Transition Coaching Targets Adults at High Risk of Readmission

Friday, October 23rd, 2009
This post was written by Melanie Matthews

Danielle Butin, former director of Northeast Health Services for SecureHorizons, a division of UnitedHealthcare, discusses how health coaching programs have benefited managed care members’ health.

Using a health coaching model in a managed care environment has positively impacted our membership in a number of ways. We have seen a steady reduction in claims based upon this program. Members have reported improved functional status and quality of life. In monitoring diabetics over several years, for example, we have seen a reduction in the related complications that one would anticipate in a Medicare population over such long periods of time. It is important to note that this is contrary to the way care is rendered to older adults in this country. There is definitely a dependency/age bias in the way care is delivered, the expectations of the older adult and people making decisions for them. Our premise is that cognitively intact older adults are capable of learning a new set of skills. In other words, “you can teach an old dog new tricks.” That is the basis for our belief system around this program. It means that members must learn a new language, use a whole new set of tools and take control of their own health.

One practical application of the programs we currently run is the transition coach program.

We are currently enrolling Medicare members into our transition coach program using a tool developed within Oxford. It weighs in aspects of hospital performance around specific Diagnosis-Related Groups (DRGs), physicians’ performance around specific DRGs and the Ingenix Impact Pro(TM) system. These factors come together to provide a predictive tool score that is sensitive and specific to those members who, within 30 days, will be back in the hospital. We assign those members a nurse practitioner (NP) to call them and initiate a home visit. It is not a visit where the expectation is to call their doctor or pharmacist or take care of them in the traditional sense. Primarily, the NP will review the medications the member was on prior to their hospitalization, as well as those they’re on following their discharge. The most powerful point in this entire intervention process is reconciling discrepant medications, since discrepant medications are the major factor that causes readmission. Therefore, the NP creates a discrepant medication list for the patient to take to their PCP. The goal is to see the patient within the first week of discharge prior to their first follow-up PCP visit.

Ideally, an informed, empowered, educated, confident member will go to their PCP with a list of medications, developed and noted by a credible and reliable NP. Typically, doctors are grateful to know that an NP reviewed these medications. They can then make decisions based on this information. There are usually two to three follow-up calls from the nurse practitioner to the patient. The goal of this program is not long-term case management. Rather, the goal is to empower members at risk for hospitalization with the knowledge they need to feel confident in taking control of their healthcare.

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