Reducing Readmission Risk for the
Elderly through Care Transition Coaching
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With
the healthcare industry focused on reducing the high numbers of
Medicare patients readmitted to the hospital within 30 days of
discharge, landmark studies of transitions in older adults at high risk
for readmission upon discharge by Eric Coleman, M.D., at the University
of Colorado are transforming care management approaches across the
country.
Reducing
Readmission Risk for the Elderly through Care Transition Coaching
presents new models of care coordination for the elderly, including an
Oxford Health Plan care transition coach program modeled on Dr.
Coleman's research. This book also reports on Inspiris's care team
approach to managing care transitions for the frail elderly —
adults 65 and older who comprise 40 percent of elderly hospitalizations
and who are particularly vulnerable during transitions from one care
site to another.
Part
of the Reducing Hospital Readmissions Toolkit, a
four-volume set with case studies from a variety of programs aimed at
reducing unnecessary hospital readmissions, from discharge planning,
transition coaching, transitions in care case management, medication
reconciliation, community partnerships, home visits, assessments to
identify high-risk patients and patient and caregiver
education.
Reducing
Readmission Risk for the Elderly through Care Transition Coaching
examines four coaching-based approaches to coordinating care across
healthcare settings from Oxford Health and the impact that these
programs are having on healthcare utilization:
- Transition
coach program for Medicare beneficiaries that includes patient
education and empowerment, health record creation, medication
management, communication with physicians, and home visits and
follow-up;
- Advanced
illness and coordinated care program for seriously ill patients who do
not yet meet hospice criteria but require assistance with medical
symptom management as it impacts end-of-life comfort care and proactive
decisions about end-of-life healthcare services;
- Health
coaching and pharmacy outreach for Medicare members designed to break
down barriers to medication adherence — drug and food
interactions, functional issues and socioeconomic factors; and
- Options
for Living self-management classes for Medicare members living with
diabetes, lung conditions and chronic pain.
Beyond
Oxford Health's coaching-based approaches, this 30-page special report
presents an analysis of vulnerabilities in care transitions for the
frail elderly — a population whose numbers are expected to
more than double by 2023 — from Inspiris, Inc. Since
self-care, self-management or behavior modification is not an option
for the majority of the frail elderly due to some degree of cognitive
impairment, Inspiris proposes a care team-centered approach:
identifying the at-risk population, developing the care plan and
providing ongoing health maintenance and acute problem management.
In
this special report, these respected thought leaders share their unique
approaches to care transition management that positively impact cost
and engage the patient and support team in their care decisions:
- Danielle
Butin, former director of Northeast Health Services for
Secure Horizons, United Healthcare;
- Gregg
Lehman, Ph.D, president and CEO of Health Fitness Corp., who
contributed to this report in his former position as president and
chief executive officer of INSPIRIS.
Table
of Contents
- Integrating
Health Coaching Into a Comprehensive Health Management Effort
- Using Health Coaching to Better Manage
Transitions and Improve Empowerment
- Implementing Health Coaching Programs
- Results of Health Coaching in Managed Care
- Transition Coach Program
- Advanced Illness and Coordinated Care Program
(AICC)
- Polypharmacy Transitions
- Options for Living Self-Management Programs
- Results of Living Self-Management Programs
- Managing
Transitions for Medicare Patients to Avoid Costly Inpatient Admissions
- The Frail Elderly: Growing Need, Growing
Problem
- The Changing Role of Family Caregivers
- Ten Most Common Reasons for Hospitalizations
Among the Elderly
- How and When Breakdowns Occur
- Acute Problem Management
- Physician Relationship Management
- Utilization and Cost Outcomes
- Q&A:
Ask the Experts
- Predicting Inpatient Acute Utilization
- Managing Fractures on an Outpatient Basis
- Criteria for Identifying Pre-Hospice Patients
- Acute Problem Management
- Geriatric Depression Scale and Mini Mental
Status Exams
- Funding & Reimbursement
- Interventions for Self-Management Disease
Programs
- Health Coaching in Pharmacy Outreach Programs
- Determining the Frequency of Maintenance Visits
- Components of the Home Visit
- Training Transition Coaches
- Training Nurse Practitioners
- Glossary
- For
More Information
- About
the Authors
Publication
Date: October
2009
Number of Pages: 30
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