Professional Documents
Culture Documents
Michelle D. Kelly*
Email: mdkelly@usfca.edu
7524 Gates Drive, Sebatopol, CA 95472
Tel. 707-498-7773
Michelle Kelly, RN, FNP, is a community-based practitioner and nurse educator. She has
successfully coordinated a care transition program based on Coleman’s model with BSN
students. Kelly has cared for populations with chronic disease in rural communities
which were in need of service beyond homecare coverage. She found a way to involve
students in providing some of these health services. Students learned quality-
improvement measures while coaching people recently discharged from the hospital.
Future endeavors will involve creating a Care Transition Advisory Group and
implementing an online Care Transition Learning Module for nurses.
Abstract
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BACKGROUND
The Problem
In 2005, chronic disease accounted for 70% of all deaths of people in the United
States (U.S.). Nearly half of all people in the U.S. currently live with one or more chronic
diseases. Chronic disease, such as cardiovascular illness (heart disease and stroke),
cancer, diabetes, and respiratory illness, accounts for 80% of all healthcare dollars spent
in the U.S. (Centers for disease Control [CDC] 2009). Thus, it cannot be overstated that
chronic disease is associated with high medical care costs. Expenditures are attributed to
the frequent utilization of health services, particularly with regard to the use of inpatient
hospital services. People with chronic diseases are more likely to be readmitted to the
hospital within 30 days of discharge, and when they are readmitted, they often present
readmissions are essentially adverse health outcomes from one or more unresolved
conditions from the first admission (Halfon, Eggli, Pretre-Rohrbach, Meylan, & Marazzi,
et al., 2006).
of patients who have been recently discharged (Medicare Payment Advisory Commission
[Medpac], 2007).
High readmission rates are attributed to a variety of influences. One of the most
significant factors leading to readmission is the inadequate preparation of clients and their
caregivers with during the hospital discharge process. Returning home after a
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hospitalization, clients are often unable to monitor and manage their disease. In contrast
to patients who are transferred to a skilled nursing facility or receive home health care
after discharge, the problem of hospital readmission is greater for clients who are 65
years old and over, have one or more chronic diseases, and are discharged to their own
communities are also at higher risk for preventable hospital readmission. Thus, a
avoidable readmissions.
Scope
The majority of healthcare dollars spent in the U.S. have been attributed to
persons with one or more chronic disease(s); an individual with one chronic disease
spends four times more healthcare dollars than does an individual without a chronic
disease; and 82% of inpatient service utilization is by people with chronic disease
(Anderson, 2007; Medpac, 2007). The demographic shift of today’s population in the
U.S. is one in which the proportion of older adults (65 and over) has grown to 10%; this
figure is expected to increase to 17% by 2030 (Christ & Diwan, 2009). The scope of
chronic disease in the U.S. population is increasing; today 25% of children already have
one or more chronic conditions (Anderson). The demand for care for people with chronic
disease is on the rise and economic factors drive the allocation of health services. The
high cost of care and higher rates of remissions in aggregates with chronic disease are
under inquiry by Medicare, which aims to decrease costs and improve quality for it’s
beneficiaries. In 2008, a review of Medicare cases found nearly 20% of beneficiaries who
were discharged from hospitals were readmitted within 30 days; the annual cost was over
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The Institute of Medicine (IOM, 2000) identified readmission rates as the primary
contributor to spiraling health costs, and suggested a strong association between low-
quality discharge processes and higher readmission rates. Hospital readmissions are
defined as patients who are discharged and then readmitted (unscheduled) within a 30-
day period. The readmission rate is considered to be a valid metric of the quality of
hospital care (Agency for Health Care Quality Research [AHRQ], 2006).
Coleman et al. (2002) and Dehia (2009) hypothesized that if clients are satisfied
with their preparation for discharge to their home, these clients are less likely to
experience a hospital readmission. Inversely, clients who are more likely to report low
satisfaction with their preparation for discharge are also more likely to be readmitted.
