Editor's Note: Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Trained in both geriatrics and health services research, Dr. Coleman has emerged as one of the world's leading authorities on issues surrounding transitions of care, particularly between acute and postacute settings. His care model, the Care Transitions Intervention, is being adopted by leading health care organizations around the country. The Intervention has been associated with significant decreases in rehospitalization rates.

Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in transitions?

Dr. Eric Coleman: My interest in transitional care started about 10 years ago as a practicing clinician. I would routinely come into my clinic, thinking I was seeing a patient coming in for follow-up, only for them to berate me about the terrible episode of care that they had just been involved with. So they had been in the hospital, they had gone to a nursing facility, now they were at home, and they couldn't understand why I wasn't part of that, given my prior relationship with them.

RW: Did your background as a geriatrician give you a unique perspective on this?

EC: Yes, I think so. From the standpoint of having the opportunity to see patients along a whole care continuum or across settings of care, if you will. I think that, increasingly, as health care professionals we are finding ourselves defined by different care settings, and whether that's a hospital or an outpatient clinic or even a nursing home. In geriatrics, we have that opportunity to see our patients across care settings and see transitions go relatively well, but we also see them go poorly at times.

RW: You've highlighted one of the tensions, which is that we now have all of these different cooks—particularly with the growth of hospitalists. Is the answer to have a single provider with you all of the time? Or is that impractical? How do we reconcile all of those tensions?

EC: I think the answer is probably some form of hybrid. In other words, I think patients who have either a high burden of illness or are challenged in their ability to take in new information probably do need someone—whether you label that person a coordinator, a navigator, or a coach. And then some patients probably don't need that level of intensity, but do recognize the value of having the next care professional they see being up to speed.

RW: One of the key epiphanies of the patient safety movement is that it's mostly about systems. As it comes to transitions, what systems help today?

EC: My bias is that, as supportive as I am of the concept of the system, I'm beginning to reach the conclusion that the word "system" represents some mythical beast, like the Loch Ness monster. I have seen in my travels across the country very few examples of a true system. Having said that, when I hear the word systems in the context of care transitions, it conjures up several areas that are critical to improving both safety and quality. The first area is how we handle information transfer across care settings. In this context, the word system makes a lot of sense. In other words, the opportunity for an electronic health information system or even a paper system—to have reliable ways of transferring information to the next care setting is an area that I think holds the most promise. But I also see that part of a system is having appropriate measurement in place so that we can actually judge whether things are going well or not. Currently, performance measurements are probably the single most important element in quality improvement for transitional care. But the other aspect that I think we sometimes miss when we start talking about systems is—if I were to encapsulate what's important about care transitions in a single phrase—preparing the patient and family for self care. This is the area where we're often the least comfortable having these conversations. Number one, because there's a notion that this is not something that falls within our accountability. But, number two, because it does raise all kinds of other questions—about literacy, about cognitive function, about language, and about cultural appropriateness—things that we don't necessarily have the infrastructure or the incentives to support.

RW: You said something interesting about the fundamental role of measurement: that there are no real performance measures when it comes to transitions. If performance measures suddenly materialized and showed that we really stink at moving information from hospitals to skilled nursing facilities or to home, what's the magic in those measures?

EC: I've had the opportunity to have these discussions, in Washington with health staffers for Congress, with quality officers at leading health care delivery systems, and with some of the nation's health care leaders. One of the things that I'm struck by is that these individuals—who have tremendous influence and who know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall through the cracks before their very eyes with their own family members. And I think that is a very powerful statement in and of itself—whether we're talking about anecdotes or rigorous measurements. The perception is clearly that there is this problem. The value of having community-wide or even nationwide quality measurements and public reporting of those measures really comes down to image, and hospitals are perhaps more concerned about what their public image is than most health care delivery venues. To have the reputation of the hospital as not only delivering high-quality state-of-the-science care, but also making sure that you get home safely and that your plan doesn't unravel as you walk out the door of the building, is something that hospital leaders will care about, and will help us move to the next level.

