As Coleman's model and others like it began to make measurable dents in rehospitalization rates, Sen. Michael Bennet (D-Colo.) took notice. Bennet crafted a bill called the Medicare Care Transitions Program Act of 2009, using components of the Care Transitions Intervention as well as some of the approaches used by Rocky Mountain Health Plans, a not-for-profit health benefits provider based in Grand Junction, Colo.
In lieu of formal coaching, Rocky Mountain incorporates its care transitions program into its coordinated care within the hospital and case management following discharge, says Sandy Dowd, director of case management. The level of follow-up is based on patients' illness acuity, and includes phone calls, health literacy assessments and referrals, she says.
According to a Dartmouth Atlas Project report released in 2006, the Grand Junction region achieved some of the lowest Medicare costs in the country and was also one of the most efficient regions for end-of-life hospital use.
Introduced by Bennet in May 2009, the bill proposed the creation of a national network of transition coaches that would be managed by community-based organizations, thus removing some of the care coordination burden from providers.
Included in the health reform law was the Community-based Care Transitions Program, a provision modeled after Bennet's bill. The program allots $500 million over five years, beginning Jan. 1, 2011, for community-based organizations to target high-risk Medicare beneficiaries with histories of multiple chronic diseases and past hospitalizations. According to the text of the provision, organizations chosen to participate in the program will provide medication management, self-management support and help arranging follow-up care. Priority will be given to organizations that target small, rural and medically underserved communities.
Interested applicants will also have to demonstrate that they are actively involved in collaborations within the community, Coleman says. “The idea is that you can't come to the dance by yourself,” he says. “You have to create and show partnerships.”
And there are plenty of other interventions that would fit within the parameters of the provision, says Mary Naylor, a professor of gerontology in the school of nursing at the University of Pennsylvania at Philadelphia.
Two decades ago, Naylor and her colleagues began work on the Transitional Care Model, a comprehensive, high-intensity intervention that targets older adults with two or more risk factors for hospital readmission. Naylor's model uses nurses with master's degrees who act as “transitional care nurses.” Nurses support patients through regular home visits and telephone calls, and they also accompany them on doctor's appointments. Unlike other programs that measure success with 30-day readmission rates, Naylor says her goal is to stop the downward trajectory that many patients are on and reduce rehospitalizations in the long term.
“In our most recent trial, we've been able to demonstrate that if you make this investment, you'll see improvements in satisfaction, cost savings and reduced hospitalization through 12 months,” Naylor says.
Naylor also responded to arguments that her approach is too expensive, citing research that shows $5,000 in mean savings per Medicare beneficiary.
“Investing in this kind of intervention gets these people and their families in a position to deal with their chronic health problems in a very different way,” she says. “I don't think it's too intensive; I think it matches their needs.”
Other sites have employed different approaches, including some that use virtual, nonhuman coaches. Project Re-Engineered Discharge is a program at the Boston University School of Medicine that stresses patient education before discharge from the hospital. Led by Brian Jack, associate professor and vice chair for academic affairs in the university's department of family medicine, Project RED uses several tools including an electronic “coach” named Louise for providing post-discharge instruction.
Created in collaboration with Tim Bickmore, a professor of computer science at Northeastern University in Boston, Louise is an animated character displayed on a touch screen mounted on a cart near the patient's bed.
Louise, or the “virtual discharge advocate,” as she is also known, talks to patients and reviews orders, and they respond using the touch screen. The Louise system also tests competency by asking questions such as, “What medications do you take?”
“Our data show that twice as many people prefer Louise to a clinician because she's not in a hurry and she will go over instructions again and again,” Jack says.
For Mary Shankle, an 87-year-old woman living in Temple, Texas, the impact of the home visits and phone calls she received from her transition coach could not be more profound. Shankle suffered from various chronic conditions including hypertension and had been in and out of the hospital several times. After her last hospitalization in September 2009, she was paired with Jamie Jones, a transition coach employed by Scott & White Healthcare, based in Temple, which uses Coleman's CTI model.
Jones worked to help Shankle learn to manage her care and reach her goal of remaining in her home and living independently. Nearly a year later, Shankle has stayed out of the hospital and has learned to spot signs of trouble.
“My life is better now at 87 because my health is better,” Shankle says. “I'm feeling good; my blood pressure is down. I'm eating good food and I'm active. It's amazing, this knowledge, it has kept me on my feet.”