Medics as Transition Coaches
by HCPro's Case Management Monthly
Published on Jun 02, 2017
John C. Lincoln Accountable Care Organization in Phoenix is hiring returning military veterans with medical experience as transition specialists, says Nathan Anspach, CEO of the Scottsdale Lincoln Physician Network and John C. Lincoln Accountable Care Organization. Transition coaches work with patients before and after discharge to address issues that might lead to preventable readmissions.
The readmission rate at the hospital network has now dropped to 6%. And the hospital is helping put some of the estimated 20,000 unemployed veterans nationally back to work, says Anspach.
The seeds of the program were sown in 2011 when the organization first began looking at preventable readmissions. The fledgling initiative got a boost the following October when administrators formed a readmission prevention team that included nurses and administrators.
Initially the group focused on patients with congestive heart failure who had been readmitted within 30 days. "So many of these patients had readmissions that were due to psychosocial and socioeconomic factors, in addition to clinical issues," says Anspach.
Members of the group learned from a National Public Radio program that combat medics and naval corpsmen were experiencing difficulty finding jobs upon returning home. Anspach and the organization's chief medical officer are Vietnam-era veterans. The issue sparked an idea?why not hire these returning veterans to assist with the readmission initiative?
The group prepared a proposal to use the veterans as transition specialists, a position designed to help certain at-risk patients ease into home life after discharge. They submitted their proposal, which initially targeted patients with acute myocardial infarction, congestive heart failure, and pneumonia, for a CMS grant.
Although the organization didn't receive the grant, it didn't give up. Instead, it submitted the idea to the Startup America Policy Challenge, a program jointly sponsored by the White House; the U.S. Departments of Education, Energy, and Health and Human Services; and Arizona State University.
This time, the submission won a national award. "It was flattering; it was a big honor and a surprise to us because we were competing against some prestigious organizations and some wonderful medical schools," says Anspach. "There seemed to be a consensus among the judges that this was something that would work."
Putting the idea into action
Although the program received a stamp of approval from the federal government, it still didn't have funding, so hospital administrators dug into their own pocket to create the initial two transition specialist positions.
"We recruited two young people, one of them three weeks off the plane from Afghanistan," says Anspach. One was a Special Forces ranger who had seen much combat. The other was a young woman, a navy corpsman, who had seen action in Kuwait and Iraq. "We paired the two of them together, and within their first four months of work they worked with 275 patients with chronic heart failure, acute MI, and pneumonia," says Anspach. "In the initial trial, they were able to reduce readmissions by 21% to about 3%."
A program in action
The success transition specialists have achieved is due in part to the bonds formed with patients, says Kathy Orona, a former navy corpsman and lead transition specialist at the organization.
Transition specialists tend to be young and energetic. Their military experience helps them be creative thinkers because they're accustomed to improvising on the battlefield, says Anspach. "They bring a lot of creativity and can-do spirit to the job," he says.
If a patient is admitted to the hospital after a heart attack, a transition specialist meets with him or her within a day or two and explains the program, says Anspach. The specialist remains involved during the patient's hospital stay, providing coaching and support so the patient knows what to ask his or her physician and make a successful transition home.
"Many older patients are intimidated by the doctor," says Anspach. The transition specialists work with patients, making lists of items they need to know and helping them to ask questions, write the answers down, and understand them. "Do you understand how to take your meds? Can you get your meds? What's your food situation at home?" says Anspach.
The day after discharge, transition coaches are there to follow up, both by telephone and in person. "They do a fall prevention screening, a food and socioeconomic assessment, and make sure there is a connection between the discharging subspecialist and the primary care physician," says Anspach. "We're learning through this program that many simple things that patients face have a lot to do with their readmission rate." This includes transportation, medication, and service delays.
Orona often must intervene when oxygen deliveries are late, which can lead to major problems if not addressed. She also helps schedule appointments for patients. "Often, older people don't like to wait on the phone for too long. If they're making a follow-up appointment and they are put on hold, they might only wait a couple of minutes and then hang up," she says.
Medication is another major issue. "The patient might be taking both a generic version and the name brand," Orona says. Transition specialists review a patient's medications, explain which ones are outdated, and make notes for the patient to give to the physician indicating which medications may be duplicates.
"Many of the frail elderly can't see or read the bottle," says Anspach. "One of the things the transition specialist does is snap a photo of the bottle with their phone, blow the image up, and tape the larger printout to the bottle so it's more visible."
Transition specialists do not focus solely on clinical issues. They help patients apply for financial assistance for medications and facilitate assistance from Meals on Wheels or the organization's food bank.
The specialists form strong bonds with their patients, says Orona. "We become daughters and sons, especially when the family members are out of town or if they live out of state." She has even called patients to check on them while on vacation. "It's not an easy job," she says. Specialists may see between five and 10 patients a day. In addition to the job skills, the ideal candidate also has to have compassion. "You've got to have a certain personality," she says.
The program pays off
Patients' first question is how much the program will cost them and they are stunned when they realize they don't have to pay for the service, says Anspach.
The transition program has paid off in patient satisfaction and has reduced readmissions, despite the changing and higher-risk population, says Anspach.
The program quickly gained momentum as word about it spread. Team members spoke at service organization meetings and received media coverage. Within two years, the program received $780,000 in grants and contributions, which it used to expand, says Anspach.. "Now we have 12 soldiers who are here and are very involved," says Anspach.
The program was not without challenges, however. "Case managers at first were terrified," says Anspach. They saw the transition specialists as a threat to their jobs. "While the transition specialists work incredibly hard and are very creative, they're not intended to replace the professional case managers," he says. Instead, they supplement the case manager role.
The transition specialist role can also be a challenge to veterans coming into the organization, he says. These individuals often have much clinical experience. Some have even performed surgery on the battlefield, where they are often called "doc." It can be difficult for these veterans to come back and work as paraprofessionals in a nonclinical role, says Anspach.
Planning for the future
The organization aims to improve and expand this initiative, says Anspach. Researchers are focusing on what works and what doesn't and will search for ways to make it even more effective, he says. "This is an important program for so many reasons," he says. "We're going to have even more young people returning from Afghanistan soon, and it's a shame to waste their capabilities and experience."