When Worth, Tierney, and Watson (2000) interviewed clients and their caregivers about
stating that they did not feel prepared to manage their care at home. Shorter hospital stays
and other cost-cutting measures have shifted chronic disease care from the formal
healthcare system to the client and his or her informal caregiver(s). A majority of people
decrease in their ability to function, which is not fully regained by time they are
hospital discharge home often requires clients to depend on informal caretakers for
personal and chronic disease care. Considering that half of all medication errors occur at
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transition points (Institute for Healthcare Improvement [IHI], 2009), such as discharge to
home, caregivers play a large role in avoidable readmissions. Caregivers are typically
unpaid, lack formal training, and are more likely to be 65 years or older (Weinberg,
The ability of the caregiver to provide a safe and effective level of chronic-disease
care after hospitalization was identified as a major concern for clients discharged home
(Coleman, 2003). In particular, the issue was the lack of knowledge of how to give
medications appropriately. Coleman indicated that clients and their caregivers recognized
their own deficiencies in knowledge, this perceived deficiency was linked to medication
discharge. The standard of practice in every discharge is to assist clients and caregivers
with understanding how to take their medications appropriately after discharge. Despite
this and other standards of practice for patient safety, 20% of readmissions did not have
Clients with chronic disease are prescribed far more medications than clients
without chronic disease. For example, a client with one chronic disease averaged eight
drug prescriptions per annum; a client with three chronic conditions averaged 26
prescriptions per year; and people with five or more chronic conditions, which comprise
especially when one considers that readmission rates are costly and that they tend to
occur more frequently with clients with one or more chronic disease(s). It should also be
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kept in mind that such clients have reported receiving low-quality care, and that this
seems related to their low levels of satisfaction and to perceived lack of preparation for
readmissions, and efforts have been made to identify the contributing causes of the
occurrence of avoidable readmissions and the steps that health institutions can take to
address this problem. New information on readmissions and the factors associated with it
affect rates of readmission (IHI, 2009). Major stakeholders evaluating chronic disease
costs and readmission rates in the U.S. include professionals working on health policy
care and patient safety initiatives that evolved as a result of IOM’s landmark report, To
Err is Human (2000). The IOM has called for significant changes in institutional attitudes
regarding basic patient safety on the part of the leaders in healthcare; it has also called for
healthcare leaders to bring new modalities and tools to “identify and learn from errors”
(p. 1) in order to improve patient outcomes. Moreover, the IOM has determined that
heaviest users of the inpatient care, is one of the top 20 priorities in assuring patient
safety. Care coordination activities were identified as a way to increase the effectiveness
and efficiency of care. Coordinating care would address gaps in quality of care in an
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increasingly fragmented service delivery system. The IOM found that the highest
utilization of health services, including admission for inpatient care, was by people with
chronic disease, usually older adults who had one or more chronic diseases.
There has been a shift in the health care environment. Hospitals now more
routinely examine their mistakes; however, the precise tools to measure and address
patient safety issues are complex, and many of these tools are still not fully in place
(Leape & Berwick, 2005). Health outcomes of people with chronic disease, including
readmission rates, are linked to medical-care quality and hospital staffs’ ability to
group of beneficiaries (Christ & Diwan, 2009). Medicare has been a pioneer in assessing
and promoting the rational use of health dollars and has highlighted patient safety as an
indicator of quality of care. This insurer is unique in linking of chronic disease treatment
and the number of inpatient days. Medicare has used a variety of fee-for-service payment
schemes to both financially reward and punish major vendors such as hospitals.
Unnecessarily high utilization of inpatient services by people with chronic disease has
even caused Medicare to redesign reimbursement policies to make wiser use of ever-
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Smith, & Frank, et al., 2004) identified the unique risks for readmission faced by older
persons. In a sample of older adults with one or more chronic disease, the researchers
found, on average, that older adults saw eight different physicians in one year. Results of
the research identified that at each point of care, there is a risk that essential information
will not be transferred in a timely manner from one physician to another. The findings
also illustrated the frequency and complexity of the different points of care for people
with chronic diseases and suggested a correlation between multiple points of care and
avoidable readmissions. Finally, the study suggested that patients who are knowledgeable
about their health become competent managers of their own disease and act as their own
patient-safety advocates, which, not surprisingly, means that they will probably be less
Aetna, Kaiser, RWJF, and others, have designed strategies or implemented programs for
addressing high readmission rates. Three types of approaches have been aimed at
lessening the problem of avoidable readmissions: (a) interagency, (b) service delivery,
and (c) client focused. The interagency approach uses case coordination to strengthen
handoffs during the transfer of care. With this approach, essential information is both
more complete and available for the next healthcare practitioner(s). The intent of a
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smooth, effective transition between care settings is to both lower costs and to effect
better client outcomes. Moreover, the transfer of information in a timely, effective way is
believed to improve client health status and lower the risk of readmission. Care
points of service throughout the care spectrum, involves the planning of required patient-
care tasks, timely communication, and the carrying out of procedures to positively impact
the outcome of patients. Care coordination models were designed to foster better health
outcomes and bridge the gap as clients transitioned between care delivery systems.
