Care Transitions 1

Running head: Care Transition

Self-Management of Chronic Disease and Hospital Readmission:

A Care Transition Strategy

Michelle D. Kelly*
Email: mdkelly@usfca.edu
7524 Gates Drive, Sebatopol, CA 95472
Tel. 707-498-7773

Biosketch of the Author

Michelle Kelly, RN, FNP, is a community-based practitioner and nurse educator. She has
successfully coordinated a care transition program based on Coleman’s model with BSN
students. Kelly has cared for populations with chronic disease in rural communities
which were in need of service beyond homecare coverage. She found a way to involve
students in providing some of these health services. Students learned quality-
improvement measures while coaching people recently discharged from the hospital.
Future endeavors will involve creating a Care Transition Advisory Group and
implementing an online Care Transition Learning Module for nurses.

Abstract

Chronic disease is increasing in prevalence, and quality improvement is needed as clients

transition between a variety of healthcare settings, particularly from hospital to home.
People with chronic disease are more likely to need inpatient care, yet studies indicate
that readmissions within 30 days of discharge occur. Hospitalizations are
considered preventable if linked to unresolved conditions present at the time of discharge
and not remunerated by Medicare. In such cases, hospitals bear 100% of the cost of
avoidable readmissions. The association of chronic disease care with the emergence of
readmission rates as indicators of quality of care is explored in this article Coleman’s
Care Transition Model (2002). This model is suggested as a practical, evidenced-based
intervention which hospitals can implement to reduce avoidable readmissions.

Keywords: Chronic disease, quality, readmission, thirty-day readmission rates, health

costs, discharge, client satisfaction, empowerment, care transition, Coleman.

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BACKGROUND

The Problem
In 2005, chronic disease accounted for 70% of all deaths of people in the United

States (U.S.). Nearly half of all people in the U.S. currently live with one or more chronic

diseases. Chronic disease, such as cardiovascular illness (heart disease and stroke),

cancer, diabetes, and respiratory illness, accounts for 80% of all healthcare dollars spent

in the U.S. (Centers for disease Control [CDC] 2009). Thus, it cannot be overstated that

chronic disease is associated with high medical care costs. Expenditures are attributed to

the frequent utilization of health services, particularly with regard to the use of inpatient

hospital services. People with chronic diseases are more likely to be readmitted to the

hospital within 30 days of discharge, and when they are readmitted, they often present

with an avoidable condition. Considered as preventable conditions, these avoidable

readmissions are essentially adverse health outcomes from one or more unresolved

conditions from the first admission (Halfon, Eggli, Pretre-Rohrbach, Meylan, & Marazzi,

et al., 2006).

Inefficient and poor-quality care leads to increased rates of hospital readmission

of patients who have been recently discharged (Medicare Payment Advisory Commission

[Medpac], 2007).

High readmission rates are attributed to a variety of influences. One of the most

significant factors leading to readmission is the inadequate preparation of clients and their

caregivers with during the hospital discharge process. Returning home after a

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hospitalization, clients are often unable to monitor and manage their disease. In contrast

to patients who are transferred to a skilled nursing facility or receive home health care

after discharge, the problem of hospital readmission is greater for clients who are 65

years old and over, have one or more chronic diseases, and are discharged to their own

home, (Coleman, 2003). Populations who live in rural areas or in marginalized

communities are also at higher risk for preventable hospital readmission. Thus, a

consistent model of effective clinical practice is needed to address and circumvent

avoidable readmissions.

Scope

The majority of healthcare dollars spent in the U.S. have been attributed to

persons with one or more chronic disease(s); an individual with one chronic disease

spends four times more healthcare dollars than does an individual without a chronic

disease; and 82% of inpatient service utilization is by people with chronic disease

(Anderson, 2007; Medpac, 2007). The demographic shift of today’s population in the

U.S. is one in which the proportion of older adults (65 and over) has grown to 10%; this

figure is expected to increase to 17% by 2030 (Christ & Diwan, 2009). The scope of

chronic disease in the U.S. population is increasing; today 25% of children already have

one or more chronic conditions (Anderson). The demand for care for people with chronic

disease is on the rise and economic factors drive the allocation of health services. The

high cost of care and higher rates of remissions in aggregates with chronic disease are

under inquiry by Medicare, which aims to decrease costs and improve quality for it’s

beneficiaries. In 2008, a review of Medicare cases found nearly 20% of beneficiaries who

were discharged from hospitals were readmitted within 30 days; the annual cost was over

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$17 billion (Jencks, Williams, & Coleman, 2009).