RW: You've come up with a model for doing this and disseminated it widely around the country. Can you describe the model?

EC: We have developed a performance measurement called the Care Transitions Measure, a patient-reported measure of their transition experience. After starting with a 15-item measurement , we have honed this down to a three-item measure, which accounts for about 90% of the predicted accuracy of the 15-item tool. This three-item measure has been endorsed by the National Quality Forum, which of course opens the door for public reporting. The measure is freely available at caretransitions.org; we've had 2300 requests for permission to use it. The World Health Organization has adopted this measure for a 12-hospital international study being done in Europe. The state of Maine has mandated that all hospitals publicly report care transition measure scores, and two other states are considering passing similar legislation. So the demand is there. We look forward to forming additional partnerships with health delivery systems interested in doing the same thing.

RW: So let's say I find out that my system is not doing a good job. What do I do?

EC: Most solutions are going to be local. But, having said that, our Care Transitions Program has developed a self-care model, called the Care Transitions Intervention, to improve care handoffs. In this model of care, the patient and the family are in the center, joined by someone we refer to as a transitions coach. The coach doesn't provide health care per se but moves with the patient across care settings. At each opportunity, the coach encourages the patient to speak up, even going as far as giving them the language or script to be effective. The coach will role play with the patient and prepare them for what's coming up next. That might be a home visit or a visit with a specialist. The coach will go through their medications with them, identify problems, and model behavior for how they might address those problems. Using this approach, which lasts about 1 month, we've been able to show significant reductions in hospital readmission rates as well as in accompanying costs. In fact, we've been able to show that, investing in this model for 1 month post-hospital, the patients were significantly more likely to stay out of the hospital 6 months later. In other words, 5 months after the coach had disengaged with the patient, these patients were still staying out of the hospital in a statistically significant manner. To date, 100 leading health care organizations have adopted this model, and we're looking forward to partnering with other organizations in the future.

RW: So in this model, if I'm about to be discharged after a hospitalization for heart failure or pneumonia, a coach would be assigned to me. What kind of person is that? Do I meet them before I leave the hospital? Do they come to clinic visits with me? How does this actually work?

EC: The model was designed for the initial encounter to take place between the patient and the coach in the hospital. The hospital visit was really designed as an opportunity for the patient and coach to begin to establish a rapport and for the coach to begin to understand what the patient's immediate care needs were going to be. Following that, if the patient goes to a skilled nursing facility, the coach would then meet them at the facility, preparing them for the impending transfer back home again, encouraging the patients to make sure that they understand what's being expected of them from the self-care standpoint as well as the follow-up standpoint. Once the patient gets home, the coach and patient would arrange for a home visit, and this would typically last about 45 minutes. The main thrust of the visit is actually reviewing the patient's medications. So for example you ask the patient, "Please show me your medications and how you take them." And you realize there are medications all over the house. There are medications in the medicine cabinet, by the bedside, on the lazy Susan. There are medications with the dog's name. There's a list of medicines from the hospital, along with other medication lists. This really provides a great deal of insight: that the medication reconciliation process in the hospital, as valuable as that is, is not over until the patient has come home and returned to their routine. Then there's a series of two or three phone calls after that, just to see how things went and whether any additional problems or questions have come up. How did your visit go? Did you get those questions addressed? Has anything else come up along the way, such as durable medical equipment that wasn't delivered? And that really is the intervention. In essence, it's an initial visit in the hospital, a home visit, and two or three follow-up visits.

RW: Is the coach a nurse?

