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Frequently Asked Questions: The Care Transitions InterventionSM
1) What are the key attributes of a Transition CoachTM?
2) What is an average caseload for a Transition CoachTM?
3) How long does the intervention take?
4) What is the duration of each of the intervention activities?
5) Do patients really need three follow-up telephone calls?
6) What if the patient is readmitted to the hospital?
7) What did the intervention cost?
8) What are the targeting criteria for this intervention?
9) What are the high impact diagnostic groups?
10) What if the person has cognitive impairment?
11) How does the coach interact with the homecare nurse or case managers?
12) What has been Primary Care Physicians’ response to the intervention?
13) Who pays for the coach?
1) What are the key attributes of a Transition CoachTM?
Rather than specifying the ideal professional training for the Transition CoachTM, it has been
our experience that when identifying a candidate it is more important to focus on certain key
attributes. The key attributes of a Transition CoachTM include:
- The ability to shift from doing things for a given patient to encouraging them to do as much as
possible for themselves
- Competence in medication review and reconciliation, and
- Experience in activating patients to communicate their needs to a variety of health care professionals.
2) What is an average caseload for a Transition CoachTM?
We have learned that the geographic distribution of patients' personal residences has the greatest influence
on a coach's caseload. In fact, we have limited patients' participation to a geographic radius that was feasible for the
Transition CoachTM to perform multiple home visits in a given day or half-day. In a metropolitan
region, a typical caseload is around 24 patients. At any given time, the Transition CoachTM is
establishing a rapport and introducing the tools to approximately 1/3 of these patients, is actively
involved in helping approximately 1/3 of these patients get their needs met, and is tapering off or identifying resources such
as longitudinal case management for the remaining 1/3 of the patients.
3) How long does the intervention take?
In our experience, patients’ post-hospital discharge needs extend from 21-28 days. As such, the Transition
CoachTM was involved and available to patients and their caregivers for up to 28 days.
4) What is the duration of each of the intervention activities?
In general, the hospital visit usually takes approximately 45 minutes, which includes time to gather
information needed to help complete the PHR and reconcile medications at the home visit, establish rapport and
explain the program to the patient and/or caregiver.
The home visit usually takes approximately 60 minutes (not including travel time).
The follow-up phone calls range between 5-15 minutes each.
5) Do patients really need three follow-up telephone calls?
Some patients already had strong support systems and were able to easily incorporate the program into an
existing routine. At the discretion of the Transition CoachTM, some of these patients did not receive all
three telephone calls.
6) What if the patient is readmitted to the hospital?
In most cases, the Transition CoachTM either visited the patient in the hospital or telephoned them
after discharge to check on their status and provide a “booster dose” of the program.
7) What did the intervention cost?
The annual cost for the Care Transitions InterventionSM was $74,310. This figure was comprised of
annual salary and benefits for the Transition CoachTM ($70,980), annual costs for a cell phone and
pager ($650), annual mileage for the Transition CoachTM ($2500), and annual costs for reproduction of
the Personal Health Record and other supplies ($180).
The cost of the Care Transitions InterventionSM is interpreted in light of the productivity of the
Transition CoachTM and the potential reduction in re-hospitalization rates and accompanying cost savings.
Depending on the number of eligible discharges per year, the number of coaches and
accompanying sizes of their panel, and the anticipated reduction in hospital readmissions based on our
published data, a health delivery system could determine whether the intervention has the potential to
at least pay for itself.
8) What are the targeting criteria for this intervention?
In order to participate in this program, patients had to meet the following criteria:
1) age 65 years or older, 2) non-psychiatric-related hospital admission,
3) community-dwelling (i.e., not a long-term care facility), 4) residence within a predefined radius of the
hospital (thereby making a home visit feasible), 5) have a working telephone, 6) have at least one of 11
diagnoses documented in their record.
These 11 diagnoses included congestive heart failure, chronic obstructive pulmonary disease, coronary artery
disease, diabetes, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture,
peripheral vascular disease, cardiac arrythmias, deep venous thrombosis, and pulmonary embolism.
The rationale for selecting these conditions was based on either their high likelihood for requiring post-hospital skilled
nursing facility or home health care (thus experiencing additional care transitions) or because of the need for
intensive anticoagulation management.
