiscal year. Hospitals can lower or eliminate those financial penalties if they lower unplanned readmissions related to certain conditions. Using coaches to assist patients in managing care transitions is a tool to achieve the better health outcomes that benefit patients and hospitals.

A Kaiser Health News analysis of Centers for Medicare and Medicaid Services data showed St. Mary Mercy Livonia had a fiscal year 2013 Medicare readmission penalty of 1 percent of its Medicare revenue and a 0.97 percent penalty in fiscal year 2014. According to hospital data, the 1 percent penalty is based on readmissions from July 2008 through June 2011, and the 2014 penalty, which could have been as high as 2 percent, was based on data for July 2009 through June 2012.

The hospital says its data are trending in the right direction in part due to the transitions coaching, with a decrease in its unplanned 30-day readmission rate for Medicare patients from 22.3 percent in 2010 to 18.8 percent earlier this year. The hospital said penalties are for past performance, so the benefit of the work being done now won't be felt right away.

Turning the tables
As patients transition from the hospital back home or to a residential care setting, St. Mary Mercy Livonia's Transitions Coaches use the Care Transitions Intervention developed by Dr. Eric A. Coleman, head of the division of health care policy and research at the University of Colorado Anschutz Medical Campus in Aurora, Colo. The protocol is designed to improve quality and safety during patient hand offs across acute and post-acute settings and to allow coaches to work with patients to become active participants in their own care.


Coleman said, "It's such an abrupt change from being in a hospital, and to some extent, being treated in a skilled nursing facility to going home. In the former two settings, people come in and do everything for you, and then 11 minutes before you're about to leave, they turn the tables on you."

He said right before hospital discharge is when health care professionals typically tell patients and their families how to change a bandage or how to keep track of the timing and dosing of multiple medications. The information comes "at a time when probably their biggest worry is how are we going to bring the car around, and is there food in the refrigerator when we get home, and how's my dog. It's just such a mismatch."

When patients set goals for what they want to accomplish outside of the hospital, they often then take steps to improve or maintain their health to make it a reality. "They need to understand what their role in their own health care is," Coleman said.

Reinforcing patient agency
St. Mary Mercy Livonia employs two full-time Care Transitions Coaches — a nurse and a social worker both certified by the Care Transitions Program developed by Coleman — and three part-time nurses who call patients and coach them on the phone.

St. Mary Mercy Livonia also created a partnership with the area's Senior Alliance that has four full-time employees who coach, a social worker and three transition field coaches to expand the numbers of patients assisted.

More than 1,300 St. Mary Mercy Livonia patients have worked with a Transitions Coach. Coaches make follow-up visits and phone calls when it seems a patient needs support beyond the 30 days of the program. They continue to focus not on solving problems for patients, but on teaching patients skills to help themselves. If patients tell a coach they need a ride to an appointment, the coach links them to one-time free transportation through the Senior Alliance, but works with the patient to determine how the person is going to get to the next appointment after that.

Ponder said outcomes for patients enrolled in the Care Transitions Intervention include lower unplanned readmission rates; improved patient engagement in working toward their personal health goals and positive feedback from physicians that patients in the program are keeping appointments and bringing questions, their medications and personal health records to appointments. Patients say they have an increased awareness of early warning signs that a medical condition may be worsening, and know when to call a health care provider to prevent an avoidable readmission.

"The main thing you're looking for is skill transfer," Ponder said. "The goal is to help them identify who can help them moving forward."

Health coaches encourage patients in behavioral changes

In the past, patients who needed to improve their health might have expected to receive some stern advice from a care provider: eliminate the bad habits, exercise more, eat more sensibly to lose weight. Leave the doctor's office, and it was anyone's guess if the patient would make the behavioral changes.

Health Coaches
Andrea Carter, a nurse and Mercy Accountable Care Organization health coach at Mercy East Family Practice in Pleasant Hill, Iowa, talks with patient Tom Shaffer about improving his health. Shaffer has lost about 60 pounds with assistance from the health coach program.