EC: We have formally tested the model using both advance practice nurses and registered nurses. And both of them performed equally well. In other words, they both were able to achieve statistically significant reductions in readmission rates. In partnering with leading health care organizations, we have seen a number of variations along the theme. We've seen social workers function as coaches. We saw pharmacy technicians. And that has really encouraged us to rethink how prescriptive we are about what makes a good coach. In fact, we've now moved away from suggesting what initials there should be after the coach's name, and are rather talking about three key attributes. The first key attribute is easier to say and much harder to do, and that is to make that shift from being a doer—and all health care professionals were trained to be doers—to being a coach. A coach listens more than talks. A coach sits on his or her hands. A coach does not grab the phone out of the patient's hand and make phone calls, but rather models the behavior and walks through these with the patient. The second key attribute is some level of comfort around medications. It doesn't require that you have an in-depth understanding of pharmacodynamics or every possible drug reaction that's out there, but rather to be able to look through what a patient is actually taking and cross-reference that against the hospital discharge list and look for any discrepancies. Again, the coach isn't going to solve all the discrepancies, but the coach needs at least to be able to see, for example, that this is a brand name and a generic name and there is a duplication here. The third key attribute is a little bit nebulous, but it is knowing that difference between being persistent and being a pest. We certainly know that the phrase "activated patient" or "empowered patient" will stir a sense of discomfort in a roomful of physicians. We often use language like "prepared patients" or "better able to participate in their care." If a coach goes too far and a patient becomes overly activated, that could potentially disadvantage the patient if the care team begins to withdraw. So it is a bit of a balancing act.

RW: You mentioned that in certain systems there might be an economic incentive to improve transitions, for example, in an integrated health care system, if this prevents patients bouncing back to hospitals. But most of America doesn't look like that, most of it is fragmented. What then are the policies that will ramp up the level of investment in and attention to improving transitions?

EC: We have sought out experts across the country to help us in our thinking, even going as far as preparing our own business case for the Care Transitions Intervention. For example, in a capitated or an integrated system, the attractiveness of the Intervention's coaching model has been around its potential to reduce hospital readmission. But leaders at the American Hospital Association have taught us how to approach our conversations with hospitals that primarily rely on traditional fee-for-service payment. Depending on the part of the country that the hospital is located in and the level of competitiveness in the community, we do recognize that this model does have a level of attractiveness above and beyond its financial argument. For example, full hospitals may be diverting away fairly high-revenue patients. An intervention that reduces readmissions and creates capacity for higher revenue patients may be particularly appealing.

RW: On top of a regulatory or reporting argument, if there was public reporting of hospitals' 30-day readmission rates, you might create an incentive to do this kind of thing.

EC: That's exactly right. MedPAC (which advises Congress on Medicare reimbursement) is very interested in this issue. In Chapter 5 of the June 2007 report, they outlined two fundamental steps. The first step would be to begin to mandate that hospitals publicly report their risk-adjusted 30-day readmission rates. But the second step that they're proposing would involve some adjustment of payment based on that readmission rate. All of a sudden this puts the financial incentive clearly in the forefront in the minds of the hospital leadership. We see that as being very important. We also tip our hats to the consumer council for the Joint Commission for raising awareness of the importance of discharge and transition planning on Joint Commission Accreditation Surveys.

RW: Where do family caregivers fit into all of this?

EC: Family caregivers have often become the de facto care coordinators for many of the patients that we discharge from the hospital. And with that in mind, particularly as we think about shortages of health care professionals in the future, one of our most valuable resources is supporting the role of family caregivers, particularly as it relates to care transitions and care handoffs. In order to do so, the health care professional community and the family caregiver advocacy community would benefit from a discussion that helps health care professionals understand the roles of family caregivers. It's not uncommon for a family member to simply appear in the course of a hospital stay and have the hospital team automatically make a whole series of assumptions about what that family member's role is going to be after the person leaves the hospital. There would be some inherent value in having a tool that would allow a fairly concise communication of the role of the family caregiver, modeled after the TNM cancer staging system "shorthand." In this case the acronym might be FACED, where F stands for financial, A would stand for advocacy, C would stand for coordination of care, E would stand for emotional support, and D would stand for direct care. And you can imagine a scale, say from zero to three that would convey how involved the individual was in those five categories. This is something that we're really excited about piloting.