Rebecca is a Quality Improvement Specialist at eQHealth Solutions, Louisiana's quality improvement organization. She is the current President of the Louisiana Association for Healthcare Quality. Rebecca also serves on the National Association for Healthcare Quality Subject Matter Expert Task Force.

Hospitals participating in a CMS-sponsored transition coaching project in Baton Rouge, Louisiana have cut their avoidable readmissions nearly in half. The five-hospital Care Transitions collaborative reduced the readmission rate among the Baton Rouge Medicare fee-for-service coached patient population to 11.2% compared to an 18.9-22.4% expected baseline.

Here are five tips to help you implement a successful coaching program in your community.

1. Start where you’ll have the most impact. Focus on diagnoses that have the highest readmission rates. You may even have existing improvement programs for these diagnosis groups that you can build on.

• For example, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, and acute-myocardial infarction were identified as priorities for the Baton Rouge community.

2. Designate a department to take the lead. Case management may be your first choice but other departments might also be a good fit.

• Consider quality management, nursing, or patient safety areas. Hospital medicine and chronic care clinics are also starting to lead coaching programs.

3. Be prepared to sell. Hospitals already provide patients and caregivers with information about their after-care at discharge. Why should leadership invest in transition coaching to provide patients with additional education on self-managing their care?

• Nurses usually don’t have time at discharge to do an in-depth review of post-discharge care steps. Patients also may not be in a frame of mind to fully understand the information while in the hospital.
• Vulnerable patients, particularly the elderly with multiple conditions, need additional support after they return home to self-manage:
  • Follow up care needs and overcome barriers to meeting those needs. For example, coaches teach patients the trigger words to use with their physician’s office to obtain a timely follow up appointment.
  • New medications including adjusting dosage or timing.
  • Health crisis before it reaches a critical point. For example, coaches teach the patient how to recognize when his or her increasing shortness of breath or weight gain indicate worsening heart failure and requires follow up from a physician.

4. Keep it on the executive agenda. You can help sustain commitment from executive and medical leadership by tracking and consistently reporting current readmission rates by diagnosis.

• Two of the Baton Rouge community hospitals participating in the Care Transitions project were able to justify hiring coaches to continue their coaching programs.

5. Communicate regularly with all stakeholders. Set up regular conference calls or webinars to bring hospital staff and post-discharge providers together to discuss barriers and ways to improve, and to share successes.

To learn more about the Louisiana Care Transitions Project visit: http://louisianaqio.eqhs.org/caretransitions.htm, and for more information on coaching tools developed for the Louisiana Care Transitions Project visit: http://www.eqhssmarterhealthcare.org/the-blame-game-patient-adherence/. A Care Transitions Toolkit with tools developed by the fourteen Care Transitions project communities is available at: http://www.cfmc.org/caretransitions/toolkit.htm.

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Rebecca Hightower, MS, RN, CPHQ, CPE
Quality Improvement Specialist
eQHealth Solutions
[email protected]