Eastern Virginia Care Transition Program panel offers results of success implementing program throughout the region.

Newport News, Va. - More than 100 healthcare professionals and community members gathered in Newport News Tuesday, February 28, at Riverside Regional Medical Center’s Annex to hear from Dr. Eric Coleman, a national expert on care transitions. Coleman travels nationally discussing a currently hot topic, “care transitions,” which he says is “creating a match between individuals care needs and the care setting.” This term refers to the handoff of patients from the hospital to a rehabilitation facility, a home health care service, a skilled nursing facility or the patient’s home. This process can be fraught with confusion and challenges, particularly if the patient doesn’t understand what happens next, or if the handoff doesn’t go smoothly. “The patient is not a FedEx package. We have to understand their needs, not just deliver them to the next place,” Coleman said.


Because of the penalties now associated with re-admissions for hospitals, a more intense focus has shone on care transitions, to ensure that follow-up care happens correctly. Currently, Virginia has a higher readmission rate at 76% than the national rate of 66%. But Coleman noted that many of the reasons for readmission are not in the control of hospitals, such as patient finances, medication preferences, mental health issues, transportation, and that a transformation is necessary to overcome these obstacles. He advocated for involving more community organizations such as agencies on aging, pharmacies, adult day care centers and non-profit groups in the transition team. 

Coleman shared one of the programs he feels strongly could benefit patients, a simulation lab that would teach patients and caregivers how to walk through and practice post-discharge plans before they leave. “We make people care coordinators by default, without giving them the skills, the tools or the confidence to do it,” he said. This includes managing medications, coordinating care with doctors and other health care professionals and skilled tasks like changing wound dressings. 

To combat that, he suggests a “coaching” program – to give people skills rather than doing it for them or telling them what to do, to actually show them and let them make mistakes before they are sent back home to try on their own. Additionally, coaches that continue working with patients after discharge can help with medication management, education, follow up appointments and medical records. Dr. Coleman developed the Care Transitions Intervention, designed to empower older adults, people living with disabilities, their families and caregivers to be more knowledgeable and confident in self-managing their care after discharge. 

After his well-received speech, a panel of five members convened to share how they are already implementing his coaching model of care through the Eastern Virginia Care Transitions Partnership, created through an application funded by the Centers for Medicare and Medicaid Services (CMS). The program includes health systems, independent physician groups, area agencies on aging, skilled nursing facilities and community organizations.

“Our coaching is based on the Coleman evidence-based model. It’s working. We work on improving outcomes and personal goals. It’s decreasing readmission rates by 20 percent,” said panelist Kathy Velsey-Massey, the CEO of Bay Aging. She touted the program, saying that out of 598 patients visited at home in December 2013, 92 percent of them have not been readmitted, remaining safely in their own homes. 

One of the EVCTP success stories was panelist Ada Allen, who worked with a Care Transitions Coach after her hospitalization for a diabetic infection. “The team helped me get back on my feet. I had always been busy, working, staying fit and keeping up with my grandkids and great grandkids. But I was in the hospital for two weeks – I’d never been in the hospital like that before,” she said. Allen, a nurse, was reluctant to participate in the program, even though it was at no cost to her as a patient. “I was a bit confused about the coach. I just wanted to go home. But she was so sensitive to my concerns and worked with me on my goals,” Allen said.

Ada Allen and Panel

Viatris Nugent, Allen’s Care Transitions Coach, said that when she coaches a patient she works hard to meet them where they are. Nugent echoes Dr. Coleman's statement that creating a match between individuals care needs and the care setting is critical to the success of the Care Transitions Intervention process. “It’s determining the key issues that can help patients realize that ‘yes’ they can manage their own health,” she said. 

“Care Transitions is a safety issue, and by working with community coalitions, we can make a difference,” said Dr. Kyle Allen, Medical Director of Geriatric Medicine and Lifelong Health and Vice President for Clinical Integration for Riverside Health System.

Published: February 7, 2014