The Institute of Medicine (IOM, 2000) identified readmission rates as the primary

contributor to spiraling health costs, and suggested a strong association between low-

quality discharge processes and higher readmission rates. Hospital readmissions are

defined as patients who are discharged and then readmitted (unscheduled) within a 30-

day period. The readmission rate is considered to be a valid metric of the quality of

hospital care (Agency for Health Care Quality Research [AHRQ], 2006).

Coleman et al. (2002) and Dehia (2009) hypothesized that if clients are satisfied

with their preparation for discharge to their home, these clients are less likely to

experience a hospital readmission. Inversely, clients who are more likely to report low

satisfaction with their preparation for discharge are also more likely to be readmitted.

When Worth, Tierney, and Watson (2000) interviewed clients and their caregivers about

their patients’ experience of discharge to home, caregivers cited feelings of anxiousness,

stating that they did not feel prepared to manage their care at home. Shorter hospital stays

and other cost-cutting measures have shifted chronic disease care from the formal

healthcare system to the client and his or her informal caregiver(s). A majority of people

admitted to the hospital with exacerbation of their chronic condition experience a

decrease in their ability to function, which is not fully regained by time they are

discharged (Anderson, 2007). These limits in function impair independence, and a

hospital discharge home often requires clients to depend on informal caretakers for

personal and chronic disease care. Considering that half of all medication errors occur at

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transition points (Institute for Healthcare Improvement [IHI], 2009), such as discharge to

home, caregivers play a large role in avoidable readmissions. Caregivers are typically

unpaid, lack formal training, and are more likely to be 65 years or older (Weinberg,

Lusenhop, & Gittell, 2007).

The ability of the caregiver to provide a safe and effective level of chronic-disease

care after hospitalization was identified as a major concern for clients discharged home

(Coleman, 2003). In particular, the issue was the lack of knowledge of how to give

medications appropriately. Coleman indicated that clients and their caregivers recognized

their own deficiencies in knowledge, this perceived deficiency was linked to medication

mismanagement at home, and ultimately led to readmission within 30 days after

discharge. The standard of practice in every discharge is to assist clients and caregivers

with understanding how to take their medications appropriately after discharge. Despite

this and other standards of practice for patient safety, 20% of readmissions did not have

reconciliation of medication orders at discharge (IHI, 2009).

Clients with chronic disease are prescribed far more medications than clients

without chronic disease. For example, a client with one chronic disease averaged eight

drug prescriptions per annum; a client with three chronic conditions averaged 26

prescriptions per year; and people with five or more chronic conditions, which comprise

4% of the population, fill over 57 medication prescriptions in one year (Medical

Expenditure Panel Survey, 2006; MedPac, 2007). Avoidable hospital readmission is a

problem of complex proportions and increasing occurrence. This is of special concern

especially when one considers that readmission rates are costly and that they tend to

occur more frequently with clients with one or more chronic disease(s). It should also be

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kept in mind that such clients have reported receiving low-quality care, and that this

seems related to their low levels of satisfaction and to perceived lack of preparation for

self-care at home (Bisognanao & Boutwell, 2009).

Emergence of Readmission Rates as Quality Indicators

Several health-related institutions have looked at the issue of preventable

readmissions, and efforts have been made to identify the contributing causes of the

occurrence of avoidable readmissions and the steps that health institutions can take to

address this problem. New information on readmissions and the factors associated with it

is emerging, sparking discussions on whether and how to measure interventions that

affect rates of readmission (IHI, 2009). Major stakeholders evaluating chronic disease

costs and readmission rates in the U.S. include professionals working on health policy

and in research think-tanks, as well as government-funded insurers, especially Medicare.

