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Wednesday, October 15, 2014

COA Care Transitions helps patients understand meds and take them correctly

Care Transitions Coach Jill Cloud reviews medications with a Care Transitions patient
Care Transitions Coach Jill Cloud reviews medications with Care Transitions client Bill, age 84.  Lack of compliance with medical instructions - including medication mix-ups - is one of the main reasons people return to the hospital within days or weeks of being discharged.

When COA health coaches visit newly discharged hospital patients in their homes, they are often presented with a basket of medications to help sort out. Patients are often confused when, after a stay in a hospital or nursing home, they have new prescriptions plus old prescriptions.

That was the case with COA Care Transitions client, Bill, age 84. Bill has had more than 10 operations since 1988 to clear blockages in his heart. But he was in the hospital for other health problems when our health coach first met him. When he was discharged to a nursing facility, she spoke with him again there and then met with him a week later when he finally returned home.

By that time, he had accumulated enough medications to fill a basket. “I had so many bottles of medicine - new ones and old ones – it was a mess,” Bill said. “She (health coach) helped me figure it all out and we made a list and all. We got it down pat now.”

Lack of compliance with medical instructions – including medication mix-ups – is one of the main reasons people return to the hospital within days or weeks of being discharged. Care Transitions is designed to stop this expensive and preventable revolving door in and out of the hospital.

The COA health coach, Jill Cloud, is based at Clinton Memorial Hospital. COA has coaches connected with nine hospitals as part of its Care Transitions program. Care Transitions is a health coaching and intervention program in Greater Cincinnati for older adults who have been hospitalized for serious and usually chronic conditions, such as heart failure. It is designed to:

  • Help frail seniors who have been discharged from the hospital avoid future preventable hospital admissions
  • Help patients access the most appropriate post-acute medical care and home and community-based services (and avoid the more costly nursing facility placements when not necessary)

The program is a 30-day intervention that is part of Medicare benefits. It involves a home visit and three follow-up phone calls. The intervention helps patients:

  • Better understand and manage medications
  • Make a plan for follow up appointments with primary care physician and other specialists
  • Recognize and respond to disease warning signs or red flags 
  • Create a Personal Health Record that includes all the information needed for medical appointments
  • Connect to community resources that can help maintain health and independence

To be eligible to participate in Care Transitions, the patient must be:

  1. admitted to a participating hospital: The Christ Hospital; Clinton Memorial Hospital; Mercy Health: The Jewish Hospital, Anderson Hospital, Clermont Hospital, Fairfield Hospital, West Hospital; University of Cincinnati Medical Center; or UC Health - West Chester Hospital
  2. enrolled in traditional Medicare, and
  3. at risk for hospital readmission after discharge due to any chronic illness or injury (heart disease, heart attack, pneumonia, diabetes, etc.).

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