Care Transition Coaching

In an effort to drive down unnecessary hospital readmission, ElderSource Institute provides evidence-based care transition services designed to assist patients moving from any healthcare facility to home.  Each patient has unique needs that must to be met in order to reduce readmission. This can be accomplished by implementing an effective transition program.

The Care Transition Problem:

Transitions between settings have been specifically identified as an area of concern contributing to the high readmission rates for aging adults.

  • The readmission rate for the state of Florida in 2015 was 19.6%. The national readmission rate was 18.6 % (Source: Integrated Care for Populations and Communities Quarterly Scorecard October 1, 2014 through September 30, 2015.)
  • Transition from one source of care to another lends itself to situations with high risk for communications failures, procedural errors and unimplemented plans. (Source: The Administration on Aging, Partnership for Patients Presentation)
  • People with chronic conditions, organ system failure and frailty are at highest risk because their care is more complicated and they are less resilient when failures occur. (Source: The Administration on Aging, Partnership for Patients Presentation)
  • Strong evidence shows that hospital readmission can be significantly reduced when flawed transitions are corrected. (Source: The Administration on Aging, Partnership for Patients Presentation)

The Care Transition Solution:

ElderSource Institute has a solution to address the multitude of concerns related to transition of care that result in unnecessary hospital readmission.

Parts of the Health Care Systems such as hospitals, affordable care organizations and plans are partnering with community based organizations such as Area Agencies on Aging and Aging and Disability Resource Centers to provide a holistic response to the problem and improve the quality of care of patients. One such opportunity is implementing Care Transition Intervention, an evidence based model developed by Dr. Eric Coleman.

Collaborative intervention can reduce readmission rates by:

  • Revamping hospital discharge education processes and improving transitions and coordination of care between care providers
  • Connecting patients with community based support and services, education, medication management and support for chronic disease self-management (Identification of red flags)
  • Redesigning processes to notify primary care doctors of patient admission and coordinating follow up appointments within 7 days post discharge

How ElderSource Institute Care Transition Works:

The Care Transition Coach encourages the patient and caregiver to assume a more active role in their care. Our Coaches do not provide skilled care. Rather, they show patients and caregivers new behaviors and communication skills so they feel confident about responding to common problems that often arise after leaving the hospital. The Coach provides information and guidance about medication; counsels patients on how to best communicate with the doctor’s office; and provides information on how to be aware of symptoms that can trigger a relapse.

  • The Care Transition Coach will visit with the patient and caregiver to prepare them for discharge.
  • The Coach will arrange for certain community-based services to help with the transition (e.g. home delivered meals, transportation, mental health counseling).
  • The Coach will visit the patient at home within three days after discharge, as well as make three follow up calls to the patient, checking on his or her progress.
  • Throughout the transition, the Coach will available to the patient for 30 days, providing information, encouragement and guidance.
  • With the Care Transition Coach, the likelihood of a patient being re-admitted to the hospital within the first 30 days of discharge is significantly reduced and their quality of life is increased.

To Further Discuss a Partnership in Care Transitions Coaching:

Please contact: Heidi Katz, 904.391.6682 or Email: Heidi.Katz@eldersourceinstitute.org