Currently, readmission rates as metrics represent the underpinnings of both quality of

care and patient safety initiatives that evolved as a result of IOM’s landmark report, To

Err is Human (2000). The IOM has called for significant changes in institutional attitudes

regarding basic patient safety on the part of the leaders in healthcare; it has also called for

healthcare leaders to bring new modalities and tools to “identify and learn from errors”

(p. 1) in order to improve patient outcomes. Moreover, the IOM has determined that

coordination of care, especially aimed at improving coordination of services for the

heaviest users of the inpatient care, is one of the top 20 priorities in assuring patient

safety. Care coordination activities were identified as a way to increase the effectiveness

and efficiency of care. Coordinating care would address gaps in quality of care in an

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increasingly fragmented service delivery system. The IOM found that the highest

utilization of health services, including admission for inpatient care, was by people with

chronic disease, usually older adults who had one or more chronic diseases.

There has been a shift in the health care environment. Hospitals now more

routinely examine their mistakes; however, the precise tools to measure and address

patient safety issues are complex, and many of these tools are still not fully in place

(Leape & Berwick, 2005). Health outcomes of people with chronic disease, including

readmission rates, are linked to medical-care quality and hospital staffs’ ability to

internally examine the level of care that their patients receive.

Medicare Examines Quality as a Cost-Saving Measure

Another party interested in reducing avoidable readmission rates is Medicare. The

largest payer of healthcare dollars, Medicare is continually examining expenditures,

service utilization, and outcomes of services delivered to their predominately older-adult

group of beneficiaries (Christ & Diwan, 2009). Medicare has been a pioneer in assessing

and promoting the rational use of health dollars and has highlighted patient safety as an

indicator of quality of care. This insurer is unique in linking of chronic disease treatment

and the number of inpatient days. Medicare has used a variety of fee-for-service payment

schemes to both financially reward and punish major vendors such as hospitals.

Unnecessarily high utilization of inpatient services by people with chronic disease has

even caused Medicare to redesign reimbursement policies to make wiser use of ever-

dwindling healthcare dollars.

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Unique Aspects of Readmission Rates and People With Chronic Disease

A study funded by the Robert Wood Johnson Foundation (RWJF) (Coleman,

Smith, & Frank, et al., 2004) identified the unique risks for readmission faced by older

persons. In a sample of older adults with one or more chronic disease, the researchers

found, on average, that older adults saw eight different physicians in one year. Results of

the research identified that at each point of care, there is a risk that essential information

will not be transferred in a timely manner from one physician to another. The findings

also illustrated the frequency and complexity of the different points of care for people

with chronic diseases and suggested a correlation between multiple points of care and

avoidable readmissions. Finally, the study suggested that patients who are knowledgeable

about their health become competent managers of their own disease and act as their own

patient-safety advocates, which, not surprisingly, means that they will probably be less

likely to experience an unplanned hospital readmission.

What’s Been Done to Date

Large stakeholders in healthcare delivery, such as WHO, Medicare, AHQR,

Aetna, Kaiser, RWJF, and others, have designed strategies or implemented programs for

addressing high readmission rates. Three types of approaches have been aimed at

lessening the problem of avoidable readmissions: (a) interagency, (b) service delivery,

and (c) client focused. The interagency approach uses case coordination to strengthen

communication between healthcare agencies to improve the effectiveness of warm

handoffs during the transfer of care. With this approach, essential information is both

more complete and available for the next healthcare practitioner(s). The intent of a

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smooth, effective transition between care settings is to both lower costs and to effect

better client outcomes. Moreover, the transfer of information in a timely, effective way is

believed to improve client health status and lower the risk of readmission. Care

coordination, which is designed to be a multiagency effort among professionals at various

points of service throughout the care spectrum, involves the planning of required patient-

care tasks, timely communication, and the carrying out of procedures to positively impact

the outcome of patients. Care coordination models were designed to foster better health

outcomes and bridge the gap as clients transitioned between care delivery systems.

