The transitions coach ducks into your mother’s hospital room for a brief introduction before she’s discharged. The coach explains that her job is to help keep patients safe at home and asks if she can call to set up a home visit.
Health researchers know that transitions — the hand-offs from one setting to another, as in hospital to home — often go awry.
“It’s so abrupt,” said Dr. Eric Coleman, a geriatrician at the University of Colorado, Denver (and a certified McArthur Foundation genius). “For three days people do everything for you, and then, 11 minutes before you leave, they turn the tables. ‘Nowyou take over.’ ”
Your parent is often sleep deprived and medicated at the time; little wonder that nationally, about one Medicare patient in five returns to the hospital within a month…
To lower that figure, Dr. Coleman began developing the Care Transitions Intervention program 15 years ago. If patients agree, a coach comes to their homes two to four days after discharge. She’s not there to change dressings or help them bathe; home health nurses or aides do that. Instead, over 45 minutes to an hour, the coach — generally a nurse, sometimes a social worker or other health care professional — asks about patients’ goals as they recover.
Here’s the RI program mentioned in the story.