A large part of the success of the John C. Lincoln Network accountable care organization (ACO) can be attributed to its Transition Coach Program, which uses trained military medics as care transition coaches, explains Heather Jelonek, the organization's CEO for ACOs.
We applied for a CMS Innovation grant in spring 2012. Our hypothesis was that we could take military healthcare professionals, medics and army corpsmen; these individuals are incredibly well trained. Army medics can do appendectomies in the field; they’re providing basic primary care services. However, when they’re discharged from the military, they have no equivalent licensure.
We decided to begin a program where we hired individuals we referred to as having ‘blood on their boots.’ Tom Jargon was our first transition coach; he started with us about 90 days after his last tour in Afghanistan ended. But what the program really does is bring these young men and women into our health system. They get six weeks of training, they meet with a cardiologist, they are introduced around the hospital staff, and they get to know how to use the EPIC® electronic health record to its most effective benefit.
These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients and develop a rapport, but they also start preparing the patients for discharge. They are doing basic things like making sure the patient has a social support system in place and transportation to their primary care or specialists’ visits. They also try to determine the patients' financial resources.
Once that patient is discharged from the hospital, our transition coaches follow them for a minimum of 30 days. They’re going into the patient’s home looking for fall risks. They’re helping the patient set up their home so that they’re a little bit safer. They’re doing a general review of cabinets: does the patient in fact have food in the refrigerator? Do they have pet food available if they have pets? Sometimes we find patients are feeding their pets rather than feeding themselves. So through our relationship with PetSmart®, we’ve been able to collect donations of animal food; we deliver those to our patients’ homes so they can afford food for themselves.
If on the other hand they’re finding evidence that the patient has pet food in the home but no food for themselves, we connect those patients with our Desert Mission Food Bank.
Transition coaches help patients learn to monitor their blood pressure. They explain their medication. They go through basic nutrition and education services. We bring in a registered dietician to work with patients who have dietary issues.
Source: Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care
Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care Reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).