Different health agencies use care coordination to meet their specific needs. Care
coordination programs can target a client group with a specific disease (such as asthma,
asthma). A Cochrane literature review of care coordination studies, done by Parkes &
Sheppard (2000), found a lack of models providing substantial evidence for achieving
limitation.
planning. In the hospital, case managers conduct activities to assure that clients prepare
for transfer to another facility, are discharged home either with or without home health
planning targets clients with specific needs, such as the need for complex care after
involves determining clients’ readiness for self-care and the level of their community
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discharge, and perhaps home visits to clients as a follow-up to their hospital stay. An
example of enhanced discharge planning for an inpatient newly diagnosed with diabetes
would likely involve educating the client about the disease and how to test blood sugars
Medicare regulation that denies hospitals payment for avoidable hospitalizations of their
(Medpac, 2007).
Interventions that are client-focused involve teaching the client and family the
skills to appropriately manage the client’s disease outside of the hospital facility. The
preparation of clients and their caregivers before discharge is linked with higher
satisfaction rates and positive outcomes, including fewer readmissions, than for clients
who report dissatisfaction with their hospital stay (Weinberg, Lusenhop, & Hoffer, 2007).
readmission in clients with congestive heart failure and other chronic conditions by
empowering clients to competently self-manage their care after discharge. Coleman and
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others (2006) conducted a randomized control in which the intervention group was
assigned a transitions coach who encouraged participants to take an active role in their
care. The intervention of coaching includes communication skill-building for clients; the
aim is to exchange essential health information across care settings and to help clients
assert their preferences. In the intervention group hospital readmission rates were reduced
by 12% in rural areas and 35% in urban areas. Additionally, Coleman’s model requires
few resources for implementation and is uncomplicated, so busy staff can easily learn the
principles and coach clients with chronic diseases on the principles of self-care and self-
management of their health conditions, thereby reducing the potential for readmissions in
clients.
to safely transition between care settings; the pillars frame the relationship between
clients and the transition coach; however, the focus remains on empowering clients to
become managers of their own care. The pillars are (a) medication self-management, (b)
person-centered health record, (c) follow-up appointments with primary care clinician
The purpose of this pillar is to reconcile differences between what medications are
prescribed with what is actually being taken at each transition point. Transition
coaches assure that the clients and caregiver have a complete list of current
medications, understand what they are prescribed, are aware of what each
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Lack of health literacy is a major problem, as clients are frequently given printed
lists of their medications by health staff with no other instructions. Clients and
their own writing, of essential health information. The coach’s role is to introduce
the person-centered health record and encourage clients to use the patient record
to keep track of their medical history, questions for the primary care provider, and
Writing down questions for health providers, bringing in all medications, and
ensuring that appointments are kept are essential to the clients’ best use of the
healthcare system.
Knowing what the red flags are and seeking the appropriate level of care, either
through a call to their provider or trip to the emergency room, can avert
Transition coaches focus on skill transfer and building self-efficacy with clients.
