“I love this job. We aren’t always heroes saving lives. We’re not always going to see immediate results. But, we help with the little things that make a big difference.”

The Community-based Care Transitions Program (CCTP), created by the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for Medicare beneficiaries (Parts A and B) and dual eligible. We asked field coach Cyndi Stubbs to explain more.
Q: How does the care transitions program work?
Cyndi: The liaison coach signs the patient up with the program while still in the hospital. Then, the liaison coach schedules the field coach. We generally try to visit within three days, but seldom the day they come home. We try to give them at least a day to get settled in before we visit.

I go to the patient’s home. I explain what I do, who I work with, and that it’s a free service, because that’s a big concern to a lot of our patients. We go over any concerns the patient may have, and summarize things we’re going to cover in the visit, so they know what to expect.

I ask the patient what led them to the hospital – a fall, an illness, a condition. I always ask about each of their medications: where they get it, why they take it, and whether they know the side effects. I may not know the side effects either, so then I add it to the list of things to discuss with the doctor.

We consult the discharge papers, and I make sure they know when their doctor appointments are. We create a list of questions for the doctor at the next appointment.

I’ll ask them what a typical day looks like and how their life is going to change due to their diagnosis. Often this is a change in diet. The patient may have spoken with a dietitian in the hospital, but often don’t understand what they need to do. I try to tell them where they can get information on how they should be eating. I can’t really tell them the diet or how to read a label, but I can help them be responsible for their diets.

At the end, I summarize all the things we talked about. I try to get them to talk to me about how they see their daily lives changing. If I can get them talking about their care and what they’re going to do then it’s been a successful visit. Basically what we’re trying to do is get them responsible for their own health through small steps. The hospitals usually cover the big steps, but they don’t always cover the day-to-day things.
Q: Can you talk about a patient you helped recently?
Cyndi: I had a relatively young, diabetic patient who had just had back surgery on seven vertebrae. The pain was so excruciating that he couldn’t move around much. When I arrived, he said he could hardly breathe. I asked, “Are you normally short of breath?” He said, ‘No, no, I think I picked up a cold from the hospital.’ Well, that’s a red flag. I suggested he call the doctor to explain how much pain he was in. I said “I’m a little worried about this congestion in your chest.” His wife said she’d called but got no call back.

I called and was able to get him into the doctor within an hour. It turned out he had double pneumonia. If I hadn’t pushed it, they were just going to wait for their next scheduled appointment. I don’t think he’d have been in very good shape had he waited that long.

We’re just there for that gentle nudge. People don’t understand that often times it’s easy to get help, but they just need to know what to ask. I had another patient with congestive heart failure who had double pneumonia. He was on limited fluids. We called the doctor, explained the situation and asked if she could explain what he could do to help himself with this double pneumonia. It’s not that he didn’t know what to do. He just didn’t know how to go about it or what to say. He talked to the doctor, got some different therapy set up, got some different medicine, and was actually able to get better a little sooner.
Q: What do patients seem to need most?
Cyndi: Sometimes, it’s just a matter of giving them some education and explaining things. We take for granted that everybody understands what they’re told. We also take for granted that everybody’s on the Internet, and that’s not true – this population especially. They’re not used to finding information at a moment’s notice. Sometimes, it’s just a matter of bringing information to them that they had no idea existed. Between friendly reminders and gentle nudges, we try to help them be responsible for their own health. I may not know the answer to a question, but you can bet I know where to find it.

help them be responsible for their own health. I may not know the answer to a question, but you can bet I know where to find it.

There are some people who may not need us, or may not think they need us, until we get there. I try to do something at each visit, even if it’s just making them laugh at a bad joke. Most of the time, they find out they have needs that they didn’t really know they had.

I had a patient who had pain on her right side that had moved to the left side. The first time she had pain in her side, it put her in the hospital. I asked if she could get to the doctor to have it checked out. She did, and it stopped her from having more problems down the road.

I had a patient who had her medications confused. I found the error when I was reviewing the medication. I asked her to tell me about it, and she realized what had been happening. She said, “No wonder I’ve been so sick.”

A lot of people have help, but unless those people helping are educated about the situation, they’re not always valuable. They don’t know what to look for. I had a patient who moved his doctor’s appointment up a week, because he was feeling so poorly and was showing bad blood sugar levels. His wife got so angry, saying she was so sick of doctors and appointments. He actually didn’t go to his doctor’s appointment because she was so angry about it. Sometimes the caregivers are just worn out. They’ve done it for a long time. When I see that, I try to persuade the caregiver to take a break. Sometimes just giving someone permission to take a day off makes a big difference in their outlook.

Q: Are there any other stories that come to mind?

Cyndi: A man in his eighties, who had no means whatsoever, and was alone, needed resources. I connected him with Meals on Wheels, so he didn’t starve. I also found him some interaction with other people. He didn’t qualify for home health. However, he was able to go into the community center and get some free education on his disease. He learned quite a bit.

We aren’t always heroes saving lives. We’re not always going to see immediate results. But, we help with the little things that make a big difference.

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Kansas City Quality Improvement Consortium
KCQIC is a community based organization dedicated to the well being of all Kansas Citians by bringing educational programs, resources, and care to the community.
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