Different health agencies use care coordination to meet their specific needs. Care

coordination programs can target a client group with a specific disease (such as asthma,

hypertension) or a subpopulation (e.g., such as people over 65, adolescents, or those

having a combination of diseases) and demographic specifics (e.g., adolescents with

asthma). A Cochrane literature review of care coordination studies, done by Parkes &

Sheppard (2000), found a lack of models providing substantial evidence for achieving

best patient outcomes. A scarcity of quantitative measures was cited as a major

limitation.

Service delivery mechanisms involve both case management and discharge

planning. In the hospital, case managers conduct activities to assure that clients prepare

for transfer to another facility, are discharged home either with or without home health

services, and, if necessary, are referred to appropriate outside services. Discharge

planning targets clients with specific needs, such as the need for complex care after

discharge or a significant reduction in their physiological function. Such planning

involves determining clients’ readiness for self-care and the level of their community

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support. Discharge interventions in some institutions involve telephone calls after

discharge, and perhaps home visits to clients as a follow-up to their hospital stay. An

example of enhanced discharge planning for an inpatient newly diagnosed with diabetes

would likely involve educating the client about the disease and how to test blood sugars

and to self-administer insulin. Discharge processes are evolving in response to a recent

Medicare regulation that denies hospitals payment for avoidable hospitalizations of their

beneficiaries, thus shifting 100% of the cost of preventable readmissions to hospitals

(Medpac, 2007).

Interventions that are client-focused involve teaching the client and family the

skills to appropriately manage the client’s disease outside of the hospital facility. The

preparation of clients and their caregivers before discharge is linked with higher

satisfaction rates and positive outcomes, including fewer readmissions, than for clients

who report dissatisfaction with their hospital stay (Weinberg, Lusenhop, & Hoffer, 2007).

Possible Solution to Preventing Readmissions: Coleman’s Care Transition Model (2002)

Whereas a variety of interventions have shown evidence of reducing

readmissions, Coleman’s Care Transition Model (2002) warrants an in-depth discussion

because of its appeal to stakeholders. The intervention is a low-cost, low-intensity model

that is easily implemented. It is evidence-based, hence effective at guiding practice, and it

has demonstrated potential for sustainability. Successfully implemented in 150 hospitals

and community-based agencies, Coleman’s Care Transition Model is aimed at preventing

readmission in clients with congestive heart failure and other chronic conditions by

empowering clients to competently self-manage their care after discharge. Coleman and

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others (2006) conducted a randomized control in which the intervention group was

assigned a transitions coach who encouraged participants to take an active role in their

care. The intervention of coaching includes communication skill-building for clients; the

aim is to exchange essential health information across care settings and to help clients

assert their preferences. In the intervention group hospital readmission rates were reduced

by 12% in rural areas and 35% in urban areas. Additionally, Coleman’s model requires

few resources for implementation and is uncomplicated, so busy staff can easily learn the

principles and coach clients with chronic diseases on the principles of self-care and self-

management of their health conditions, thereby reducing the potential for readmissions in

clients.

Coleman’s (2002) model is comprised of four pillars designed to prepare clients

to safely transition between care settings; the pillars frame the relationship between

clients and the transition coach; however, the focus remains on empowering clients to

become managers of their own care. The pillars are (a) medication self-management, (b)

person-centered health record, (c) follow-up appointments with primary care clinician

and specialists, and (d) how to notice red flags.

(a) Medication Self-Management:

The purpose of this pillar is to reconcile differences between what medications are

prescribed with what is actually being taken at each transition point. Transition

coaches assure that the clients and caregiver have a complete list of current

medications, understand what they are prescribed, are aware of what each

medication does, and know how to take their medications

(b) Person-Centered Health Record:

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Lack of health literacy is a major problem, as clients are frequently given printed

lists of their medications by health staff with no other instructions. Clients and

their caregivers are empowered to become health-literate by keeping a record, in

their own writing, of essential health information. The coach’s role is to introduce

the person-centered health record and encourage clients to use the patient record

to keep track of their medical history, questions for the primary care provider, and

emergency contact information. The Person-Centered Health Record will stay

with clients and is updated with each health encounter.