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They do this through the use of specific self-care tools, such as the person-centered health
record, and role-playing how, for example, a client might call a medical office to
professionals. The model is used with clients who are ready to be discharged home or to a
skilled nursing facility for less than 6 weeks. A trained transition coach would approach
clients in the hospital, give an explanation of the care transition program, offer to see
them in their home two days after their discharge, and facilitate completing their own
personal health record, especially comparing their discharge instructions and medication
list to how they are currently taking their actual medications. Coleman’s model
person-centered health record keeping, knowledge of red flags, and follow-up care with
reducing readmission rates. Coleman’s Care Transition Model (2002) developed and
piloted the Medication Discrepancy Tool, which provides quantitative and qualitative
errors between what was ordered and what the client is actually taking after discharge. At
the posthospital home visit, the coach correlates what was prescribed according to the
hospital discharge summary with the actual medications the client is taking. Studies
reveal that 14.1% of clients had one or more medication discrepancies on the initial home
visit, and readmission within 30 days occurred with 14.3% of the clients with one or
more medication discrepancies, in contrast to 6.1% rate of readmission of clients who did
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provides invaluable data in that it reveals the prevalence of a medication discrepancy and
Recommendations
A vast majority of healthcare resources are needed for individuals with chronic
disease. Avoidable readmissions not only indicate a poor quality of discharge teaching,
but also add to spiraling healthcare costs. Readmissions are exacerbated as clients with
chronic disease move through multiple points of care with limited continuity and
to align their common agenda; patients want to stay out of the hospital, and hospitals
want to improve the quality of care after patients are discharged to prevent unplanned
readmissions. The AHRQ (2007) called for practical answers on how to implement
posthospitalization of older adults with chronic disease goes beyond giving patients a
phone number to call for a follow-up appointment. Discharge activities leave patients and
caregivers dissatisfied and unprepared to manage their care, including safe medication
administration at home.
Coleman’s (2002) model provides a template for hospitals to use and to build self-
care into a client’s discharge process. The literature emphasizes that client and caregiver
involvement is central to the positive health outcomes and is associated with lower
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hospitals to rectify root causes. Hospitals are faced with significant economic
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References
Anderson, G., (2007). Chronic conditions: Making the case for ongoing care chartbook:
Partnership for Solutions. Baltimore, MD. Retrieved from the Robert Wood
Agency for Health Care Quality Research (AHRQ). (2006). Closing the quality gap: A
AHRQ Medical Expenditure Panel Survey (2006). Average number of total (including
http://www.meps.ahrq.gov/mepsweb
Bisognanao, M., & Boutwell, A., (2009). Improving transitions to reduce readmissions.
Centers for Disease Control. (2009). Chronic disease overview. Retrieved from
http://www.cdc.gov/NCCdphp/overview.htm
Christ, G., & Diwan, S., (2009). Chronic Illness and Aging (Section 1). The
National Center for the Gerontological Social Work Education. Retrieved from
http://depts.washington.edu/geroctr/mac/1_6health.html
Coleman E., Smith J., Eilertsen, T., Frank, J., Thiare, J., Ward, A., et al. (2002).
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from http://www.ijic.org/archive.html
Coleman, E. (2003). Falling through the cracks: Challenges and opportunities for
improving transitional care for persons with continuous complex care needs.
Coleman, E., Smith J., Frank J., et al. (2004). Preparing patients and caregivers to
Coleman, E., Parry, C., Chalmers, S., & Min, S., (2006). The Care Transitions
http://archinte.highwire.org/cgi/content/full/166/17/1822
Darwin, B., & Parrish. M., (2008). Navigating care transitions in California: Two models
http://www.chcf.org/topics/view.cfm?itemID=133766
Dedhia, P., Kravet, S., Bulger, J., Hinson, T., Sridharan, A., Kolodner, K., et al. (2009).
5415.2009.02430.x
Jencks, S., Williams, M., & Coleman, E. (2009). Rehospitalizations among Patients in the
1418-1428.
Halfon, P., Eggli, Y., Pretre-Rohrbach, I., Meylan, D., Marazzi, A., & Burnand, B.
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http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Reconc
ile+Medications+at+All+Transition+Points.htm
Leape, L., & Berwick, D. (2005). Five years after To Err Is Human: What have we
http://www.medpac.gov/chapters/Jun07_Ch05.pdf
Medical Expenditure Panel Survey. (2006). Average number of total (including refills)
http://www.medpac.gov/documents/Jun09_EntireReport.pdf
Parkes J., & Shepperd S., (2000). Review evidence of the effectiveness of discharge
Weinberg, D., Lusenhop, R., & Gittell, J., Hoffer, J., & Kautz, C. (2007). Coordination
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doi: 10.1097/01.HMR.0000267792.09686.e3
World Health Organization (WHO). (2008). 2008-2013 action plan for the global
strategy for the prevention and control of noncommunicable diseases: Prevent and
http://www.who.int/nmh/publications/ncd_action_plan_en.pdf
inpatient hospital care for the elderly reduce readmission rates, length of
Worth, A., Tierney, A., & Watson, N. (2000). Discharged from hospital: Should more
the community? Health & Social Care in the Community, 8(6), 398-405.
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