https://nursing.ouhsc.edu/Care-Management Parent Page: Care Management id: 24093 Active Page: Care Transitionid:26379

Ashley Jones

405-595-7430
Monday - Friday 
8am - 5pm

Ashley Jones

The Care Transition Coach will: 

  • Help Patients with self-management skills
  • Enhance patient-provider communication 
  • Resolve medication discrepancies
  • Review the personal health record
  • Ensure follow-up appointments are establishes
  • Connect patients to community resources 
  • Support the patient to achieve optimal health care

 

Care Transition Program

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Clients who may qualify for Transition Coach services:

  • Frequent hospitalization
  • Readmissions due to chronic disease symptom exacerbation
  • Community-acquired and hospital-acquired pneumonia
  • New onset of falls/syncope
  • Emergent general surgery
  • COVID-19 positive

Population exclusions:

  • Dementia and/or unable to self-manage (unless active caregiver is available)
  • Active use of drugs and/or alcohol abuse
  • Hospice enrolled
  • Unable to take medications or attend physician appointments

OU Nursing Care Transition Coach provides the following services: 

  • A hospital visit with the client for program overview, to provide client with copy of  Personal Health Record, and to notify client of future contact. 
  • Scheduled home visit with client to address medication self-management, review symptom awareness and red flags, support patient with scheduling primary care and other specialist appointments, and advising client to complete Patient Health Record. 
  • Follow-up phone calls to increase client self-management skills, personal goal attainment, and to provide continuity across the transition. 

The Transition Coach will assist the client to develop a reliable approach to medication management and will rehearse the client's health-related questions so the client can more efficiently communicate with their healthcare providers. The Transition Coach seeks to empower the client to manage their own healthcare. 

This OU Care Transition Program is offered at no cost to the client.

What Providers Should Know About Care Transition Program

1. The Care Transition (CT) Coach is key to encouraging the patient and family caregiver to assume a more active role in their care. The CT Coach does not fix problems and does not provide skilled care. Rather, CT Coaches model and facilitate new behaviors, skill transfer, and communication strategies for patients and families to build confidence that they can successfully respond to common problems that arise during care transitions.

2. Selected patients will have a meeting with a CT Coach in the hospital (where possible—this is desirable but not essential) to discuss concerns and to engage patients and their family caregivers in the CT intervention. After discharge the CT Coach will make a home follow-up visit and accompanying phone calls designed to increase self-management skills, personal goal attainment and provide continuity across the transition.

3. CT Coaches work with your patients to develop a reliable approach to medication management and encourage them to co-own their medication list with you. They also have patients rehearse their medication questions to more effectively and efficiently communicate with you.

4. Patients who receive the CT intervention are:

     a. Significantly less likely to be readmitted to a hospital.

     b. Less likely to incur further high cost utilization

     c. More likely to achieve self-identified personal goals around symptom management and functional recovery. These findings are sustained for at least six months after working with the CT Coach.

What You Can Tell Your Patients About the OU Care Transition Program

“The Care Transition Program is designed for patients who want to stay out of the hospital.” 

“Patients who participate in the 30-day Care Transition intervention are significantly less likely to be readmitted to the hospital.” 

“A certified Transition Coach will visit you in your home within 1 week of discharge from the hospital, and will contact you weekly for the next 3 weeks. If you are interested, the next step will be for the Transition Coach to visit you here in your hospital room prior to discharge.” (NOTE: Provide the patient with a Meet Your Care Transition Coach card). 

“The Transition Coach does not fix problems and does not provide skilled care. Rather, the Transition Coach will model and facilitate new behaviors, skill transfer, and communication strategies for you and your caregivers to build confidence that you can successfully respond to common care transition problems, such as medication changes, scheduling follow-up appointments with new or existing providers, coordinating the use of community resources, etc.”


Next Steps: Once the patient has been introduced to the CT Program and has expressed an interest in participating, please submit a referral by phone (405) 271-8767, fax (405) 271-2626, or email caretransitions@ouhsc.edu, or meet directly with Transition Coach, as available.