The Care Transitions InterventionSM model relies on a Transition Coach to help empower patients to take a more active and informed role in their transition from one care setting to another. In the original implementation of the model, the Transition Coach was an advanced practice nurse (APN) with strong competence in medication review and reconciliation, experience helping patients communicate their care needs effectively to caregivers, and the ability to coach patients in doing things for themselves. The model has also been tested with a RN performing the coach role and comparable outcomes were achieved.

The Transition Coach works with a panel of patients whose size depends on the geographic area covered. In metropolitan areas, a typical Coach caseload will be around 24-28 patients.

The Transition Coach’s work with each patient is broken into three key activities discussed below.

• Hospital visit—the Transition Coach first meets the patient in the hospital before discharge to introduce her/himself, to introduce the Personal Health Record, and to schedule a home visit with the patient.
• In-home visit—the Transition Coach visits each patient once, ideally within 48 to 72 hours post-discharge. A primary purpose of the home visit is to help the patient reconcile her or his medication regimen. Together, the patient and Transition Coach will update the patient’s Personal Health Record with the newly reconciled medication list. In addition, the Transition coach uses the home visit to help teach the patient how to effectively communicate care needs with various caregivers. Finally, the Coach reviews with the patient any red flags that could indicate a worsening of her or his condition, how to respond to red flags, and when to contact a health care professional.
• Follow-up phone calls—after the home visit, the Transition Coach contacts the patient by phone 3 times in the next month. With the phone calls, the Coach reviews the patient’s progress towards goals, discusses encounters with health care professionals and reinforces the importance of updating and sharing the Personal Health Record.

The Transition Coach works with patients around the four pillars of the model (Personal Health Record, Medication Self Management, Patient Follow-Up with PCP/Specialist, and Patient Knowledge of Red Flags), which are described below.

Some of the organizations adopting The Care Transitions InterventionSM have used social workers as Transition Coaches. In addition, two settings have used nursing students with appropriate preceptorship as Coaches.

The PHR is a patient-centered document that contains key information needed to help facilitate the continuity of the patient’s care across settings. Key elements of the PHR include:

• Patient demographic information
• Patient medical history
• Discharge preparation checklist—a structured checklist of critical activities that patients should complete before leaving the hospital or nursing facility
• Caregiver information
• Blank space for patients to record follow-up questions for caregivers
• Patient medication record
• Patient’s personal health goal—what the individual patient hopes to achieve as a result of the Care Transitions Intervention

During the home visit, the Transition Coach helps the patient fill in important details of the PHR and encourages the patient to use the PHR as a tool to improve communication with her or his physicians.

A critical aspect of The Care Transitions InterventionSM is ensuring that the patient understands each medication s/he is taking and helping the patient develop an effective medication management system. The Transition Coach uses the home visit to reconcile the patient’s medication regimen, using the Medication Discrepancy Tool ©, a tool designed to help the Coach identify any significant medication problems (e.g. adverse drug events, patient non-adherence, patient lack of understanding of medication regimen). The Coach educates the patient on what to do when a medication discrepancy is detected and how to engage existing community resources (community pharmacist, primary physician, home care nurse if applicable) to receive advice or clarification.

The Transition Coach encourages each patient to follow-up with her or his primary care physician or specialist in a timely fashion. The Coach teaches the patient skills for effectively communicating care needs to health care professionals. During the home visit, the Coach conducts role-plays and/or has the patient rehearse questions for physician appointments. In follow-up phone calls, the Coach discusses visits with health care professionals.

A key aspect of the Transition Coach’s job is to ensure that the patient is knowledgeable about indicators that suggest her or his condition is worsening. The Coach provides education about the specific steps to take to respond to each red flag and about when it is appropriate to contact a health care professional.