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News Release
Transition Coaches Help Older Patients Take a More Active Role in Their Care
DENVER (November 5, 2004) — Researchers at the University of Colorado Denver recently concluded a study that tested interventions designed to encourage older patients to assert a more active role during the hospital discharge process.
The study, led by Eric A. Coleman, MD, MPH, associate professor of medicine in the Division of Health Care Policy and Research at UCD, found that older patients who received the intervention were half as likely to be re-hospitalized than those who did not receive the intervention. The positive results were sustained for six months or more, suggesting that older patients were able to apply the new skills learned during intervention to future self-care.
Published in the November issue of the Journal of the American Geriatrics Society, the "Care Transitions Intervention" study was created in direct response to what older patients and family members indicated they needed during the vulnerable transition from the hospital to home or further care. Older patients participating in this program received more support than is usually provided and specific tools for facilitating safe and effective hospital discharges.
"The support came primarily from a new role - the transition coach," said Coleman. "The transition coach is typically an advanced-practice nurse who assists patients, their families and caregivers as they move across health care settings and back to the home.
"The coach prepares the patient and family for what to expect in each care setting after discharge, such as a rehabilitation facility, home health care, or visits to their primary care physician," Coleman added.
In addition, the coach and patient participate in "role play" scenarios and practice what the patient might say to each health care practitioner throughout the stages of their care, so patient preferences are honored and questions answered.
The coach also helps older patients reconcile the new medications they receive from the hospital with the medications taken prior to hospitalization. Specific tools include a personal health record used to record medications, allergies and medical problems.
Coleman indicated that the results of the intervention program include improving patient safety, controlling health care costs and encouraging more patient-centered care. Coleman's "Care Transitions Intervention" is already being adopted by a number of leading health care delivery systems across the country. For more information, visit www.caretransitions.org.
The University of Colorado Denver is one of three campuses in the University of Colorado system. Located in Denver and Aurora, Colo., the center includes schools of medicine, nursing, pharmacy, and dentistry, a graduate school and a teaching hospital. For more information, visit the Web site at www.uchsc.edu.