Eric A. Coleman

The aims of this study were to (a) describe the nature of patients’ goals upon discharge from hospital, family caregivers’ goals for their loved ones, and family caregivers’ goals for themselves; (b) determine the degree of concordance with respect to the three elicited goals; (c) ascertain goal attainment across the three elicited goals; and (d) examine factors predictive of goal attainment. Our findings support the position that eliciting patient and family caregiver goals and promoting goal attainment may represent an important step toward promoting greater patient and family caregiver engagement in their care.

Background/Objectives: The number of patients discharged to postacute care (PAC) facilities after hospitalization increased by 50% nationally between 1996 and 2010. We sought to describe payors and patients most affected by this trend and to identify diagnoses for which PAC facility care may be substituting for continued hospital care. Design: Retrospective analysis of the National Hospital Discharge Survey from 1996 to 2010. Setting: Adult discharges from a national sample of non-Federal hospitals. Participants/Exposures: Adults admitted and discharged to a PAC facility between 1996 and 2010. Our analysis includes 2.99 million sampled discharges, representative of 386 million discharges nationally. Measurements: Patient demographic and hospitalization characteristics, including length of stay (LOS) and diagnoses treated. Results: More than half (50.7%) of all patients discharged to PAC facilities were 80 years old or older in 2010; 40% of hospitalizations in this age group ended with a PAC stay. Decreases in LOS and increases in PAC facility use were consistent across payors and patient demographics. PAC facilities may be substituting for continued inpatient care for patients with pneumonia, hip fracture, and sepsis as these diagnoses demonstrated the clearest trends of decreasing LOS and increasing discharges to PAC facilities. Conclusions: The rise in discharges to PAC facilities is occurring in all age groups and payors, though the predominant population is the very old Medicare patient, for whom successful rehabilitation may be most unsure. PAC facility care may be increasingly substituted for prolonged hospitalizations for patients with pneumonia, hip fracture, and sepsis.

Integrated care promotes a key element of population-based health-supporting individuals and their family caregivers in the self-management of chronic health conditions. Inadequate support for self-care in turn leads to poor health outcomes, recidivism, and subsequent higher health care expenditures. In the absence of any type of feedback loop, health care professionals are simply unaware of where the breakdown occurs. When it comes to how we prepare health care professionals to manage acute and chronic health conditions, simulation experiences are recognized as the single most prominent innovation in medical education. If there is such consensus on the effectiveness of simulation, why don't we offer this learning approach to our patients? Offering patients a simulation experience would help us to identify obstacles and adjust the care plan accordingly. Proof of concept for the feasibility and value of offering patients and their family caregivers simulation experiences is found in a growing number of illustrative examples that will be described. Simulation has become the gold standard for how we train health care professionals to manage health conditions. Perhaps now is the ideal time for us to ask: shouldn't our patients learn about managing chronic health conditions the way we do?

Background: Family caregivers play a central yet often under recognized role in ensuring quality and safety during a loved one's transition out of the hospital. Purpose And Objectives: To explore challenges family caregivers face in assuming postdischarge family caregiving roles. Methods: A qualitative study was conducted that included 32 family caregivers with family caregivers whose loved one was recently discharged from hospital. A modified Grounded Theory approach was used to analyze the data. Results: Five central themes related to post discharge caregiving emerged from our analysis: (1) the roles and contributions of family caregivers occur along on a spectrum where the readiness, willingness, and ability of both parties is often dynamic and unrecognized; (2) family caregivers have unique and often incongruent goals from that of the patient; (3) family caregivers feel unprepared and overwhelmed by post-discharge medication reconciliation and management; (4) family caregivers need role clarification and encouragement to assert an identity; (5) family caregivers often assume the responsibility for the sequencing of care plan tasks and anticipating next steps. Discussion: This study highlights a number of unmet and unaddressed needs among family caregivers. These five themes are being incorporated into a widely disseminated evidence-based model of transitional care.

The Centers for Medicare and Medicaid Services (CMS) has launched the Partnership for Patients initiative, promising a 20% reduction in readmissions nationally across all payers by December 31, 2013. To address this ambitious goal, CMS has awarded grants to Hospital Engagement Networks, Pioneer Accountable Care Organizations, and the Community-based Care Transitions Program, as well as instituted new penalties for excessive readmission that began in October 2012. National efforts aimed at realizing this goal are predicated, in part, on our effectiveness in disseminating evidence-based care models into practice to improve outcomes and reduce costs. The Care Transitions Intervention (CTI) has been developed, tested, and disseminated to over 750 health care organizations in 40 states nationwide. Four factors promote wide-scale CTI dissemination. The first factor focuses on model fidelity whereby adopters are given insight into which elements of the intervention can be adapted and customized. The second factor concerns the selection of Transitions Coaches and reinforcement of their role through training and participation in a national peer learning network. The third factor relates to model execution with attention to integrating the intervention into existing workflows and fostering relationships with community stakeholders. The fourth factor involves cultivating the support to sustain or expand the intervention through continually making the business case in a changing health care landscape. The lessons learned through the dissemination and implementation of the CTI may be generalizable to the spread of a variety of evidence-based care models. ( Population Health Management 2013;16:227–234)

During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a ‘Transitions Coach,’ to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity intervention comprised of a home visit and three phone calls. In contrast to traditional case management approaches, the Care Transitions Intervention is a self-management model. The Care Transitions Program has modeled national Medicare data sets to demonstrate the frequency with which older adults making care transitions across settings will experience another transition in the near future. In other words, for most of these individuals, there will be a ‘next time’. Using qualitative techniques, the Care Transitions Program worked with older adults to identify the key self-management skills needed to assert a more active role in their care. Next, a Transition Coach was introduced to help impart these skills and help the individual and the family caregiver become more confident in this new role. Although critics are quick to point out that this is only applicable to highly educated or motivated patients, our studies have shown that most patients and family caregivers are able to become engaged and do considerably more for themselves. In essence, the model involves making an investment in helping patients and family caregivers become more comfortable and competent in participating in their care during care transitions. Five months after the Transition Coach signed off, these patients continued to remain out of the hospital demonstrating a sustained effect from coaching. 1. Medication self-management 2. Use of a dynamic patient-centered record, the personal health record 3. Timely primary care/specialty care follow-up 4. Knowledge of red flags that indicate a worsening in their condition and how to respond Patients who received this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention. Thus, rather than simply managing post-hospital care in a reactive manner, imparting self-management skills pays dividends long after the program ends. Anticipated net cost savings for a typical coach panel of 350 chronically ill adults with an initial hospitalization over 12 months is USD$ 295,594. Patients who received this program were also more likely to achieve self-identified personal goals around symptom management and functional recovery. To date more than 160 organizations have adopted the care transitions intervention. The John A. Hartford Foundation and The Robert Wood Johnson Foundation Please visit www.caretransitions.org or email: Eric.Coleman@ucdenver.edu

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations—The Care Transitions Intervention—could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.