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CARE COORDINATION TRANSITION MODEL
Josefina Turnek
Western Washington University
Interdisciplinary Care Coordination
Instructor Bonnie Blachly
CARE COORDINATION TRANSITION MODEL
Peace Health United Cancer Care Center in Sedro Woolley does not particularly follow a certain care coordination transition model. Their patient population being treated for cancer also have many other health comorbidities. I believe that the best model the facility could use and benefit from is the “Coleman Care Transition Intervention Model” (CTI). By following this model, the patient will have improved transitions and continuity of care upon discharge from the hospital, thereby avoiding the need for hospital readmissions and reduces costs to the United States (US) ailing healthcare system. The CTI is based on the work of Dr. Eric Coleman, MD., M.P.H., from the University of Colorado (The Care Transitions Program [CTP], n.d.). It is a program with 4 components:
· Medication self-management. Patients need to be knowledgeable about their medication regimen and have a medication management system in place.
· Use of a patient-centered personal healthcare record to guide patients through their care process.
· Primary care provider and specialist follow up coordination.
· Increased patient knowledge and understanding of” red flags”. The patients will know and be able to recognize indications of worsening of their condition and what actions to take to reduce the risk of hospital readmission.
Health care costs are very expensive here in the US. President Obama stated, “The rising cost of healthcare is the nation’s number one deficit problem-nothing else even comes close”, (Amedisys, n.d. p.2.). Health care costs has always been an issue in the US. It has always been debated and has been a platform of many politicians especially during election time. The CTI model has been proven to improve patient discharges and care transitions and reduce hospital readmissions. In 2015, hospitals faced a penalty of three percent of their medical billings if they have an excessive number of patients being readmitted. It was estimated that one in five Medicare patients are readmitted to the hospital within 30 days after discharge (Amedisys, n.d.; The Rosalynn Carter Institute of Caregiving (RCI), n.d). Use of this model has shown an approximated cost savings of $300,000 for 350 chronically ill adults participating in CTI over a 12-month period (CTP, n.d.).
The CTI seems to be an appropriate care transitions model for Peace Health United in Sedro Woolley. It will assist in the facilitation of their adult patient population and their family members or caregivers in making a smooth transition and improve their continuity of care. Patients and their caregivers will be empowered by having a transition coach available to teach them the skills they will need so that they can be proactive in managing their health, thereby avoiding or reducing rates of readmission (CTP, n.d.; RCI, n.d.). Studies show evidence that the use of the CTI model has resulted in reduced readmission rates, however there were also limitations in the study because of the inclusion criteria of the participants. These include: (1) patients have to be 65 years or older, (2) admitted in a participating hospital for non-psychiatric condition, (3) not from a long-term care facility, (4) live in close proximity to the hospital making home visits possible, (5) have working telephone, (6) English speaking, (7) no record of dementia, (8) no plans for hospice, (9) not a participant of another research group (10) have at least 1 of 11 diagnoses, including congestive heart failure (CHF), coronary vascular accident (CVA), coronary artery disease (CAD), cardiac arrhythmias, chronic obstructive pulmonary disease (COPD), diabetes, spinal stenosis, hip fracture, peripheral vascular diseased (PVD), deep vein thrombosis (DVT), and pulmonary embolism (PE) (Coleman et al. 2006).
Although the CTI model is successful in patient care transitions, it also has its limitations. The CTI program is only good for four weeks with one initial visit in the hospital, a home visit and three follow up phone calls. Patients need to be willing to participate in this program for it to be effective. For those patients who do not want to participate in this program for whatever reason, there is an increase likelihood of hospital readmissions especially with our fragmented healthcare system and poor clinician communications. Another drawback to the CTI program is that the transition coaches need to be advanced practice nurses with master’s degree. For aspiring registered nurses (RN) who do not possess a master’s degree and want to be transition care coach, it means that they have to go back to school to obtain their masters degree.
In summary, even with the above limitations it appears that CTI model is a very effective care transition model and has been adopted across the country in many healthcare agencies. Patients who have used the CTI model rated their hospital discharge experience- very good or excellent (CTP, n.d.; RCI, n.d.). So I believe that Peace Health United, Sedro Woolley and their adult cancer patients could benefit from the CTI model. It will empower patients, their families and their caregivers by having a transition coach to serve as a bridge in their care and also giving them the tools and skills necessary to avoid hospital readmissions. This will mean a huge cost savings to our already ailing US healthcare system and better care for older patients with many chronic health comorbidities.
References
Amedisys. Care transitions amedisys. (n.d.). Retrieved from
http://www.amedisys.com/assets/pdfs/care_transitions_amedisys
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. https://doi.org/10.1001/archinte.166.17.1822
The Care Transitions Program. CTIinfobooklet2013.pdf. (n.d.). Retrieved from http://www.rcaging.org/Portals/0/uploads/CTIinfobooklet2013.pdf
The Rosalynn Carter Institute for Caregiving. Care transitions (Coleman). (n.d.). Retrieved January 27, 2017, from http://www.rosalynncarter.org/caregiver_intervention_database/miscellaneous/care_transitions/
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