RUNNING HEAD: CARE TRANSITIONS PROGRAM

Care Transitions Program at Christian Health Care Center

Lilia Murashov and Joan Gapuz
Western Washington University

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Care Transitions Program at Christian Health Care Center

The patient population this paper will be focusing on is Christian Health Care Centers
Care Transitions Program participants. Christian Health Care Center (CHCC) is a skilled
nursing and rehabilitation facility located in Lynden, Washington. Their short term rehabilitation
patients are offered complimentary visits from Faith Community Nurses. These nurses help
patients and their loved ones with a transition process from the CHCC back to home. Those
patients, who qualify, will receive up to one pre-discharge visit at CHCC, one post-discharge
visit at their home, and 2-3 phone calls over 3-4 week period. Faith Community Nurses are all
professional RNs, who received a special training to provide special consultations with seniors
and offer education, counseling, and referrals. The aim of this paper is to discuss a care
coordination model used by the Care Transitions Program at CHCC, illustrate a care map that
reflects different aspects of care affecting a specific patient, and a plan of care including relevant
patient interventions, SMART goals, and evaluation of the plan of care execution.
Literature Review
The Care Coordination Model used by the Care Transitions Program Registered Nurses
(RNs) at CHCC is the Care Transitions Intervention (CTI) developed by Eric Coleman. This
program is initiated in the community setting with a purpose of keeping patients as healthy as
possible and to avoid unnecessary readmissions. CTIs mission is to improve quality and safety
at times of transitions or care handoffs across setting for individuals with complex care needs
(Coleman, Rosenbek, & Roman, 2013, p.2). The main goal of CTI is providing tools and support
to encourage patients and their caregivers to actively participate in the care transitions from one
setting to another (for example: from hospital or rehabilitation facility to home) (Coleman, Parry,
Chalmers, & Min, 2006). This is essential because during the transition process from one health

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care facility to another or home, people are very vulnerable to serious health and safety problems
(Coleman et al., 2013).
Due to insufficient communication and coordination between providers, patients and their
caregivers are placed under spiritual and emotional crisis, which leads to increased anxiety
levels. Very often they do not have adequate skills or confidence to function successfully.
Through the CTI, nurses work directly with patients and their loved ones. They learn about selfmanagement strategies, medications, as well as when to contact their healthcare providers
(Coleman et al., 2013).
The CTI is a 4-week intervention: a hospital/skilled nursing facility visit, a home visit,
and 3 follow-up telephone calls. Through these encounters, Transitions Coaches (RN or APRN)
encourage patients and their caregivers to have a more active role in their care, state their
preferences, and anticipate care needs. During the first introduction at the hospital or short-term
rehabilitation facility, the patient is introduced to the CTI model of care and how it is different
from case management services. Also, during this time a home visit is scheduled. This next visit
is centered on the patient and in creating health related goals and how to accomplish them. These
goals are usually about quality of life and symptoms control (Coleman et al., 2013).
In addition, Transition Coaches introduce the patients and their caregivers to Four Pillars of
self-management, which includes: (1) medication self-management, (2) patient-centered health
record, (3) primary care or specialty physician follow-up, and (4) education about red flags
(Coleman, Parry, Chalmers, & Min, 2006). Transitions Coaches assist the patient with
medication self-management and help identify and correct discrepancies, assist the patient in
reviewing and updating the patient health record (PHR), emphasize importance of follow-up visit
and encourage patient to write down questions to ask the physician, and lastly educate the patient

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about red flags or symptoms of his/her diagnoses and how to respond to such warning signs
(Coleman, Parry, Chalmers, & Min, 2006). During this conversation it is important to encourage
the patient and family caregiver to engage with the hospital and local pharmacists as a valuable
care partner. In order to identify medication problems and errors, Transitions Coaches use a
Medication Discrepancy tool and to track progress across the Four Pillars, a Patient Activation
Assessment tool is used (Coleman et al., 2013).
Coleman et al. (2013) states that during the CTI design phase, the study team directly
followed the Institute of Medicines 6 domains of quality: effectiveness (reducing preventable
hospital readmissions), patient-centeredness, timeliness (home visits occur within 24-72 hours of
discharge), safety (respond to medication errors or problems), efficiency (retooling of an existing
workforce to become Transitions Coaches), and equity (dissemination across diverse patient
population).
Case Study & Care Map Explanation, Analysis, & Synthesis
For our case study, we have a 67-year-old woman, G.H., who lives in Lynden,
Washington. G.H. was admitted to PeaceHealth St. Joseph Hospital (SJH) on 06/18/16 for a
Urinary Tract Infection (UTI) with E. coli sepsis, multidrug resistant. PICC line was placed at
the SJH for IV antibiotic administration. After four days, patient was transferred to Christian
Health Care Center (CHCC) to finish the course of IV antibiotic treatment. Patient stayed at
CHCCs rehabilitation department for almost two weeks. On 07/04/16, patient was discharged
to home. Follow-up services were arranged such as primary care physician (PCP) appointment,
home health services (Signature Home Health), therapies, bath & care, and transition nursing
(Care Transitions Program. See Appendix A for the care map.

