In recent years, several possible approaches to improving care during these transitions have been tried and tested—notably the pioneering Transitional Care Model project led by Naylor in Pennsylvania, the Guided Care program led by Chad Boult, M.D., professor of public health at Johns Hopkins University in Baltimore, and the Care Transitions Program led by Coleman in Denver.
Naylor’s approach focuses on using specially trained nurses to act as care coordinators on a health team. They work personally with patients and caregivers to develop a tailored care plan that includes regular home visits for two months after discharge and telephone support available daily. They also arrange follow-up visits to the hospital and doctor’s office, call on any community services that are needed and help patients manage their medications, exercise regimes, and other therapies. Supporting family caregivers is also seen as a vital part of the care.
Boult’s approach uses nurses based in primary care doctors’ offices who assess patients’ needs, monitor their conditions, help them become engaged in their own care, and work with community services to ensure that their health goals are met.
Coleman’s approach is less labor-intensive. His program focuses exclusively on teaching patients to help themselves. Trained coaches—who may be nurses, social workers, or health plan employees—spend four weeks showing newly discharged patients how to manage their medications, spot symptoms that indicate their condition is getting worse, and learn how to respond. They also teach patients how to use a personal health record to track their own progress and be proactive in scheduling doctor appointments. “We make patients and caregivers explicit members of our team and not just passive recipients of care,” Coleman says.
Such approaches have been shown to reduce hospital readmissions by about half. In one study of patients in Naylor’s Transitional Care group, 28 percent were back in the hospital within 26 weeks, compared with 56 percent in a control group. In a study using Coleman’s coaching method, 15 percent of patients were readmitted within 60 days, compared with 29 percent of those who had not been coached.
Currently the federal Medicare agency is funding 14 projects around the nation to study how transitional care can reduce readmissions and cut costs. All of these programs provide experiences on which lawmakers can draw in crafting a Medicare transitional care benefit.
Patricia Barry is a senior editor at AARP Bulletin Today.