Transitional Health Coach

Transitional Health Coach

The Center for Healthy Aging (CHA) is a new non-profit organization. It’s CEO, Dr. Larry Weiss, directed the Sanford Center for Aging at the University of Nevada Reno for 13 years and has been developing innovative health programs for 35 years.  The CHA is designed to help educate and train caregivers, empower elders, enhance wellness, and provide models of care that demonstrate efficiencies and cost savings while improving the quality of life for elders.  The mission is to develop innovative, effective, and efficient programs for elders through research, education, and services designed to improve quality of life and to promote easy access to programs throughout the state of Nevada.

CHA’s proposed project is to utilize the ‘Transitional Heath Coach’ model built on the work of Coleman, et. al. (2004) Care Transitions program in Colorado to help older adults and family caregivers become more comfortable and competent in participating in their care during care transitions, and ultimately, keep the elder out of long term placement in a nursing home.  Transitional care is designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location; such as hospitals to sub-acute or post-acute nursing facilities, the home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care with the chronic care practitioner team that have current information about the client’s goals, preferences, and clinical status. It includes logistical arrangements, education of the client and family, and coordination among the health professionals involved in the transition. The Transitional Health Coach (THC) will serve as the eyes and ears for the health care team that will advocate, support, educate, and guide the client and their caregivers to secure appropriate community services and to be able to maintain functional abilities to stay out of being re-admitted to acute hospital and long term placement in a nursing home.

CHA’s model differs from the Coleman model in that the Transitional Health Coach will be a trained volunteer (i.e., retired nurse or health care professionals recruited and connected to appropriate volunteer programs).  The THC will be trained in the federal Aging and Disability Resource Center’s (ADRC) core curriculum for chronic disease and disability self-management. The THC will work closely with the client’s care team (family, professionals, paraprofessionals, etc.) to foster collaboration between key providers, promote confidence and independence with the client, help with follow-up on medication therapy reviews, help acquire skills to self-manage, secure necessary resources to promote self-care, and generally advocate for the client and caregiver within and between the various health and social services.  We specifically will partner the THC with students in health care to provide team training in community care for the student and advocacy support for the THC volunteer. We are proposing to work with Northern Nevada hospitals to allow THC’s to be part of the care team for frail elders who have no family/friends and are at risk of nursing home placement when discharged from the acute care hospital.

The program will address the Affordable Care Act Section # 3035 and intervene in the 20-25% of Medicare patients that are re-admitted to acute care within 30 days. The targeted Medicare patient group identified by the ACA will be three diagnoses – MCI, CHF, and Pneumonia, and maintain them in the community.

The THC would begin the assignment in the hospital, prior to client being discharged, and continue until the client is stabilized in the community. The THC will be a member of the team and report to the Washoe County social worker, ADRC care manager, Hospital discharge planners, and the project’s coach coordinator. The THC will be knowledgeable of community resources and provide guidance in self-directing the chronic care plan. The THC will have access to and utilize the client’s health history, medications, social and caregiving support, functional abilities, and community resources to aid the care manager in facilitating timely and appropriate services. Communication with providers, especially physicians, will be one of the functions of the THC. Once stabilized in a community setting, the THC will continue with a less intense follow-up with the client for the duration of the project.

Anticipated outcomes of the Transitional Health Coach evaluation are a reduction of the need for Medicaid spend-down and long term placement in a nursing home. In addition, expected outcomes would include increased health literacy and health outcomes, reduction in health care utilization for hospital days, readmissions, ER visits, and an increase in client and caregiver satisfaction.  In addition, those caregivers that are employed will demonstrate reduced absenteeism and lost productivity at work due to care for their elder family or friends.

If the THC model project is successful during the first year, the second and third year funding will demonstrate that sustainability can occur on an ongoing basis by working with the hospitals and the employers of the caregivers that benefit from the THC program.  A return on investment will be determined for the hospital and the employer, which in turn will demonstrate the value of sustained funding for the program.