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Health
Healthcare providers
This patient has a complex history with various diagnoses such as diabetes, dementia,
depression, gastro esophageal reflux disease (GERD), and irritable bowel syndrome (IBS). Due
to the patients complex history and diagnoses, she sees a variety of health care providers on a
regular basis. The progression of patients dementia makes her care more complicated and
challenging to manage. We included in the care map different healthcare providers that are
related to the patients management of care.

PCP general, regular check-ups

Endocrinologist due to uncontrolled diabetes

Neurologist generalized weakness and dementia

Gastroenterologist GERD, IBS, peptic ulcer disease

Orthopedic she has a history of knee arthroplasty, cervical diskectomy and fusion

Pharmacist related to patients management of care due to complex medication list

Physical therapist recent fall and back pain

Healthcare settings

SJH recent admission for UTI w/ E. coli sepsis

CHCC recent admission for IV antibiotic administration via PICC line

Insurance

Medicare patient has medicare insurance

Church church members help/assist with co-pays

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Support
Patient is a retired teacher who lives in her own home with a friend/roommate. Patient
has limited support from family members because they dont live nearby, but other people from
the community are able to provide support to her.
Friends

Friend/roommate helps G.H. manage her appointments, medications, and housework

Neighbors provide work outside patients house (gardening, mowing the lawn)

Church members help financially, serve as spiritual support, and provide transportation
to patient as needed

Professional support

Transitions Nurse from CHCC talks to patient about concerns, challenges, and goals,
educates patient about diagnoses, symptoms (red flags), medications, and when to contact
PCP

Signature Home Health Nurse assesses patient and patients home environment and
provides necessary care

Signature Home Health Social Worker will provide local support organizations and
resources that patient is eligible/qualified for

Recreation & Community

Patient is a retired missionary and an active member of the local church.
Legal & Financial
Patient has her own house in Lynden, but voiced out that she only has limited amount of
money in her bank. Patients friend/roommate serves as her planner when it comes to paying
bills. Also, patients roommate pays half of the mortgage payments.

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Information, Advocacy, & Leadership
Organizations

CTK church church members/prayer group members provide patient with information
about different resources and provide transportation as needed

CHCC transitions nurse encourages patient to advocate for self, to set up goals, to have
a more active role in her health

Northwest Regional Council possible assistance arranging patients transportation,

finances, in-home care, and so forth

Signature Home Health Social Worker

Signature home health social worker is scheduled to visit patient at home to answer
questions and provide information regarding different resources that patient might be eligible for.

Discuss the strengths of the care that you identify in the care map
Patient gets a lot of support from community members (friends, church members,

healthcare professionals). Also, there are a lot of resources available that are/can be offered to
her.

Discuss the risks that may result in an Emergency Room visit or a hospitalization/rehospitalization in less than 30 days of discharge.
The risks that this specific patient has that may result in an emergency room visit or a re-

hospitalization in less than 30 days of discharge are:

1. Verbalization of UTI symptoms (UTI can reoccur)
2. Uncontrolled diabetes
3. Unorganized medications
4. Lack of knowledge regarding medications (especially insulin)

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5. Missing/rescheduling/late arrival to appointments

6. Increased anxiety levels due to roommate moving out
7. Patient now living independently.
Plan of care
During our last home visit, patient verbalized symptoms similar to urinary tract infection
(UTI). Therefore, we decided to use recurring UTI as the main risk or problem that can lead to a
hospital readmission. Also, patients roommate used to manage her appointments, drive her to
places, and take care of her. Now that her roommate moved to Florida, based on our assessments
and together with home health nurse, we strongly believe that the patient requires extra
assistance and support.
Problem: Recurring UTI
Goal: To avoid readmission, patient will know what UTI signs and symptoms or red flags to
watch for and who to contact when such symptoms occur.
S: Patient will be aware and will know specific signs and symptoms of UTI such as flank pain,
burning pain with urination, urinary frequency, foul smelling urine, and cloudy/dark/bloody
urine. Patient will contact primary care provider (PCP) to report symptoms and ask for advice.
M: Patient will verbalize understanding of UTI red flags and will be able to list at least 3 red
flags to the care transitions nurse.
A: Patient will be provided with handouts about UTI signs and symptoms and will also receive
teaching from the care transitions nurse.
R: This goal is realistic because this patient has a history of UTIs in the past and
achieving/maintaining this goal will prevent the patient from further readmissions.

