Eric Coleman, MD, MPH Eric Coleman, MD, MPH

 

Eric Coleman, MD, MPH
Professor of medicine and head of the University of Colorado Denver School of Medicine's Division of Health Care Policy and Research

Miscommunication each time a patient is transferred between healthcare teams – from a hospital to post-discharge homes or their own home, for instance – can create more medical problems, lead to costly hospital readmissions and endanger lives.

Interspersing his passion for dealing with this problem with flashes of humor, Dr. Eric Coleman described his Care Transitions Program. Its primary goals include:

  • Preparing patients and family caregivers for self-care
  • Preparing patients’ receiving team to assume their case

It’s based on forging partnerships by:

  • Rethinking how we communicate across settings
  • Meeting patients at their level
  • Building cross-continuum collaboration – in short, building a team

There are so many patient education pamphlets sent home with the patient, they could be “used as an ottoman” -- but Coleman questioned whether they are used by the patient. In the hospital, healthcare workers do things for the patient around the clock, “but then after 14 minutes of ‘education’ just before release, they go home and have to do it themselves... Imagine what it’s like to be this person with no health professional around,” he said.

Teach patients to fish

Coleman’s approach includes meeting the patient at his level. A patient identifies his goals – it may be putting on real shoes to go to church rather than slippers or flipflops because of swollen ankles. Patients don’t usually say their goal is to reduce a level in their hemoglobin, he said.

Coleman developed Care Transitions Interventions, which trains transition coaches who are the vehicle to building skills and confidence of patients and families and providing tools to support self-care.

Information vs. communication

“Don’t confuse information with communication,” Coleman said.

Look to the future instead of the historical, he said. “We collect a lot of data but don’t actually use it.” A change in perspective is the key – the new team doesn’t “need to know (the patient’s) blood gas level on a certain day.” Look to the future and “anticipate the problems.”

When a patient is being transferred, “put yourself in the shoes of the next care team. Even better — reach out and ask them!” he said.

Economic and human benefits

  • Significant reduction in 30-day hospital readmits (time in which a Transition Coach is involved.)
  • Significant reduction in 90-day and 180-day readmits
  • Net cost savings of $300,000 for 350 patients/12 months

The prescriptions in the program have been adopted nationally and are essential elements in Medicare’s Community-Based Care Transitions Program, a new national initiative.

A 2012 recipient of a five-year “genius grant” from the MacArthur Foundation, his prescriptions have been adopted nationally and are essential elements in Medicare’s Community-Based Care Transitions Program, a new national initiative.

Learn more about the Care Transitions Program

Read two articles on Dr. Coleman’s work on the value of care transitions: Rehospitalizations among Patients in the Medicare Fee-for-Service Program and The Care Transitions Intervention: Results of a Randomized Controlled Trial.

Eric Coleman, MD, MPH