Possible Coach Talking Points

Hospital Visit:

  • Hi. I’m ___. I’ll be your Transition Coach and we will work together for the next 30 days.
  • This will be very different from any other provider visit you may have had in the past.
  • This is a Personal Health Record. We will work on it at your home visit.
  • When you get home, I’ll be visiting you for 1 home visit and a series of follow up phone calls.
  • Call me after you are discharged.
  • (Set up availability) I may not answer right away, but I will call you back.
  • I’m here to help you prepare for your transition home. (Try not to use the word discharge).
  • I’ll help you understand you r medications and condition better so you don’t come back to the hospital.

Phone call to set up Home Visit:

  • I’m the person you met in the hospital who gave you that (color) book. As I mentioned in the hospital I’ll be coming to your home to help you in your recovery, to go through your medications, to go over any questions you may have and to get you ready for the follow up apt with your doctor. Is everything ok?
  • Do you have any questions regarding your discharge instructions?
  • Were you able to get any medications?
  • Do you have any questions about your medications?
  • I’d like to set up a time that is convenient for you and anyone who is important in your health care that should be at our home visit?
  • It would be helpful if you can take a few minutes before our visit to gather up all of your medications, any medication lists you have, and the discharge papers for the hospital.
  • I’ll see on you ____.

Home Visit:

  • I’m ___, I met you in the hospital. I gave you the (color) Book. I’m here to help you in your recovery and get all of your questions answered. This is the only time we will meet in person, but I’ll be calling you a few more times to check up and see how you are doing.
  • Why don’t we start with your PHR?
  • PHR: This is your record. You take it to the doctor apt. You update it. You keep track of your health record
  • The PHR will help you take ownership of your information.
  • F/U apt: I’m going to help prepare you to see your doctor.
  • Goal: What is 1 personal goal that is important to you to achieve in 1 month?
  • Dx: With your (chf) tell me about the signs to watch for that you may be getting in trouble?
  • Meds: Why don’t you gather all of your medications even the over the counter and expired ones. Tell me what you take and when. Is this how you took this med before you went to the hospital?
  • Questions: That is a good question to write down for your doctor apt.
  • I’ll call you on ___ to check to see if you ( called MD, called pharmacy, etc).
  • Wrap up/ Re-quiz the patient on what was reviewed: So we’ve gone over a lot of things today. Let’s review the most important things we’ve touched on, including your questions and things that need to be done. What are the top 3 questions you like to get answered form your doctor? Remember to take your PHR to the doctor apt and update it with any changes the two of you may make. What other things need to be done before my next call ( schedule apt, call pharmacy, pick up testing supplies, arrange for visiting nurse, get prescriptions filled)?
  • I’m going to call you (later this afternoon, tomorrow, in a few days, next week) to follow up and see how things are going and if you got your questions answered.
  • Do you have any further questions before I go?
  • On the front of your PHR is my name and number. If you hit any roadblocks, please call me. I’m available on ___.

Follow-up Phone Calls (F/U on actions items discussed at previous interaction with patient)

  • Did you schedule your MD apt? Did you call the pharmacy about your medication discrepancy?
  • Did you go to your MD apt? Did you talk to your doctor about a plan?
  • Did you take your PHR to the MD apt?
  • How did the doctor address your questions?
  • Did you update your PHR (with the med changes your doctor made, etc)?
  • Have you been back to the hospital since we last spoke?

This material was prepared by Quality Insights of Pennsylvania, the Quality Improvement Organization for Pennsylvania. It is redistributed by the Colorado Foundation for Medical Care (CFMC), the Integrating Care for Populations & Communities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services.