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Helping patients take charge: CDH's Care Transitions Program improves move from hospital to home

Paul Vasconcellos works with Chris Orlen of the Care Transitions Program at Cooley Dickinson Hospital recently. Orlen helps patients set health goals, assemble health documents and take other steps to manage their own care. 

COURTESY OF COOLEY DICKINSON HOSPITAL

Paul Vasconcellos works with Chris Orlen of the Care Transitions Program at Cooley Dickinson Hospital recently. Orlen helps patients set health goals, assemble health documents and take other steps to manage their own care. COURTESY OF COOLEY DICKINSON HOSPITAL Purchase photo reprints »

After being treated for congestive heart failure and diabetes, Paul Vasconcellos had to retire in 2008.

Having been a dean in the Dean of Students office at the University of Massachusetts for around 30 years, he said he was used to advocating for other people.
But in dealing with chronic illness, he said, he had to learn how to advocate for himself.

This is why, when Christine Orlen, care transitions coach for Cooley Dickinson Hospital, offered to help him manage his own care following a hospitalization for congestive heart failure in 2012, he enthusiastically accepted her offer.

“At times, you can feel defeated,” said Vasconcellos, 64, in a recent interview at his home in Amherst. “And the worst thing you can do when you have a chronic illness, in my opinion, is to give that over, because when you give that over, you’re basically saying, ‘Other people know what’s best for me.’”

Reducing hospitalization

After receiving a two-year grant of $165,000 from the Massachusetts Attorney General’s Office in January 2011, Cooley Dickinson Hospital began the Care Transitions Program in April 2011 to decrease hospital readmission rate for patients dealing with chronic illness. The program was originally developed by Dr. Eric Coleman of the University of Colorado at Denver.

Today, it has helped more than 120 patients in the Valley, and the 30-day readmission rate at Cooley Dickinson has decreased from 9.2 percent to 7.6 percent, according to hospital records.

Jeanne Ryan, executive director of the Visiting Nurses Association and Hospice of Cooley Dickinson and Cross Continuum Services, said that health care providers in Massachusetts are working to decrease hospital readmissions through improving the transitions between care, such as, in Vasconcellos’ case, going from the hospital to home care.
She likens the transition between health care providers to a relay race.

“If you think of a relay race where you have four people and you’re handing off a baton, what’s really really important is not that the runner runs fast and runs the quickest only, it’s what does that hand off look like?” Ryan said. “If that’s not a great handoff, then it’s not easy for patients to go to the next venue of care.”

Orlen’s role is to help patients adjust and manage their care after returning home from the hospital. In his home, Vasconcellos currently receives assistance from the Cooley Dickinson VNA and from personal care assistants from Franklin County Home Care and Elite Home Care Agency.
Orlen, who is also a registered nurse, said her visits are different from nurses’ visits. She does not carry “the typical tools of the nurses’ trade,” and does not take blood pressure, she said.

“I don’t give direct care of any kind,” she said. “My focus is really on skill transference, and being sure that people can provide and make the most of their own resources which is what they’re going to have to do for a long time to come after I go.”

She added that around half of the patients she sees as a care transitions coach also have a visiting nurse, and stresses that her goal is not necessarily to keep patients out of the hospital, but to keep them where they would like to be.

“The hospital is no place to be if you don’t need to be there, but not coming back doesn’t really measure what the quality of somebody’s life is while they were not coming back to the hospital,” Orlen said.

At the beginning of the program, Orlen visits patients at home, and helps them compile a “Personal Health Record” that includes all of their medications, when and why it is to be taken, as well as warning signs associated with their ailments. The booklet also has a section where patients can list their personal goals.

She said it can often take a long time to go over all of a patient’s medications, particularly because of safety concerns. She gave the example of some patients having a generic brand of medication in their home that they have taken for years, and then being prescribed the brand name from the hospital. If the patients do not know the difference, she said, it can lead to double dosages.
“People work pretty hard when I visit them,” she said. “But when I leave, they have something that’s helpful.”

Taking charge of care
Vasconcellos said that Orlen’s coaching, as well as having a written health record available to him, has given him more confidence about going to the doctor’s office.

“We start to think about: How am I going to go to the doctor’s appointment? What questions am I going to ask? What do I need from that appointment? What information am I taking from it?” he said. “You start to think in a different way, and that in turn empowers you so that you’re not passive. You don’t just go there and sit there.”

After the home visit, which she said usually lasts between one and two hours but sometimes becomes spread into two visits, Orlen follows up with the patients through two or three phone calls over the course of a month.

Typically, the care transitions program lasts for 30 days, but Orlen makes herself available for the patients to call anytime with questions.

Vasconcellos said that when his primary care doctor retired, Orlen was one of the first people he called to help him prepare for a visit with a new provider.

When he arrived at the appointment, he said, he brought his personal health record that Orlen helped him put together as well as a list of points he wanted to make sure he covered.

“It made such a different because when I went to the appointment, I was prepared,” Vasconcellos said.
Patients with chronic illnesses, he added, should not forget to keep in mind how they want to be treated.

“I’m not the illness; I’m the person,” he said. “So if you can think about that, then I think you go into the appointment in a different way, because we’re all more than the illness, right?”

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