In recent years, health care systems and hospitals have turned to health coaches to help patients set health goals, identify how they can overcome obstacles and track their progress outside of the doctor's office. While a certified Transitions Coach is someone who has gone through the trademarked Care Transitions Program developed by Dr. Eric Coleman and works with patients transitioning between care settings, there's no one type of training or certification for a health coach, many of whom are health care professionals, such as nurses.

Some health care systems offer their own educational programs for their health coaches.

Many health coaches study a technique called motivational interviewing to key in on what a patient wants to improve and what steps the patient is willing to take to meet his or her objectives.

Health reform is fueling a greater interest in ways to engage patients in taking charge of their own health. Some health care systems are introducing health coaches and others that have used health coaches for years are expanding their use, saying well-trained health coaches, who employ evidence-based methods, can improve patient outcomes.


More than 20 nurses work as health coaches for the Des Moines, Iowa-based Mercy Accountable Care Organization, and they conduct about 500 motivational interviews with patients each month, said Dr. David Swieskowski, the ACO's chief executive. "It's becoming more widely recognized as a way to get adults to change their behavior," Swieskowski said of health coaching. The Mercy Health Network in Des Moines plans to use part of a $10.1 million Centers for Medicare and Medicaid Services Health Care Innovation Award announced in July to pay three years' salary for 41 new health coaches and 14 clerical assistants. The coaches will work with patients of Mercy's critical access hospitals.

Leading questions
Health coaches ask questions designed to help patients set a behavioral goal for themselves, Swieskowski said. So, for instance, if a patient said her goal is to "lose 10 pounds" — an aim that doesn't address how she's willing to modify her behavior — her coach would prompt her to restate the goal in terms of action steps such as eating more fruits and vegetables.

Swieskowski said in one instance, a patient's goal was to get a dog — not the usual objective heard by health care practitioners. Nevertheless, the health coach was supportive. Then, when the patient told his coach he was too tired to walk the dog, the health coach encouraged the patient to cut down on salty foods, take his medication as prescribed and begin a walking program. The patient received an energy boost, making it easier for him to exercise his dog, and improved his heart health in the process, Swieskowski said.

Health coaches and trained volunteers, called supportive guides, working with Centura Health in Colorado and western Kansas also use motivational interviewing as a technique to assist patients seeking to make behavioral changes. "It's really powerful," Drew Weilage, director of the Health Passport program with Centura Health's Second Curve Partners, said of the coaching experience. "It helps individuals cut through the clutter and prioritize what's important." Weilage works on community health improvement and community benefit programs for Englewood, Colo.-based Centura Health.

In Lakewood, Colo., Centura Health's St. Anthony Hospital teams with the area's Consortium for Older Adult Wellness and city government in a program called Healthy Lakewood. Health coaches employed by the hospital and trained volunteers work for up to six months with participants whose ability to manage chronic disease might be improved with a strengthened commitment to healthy behaviors. The Consortium for Older Adult Wellness program assists area residents with self-management of chronic illness and falls prevention, and the city coordinates health assessments and recreational and community education opportunities.

The coaches use motivational interviewing techniques to help Healthy Lakewood participants overcome ambivalence they have to change. The coaches encourage patients to set goals to manage a condition or improve health, and help them gain knowledge about healthy choices and skills to put plans into action. Participants also learn techniques from a chronic disease self-management program developed at Stanford University.

Centura Health has exported the Healthy Lakewood coaching model to Wheat Ridge and plans to expand it to two other Denver-area communities: Westminster and Church Ranch.

During the Healthy Lakewood pilot that evolved into the ongoing initiative, participants filled out a survey before and after the program to allow researchers to assess their engagement in self-care. Most showed a higher level of "activation" in their own care following the program.


Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.


Copyright © 2014 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.