In addition, the University of Colorado Care Transitions Research Team has performed risk modeling in
a representative sample of Medicare beneficiaries. They have developed a risk algorithm for identifying patients
at risk for complicated care transitions using either administrative/claims data or administrative/claims data
combined with patient-level information regarding functional status and caregiver participation available at the
time of hospital discharge. This project was published as:
Coleman EA, Min S, Chomiak A, Kramer AM. Post-Hospital Care Transitions: Patterns, Complications, and
Risk Identification. Health Services Research. 2004;37(5):1423-1440.
9) What are the high impact diagnostic groups?
Among the 11 diagnoses included in the initial targeting for the
Care Transitions InterventionSM, there are particular conditions
that appear particularly amenable to this type of program. These are conditions that require a great deal of
coordination, medication reconciliation, laboratory monitoring, and durable medical equipment.
Based on our work, patients with CHF, COPD, and recent stroke appear particularly well suited, as do
patients requiring short- or long-term anticoagulation such as atrial fibrillation, deep
venous thrombosis, and pulmonary emboli.
10) What if the person has cognitive impairment?
Realizing that it may not be feasible nor clinically reliable to administer a fully cognitive assessment to a
hospitalized older adult, we have followed the following protocol. When a patient is approached and invited to
participate, a brief 4-item cognitive screening is administered. Patients are asked their current age, today’s
date, the name of the facility in which they are hospitalized, and their telephone number. Patients who answered
fewer than three questions correctly could still participate in the study provided they
could identify an able and willing proxy.
11) How does the coach interact with the homecare nurse or
case managers?
As long as the Transition CoachTM is not billing Medicare for home visits, there is no concern over
duplication of services. The patient and Transition Coach often practiced or “role played” the upcoming
visit with the home health nurse in order to ensure that the patient was able to articulate his/her health care needs.
The same was true for the case manager. However, often the case manager was not aware that the patient had
been hospitalized and one of the actions for the Transition CoachTM was to re-unite the patient with his/her case manager
or to make a referral if longitudinal case management was indicated.
In many respects, it would be natural for the home care nurse to assume some of the roles of the
Transition CoachTM, engaging the patient and family members to promote greater participation in
the process. Disease management and case managers could also take on some of the Transition CoachTM functions.
12) What has been primary care physicians' response to the intervention?
In general, primary care physicians have been supportive of the intervention. They have been particularly
appreciative of receiving an already reconciled medication list and also a more timely and complete listing of what
lab or test results are outstanding.
13) Who pays for the coach?
The intervention was specifically designed to be compatible within both Medicare Advantage and
traditional Medicare fee-for-service payment systems. The financial incentives of capitated payment
are well aligned to support an intervention designed to better integrate care across settings and reduce
subsequent use of acute services such as hospitalization. The cost of the Transition CoachTM would likely
be assumed by the Medicare Advantage program.
In a traditional Medicare fee-for-service payment environment, financial incentives do exist, but are
less apparent. There are incentives, for example, for acute care hospitals. Many hospitals across the
country are operating at capacity and frequently need to divert patients to other hospitals. Hospitals
operating in these environments have a financial incentive to facilitate transfer of complex older
patients for whom reimbursement is less favorable to other care settings (such as skilled nursing
facilities) to create bed capacity for patients for whom reimbursement is more favorable (e.g.,
orthopedic surgery and interventional cardiology patients).
An additional financial incentive for effective care transitions concerns re-hospitalization. When patients
are re-hospitalized for the same condition shortly after discharge, the hospital may have to cover
the costs of the subsequent stay under the initial Diagnosis Related Group (DRG). Increasingly, performance measurement
for care coordination/care transitions is receiving national attention from groups such as National Quality Forum
and the Institute of Medicine. A program such as the Care Transitions InterventionSM may
help hospitals improve their performance ratings. Finally, accreditation by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) includes items on continuity of care for discharged patients, and the new Tracer
Methodology examines care “hand-offs” both within and out of the hospital setting. For one or more of these
reasons, a hospital may choose to invest in the services of a Transition CoachTM.
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Transitional Care