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T: In order to avoid readmission, patient will be able to report UTI red flags to PCP in a timely
manner.
Interventions:
1. Care transitions nurse will educate patient about UTI red flags.
2. Care transitions nurse will provide patient with educational handouts about UTI.
3. Care transitions nurse will inform patient when to contact her PCP.
4. Patient will monitor urines odor and appearance.
5. Patient will monitor voiding pattern (frequency).
6. Patient will note the location and intensity of pain.
Evaluation:
Patient will verbalize understanding of UTI red flags and will be able to list at least 3 red
flags to the care transitions nurse.
Patient will verbalize when to call PCP.
Patient will not be readmitted to the hospital in the next 30 days.
Problem: Patient is living independently and requires extra assistance and support.
Goal: Patient will choose, contact, and utilize a local community agency in the next month.
S: This goal is specific because patient will contact and utilize a local community agency.
M: Patient will verbalize awareness of available local community agencies and will choose one
to contact and utilize.
A: Patient will be provided with handouts with contact information of different local community
agencies.
R: This goal is realistic because patient is living independently and based on the assessments,
patient requires extra assistance and support at home.

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T: Patient will choose, contact, and utilize a local community agency in the next month.
Interventions:
1. Patient will meet with a social worker.
2. Social worker will screen/assess the patients needs and explore different local
community agencies.
3. Patient will receive handouts with contact information of different local community
agencies.
4. Patient will contact chosen/referred local community agency and set up an appointment.
Evaluation:
- Patient will verbalize awareness of available local community agencies and will choose one to
contact and utilize.
- Patient will have a scheduled appointment with the chosen local community agency.
Care Transitions Program Patient Satisfaction Survey
This survey was created to assess patients satisfaction with the Care Transitions Program
at Christian Health Care Center (CHCC). We utilized the Care Transitions Measure (CTM-15)
and the Client Satisfaction Questionnaire (CSQ-8) as a guide in creating this survey. This survey
will provide Care Transitions nurses with ideas and patient input and suggestions on how to
improve the program in the future. This survey can be completed in several ways (mail, phone,
in person, and so forth). We recommend that an individual, who is not a Care Transitions nurse,
to contact the patient by phone and conduct this survey. If decided that this survey will be
conducted by mail, it can be done anonymously to allow patients to express honest opinions and
experience with the Care Transitions Program. Future Western Washington University RN-toBSN students can follow-up with survey results and evaluate patients satisfaction levels with the

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program. Care Transitions nurses can revise this survey by adding or eliminating questions
based on initial survey results. See Appendix B for the Care Transitions Patient Satisfaction
Survey (in lieu of the Executive Summary).

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References

Coleman, E. A., Rosenbek, S. A., & Roman, A. P. (2013). Disseminating evidence-based care
into practice. Population Health Management, volume 00. Retrieved from
http://caretransitions.org/wp-content/uploads/2015/06/65_Disseminating-EvidenceBased-Care-into-Practice.pdf
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The care transitions intervention.
Journal of the American Medical Association. Retrieved from
http://archinte.jamanetwork.com/article.aspx?articleid=410933

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Appendix A
Care Map

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Appendix B
Care Transitions Patient Satisfaction Survey
Please help us improve our program by answering some questions about the services you
have received from the Care Transitions Program.
1. Knowing that the care transitions program/service is available at Christian Health Care
Center reduced my anxiety about discharge.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

2. It was valuable for me that the care transitions nurse asked about my personal health
goals.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

3. It was helpful for me that the care transitions nurse and I established questions to ask
my primary care doctor.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

4. The care transitions nurse clearly discussed the red flags I should watch for and when
to call someone for help.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

5. It was helpful that the care transitions nurse and I went over my medications.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

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6. I received quality care from the care transitions nurse.

Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

7. Care transitions program met my needs.

Strongly
Disagree

Disagree

Agree

8. I am satisfied with the amount of help I have received from the care transitions nurse.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

9. The services I received helped me to manage my health better.

Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

10. After meeting with the care transitions nurse, I feel more confident to manage my
health.
Strongly
Disagree

Disagree

Agree

Strongly Agree

Don't Know/
Don't
Remember/ Not
Applicable

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Thank you for participating in our survey. We would appreciate hearing from you.
Please let us know about your experience with the Care Transitions Program:
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