(c) Follow-up appointments with primary care providers and specialists:

Close follow-up after discharge to monitor the effect of newly prescribed

medications and prevents worsening of the condition and possible readmission.

Writing down questions for health providers, bringing in all medications, and

ensuring that appointments are kept are essential to the clients’ best use of the

healthcare system.

(d) Noticing Red Flags:

Clients’ and caregivers’ knowledge of early signs of worsening of their chronic

disease is key to the successful management of clients’ health condition at home.

Knowing what the red flags are and seeking the appropriate level of care, either

through a call to their provider or trip to the emergency room, can avert

exacerbation of their disease progression.

Transition coaches focus on skill transfer and building self-efficacy with clients.

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They do this through the use of specific self-care tools, such as the person-centered health

record, and role-playing how, for example, a client might call a medical office to

schedule an appointment. Coaches are nurses, social workers, or allied health

professionals. The model is used with clients who are ready to be discharged home or to a

skilled nursing facility for less than 6 weeks. A trained transition coach would approach

clients in the hospital, give an explanation of the care transition program, offer to see

them in their home two days after their discharge, and facilitate completing their own

personal health record, especially comparing their discharge instructions and medication

list to how they are currently taking their actual medications. Coleman’s model

demonstrated improvement in clients’ ability with regard to medication self-management,

person-centered health record keeping, knowledge of red flags, and follow-up care with

primary care providers and specialists (Darwin & Parrish, 2008).

Determining root causes of medication errors after discharge is essential for

reducing readmission rates. Coleman’s Care Transition Model (2002) developed and

piloted the Medication Discrepancy Tool, which provides quantitative and qualitative

measurements of posthospital medication discrepancies. Medication discrepancies are

errors between what was ordered and what the client is actually taking after discharge. At

the posthospital home visit, the coach correlates what was prescribed according to the

hospital discharge summary with the actual medications the client is taking. Studies

reveal that 14.1% of clients had one or more medication discrepancies on the initial home

visit, and readmission within 30 days occurred with 14.3% of the clients with one or

more medication discrepancies, in contrast to 6.1% rate of readmission of clients who did

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not have a medication discrepancy (Coleman). This Medication Discrepancy Tool

provides invaluable data in that it reveals the prevalence of a medication discrepancy and

whether that discrepancy was patient or system related.

Recommendations

A vast majority of healthcare resources are needed for individuals with chronic

disease. Avoidable readmissions not only indicate a poor quality of discharge teaching,

but also add to spiraling healthcare costs. Readmissions are exacerbated as clients with

chronic disease move through multiple points of care with limited continuity and

coordinated treatment. An evidenced-based practice model allows hospitals and patients

to align their common agenda; patients want to stay out of the hospital, and hospitals

want to improve the quality of care after patients are discharged to prevent unplanned

readmissions. The AHRQ (2007) called for practical answers on how to implement

strategies to reduce readmission rates. The complex care required with

posthospitalization of older adults with chronic disease goes beyond giving patients a

phone number to call for a follow-up appointment. Discharge activities leave patients and

caregivers dissatisfied and unprepared to manage their care, including safe medication

administration at home.

Coleman’s (2002) model provides a template for hospitals to use and to build self-

care into a client’s discharge process. The literature emphasizes that client and caregiver

involvement is central to the positive health outcomes and is associated with lower

readmission rates. Medication reconciliation after discharge lessens the risk of

medication error and avoidable readmissions. The Medication Discrepancy Tool

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(Coleman) accurately identifies prevalence of readmission and provides information for

hospitals to rectify root causes. Hospitals are faced with significant economic

consequences of bearing the cost of avoidable hospitalizations. The literature suggests

that Coleman’s Model of Care Transition is an effective way to reduce avoidable

readmissions for older adults with chronic disease.

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