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"I thought it was a joke, and was wondering who would play such a mean trick!" That's how Robert Wood Johnson Foundation (RWJF) Clinical Scholars program alumnus Eric Coleman, MD, MPH, describes his first reaction to the news that he'd been named a MacArthur Foundation Fellow, more popularly known as the "genius award."
A geriatrician and an associate professor of medicine at the University of Colorado Health Sciences Center, Coleman says his time in the RWJF Clinical Scholars program, from 1995 to 1997, helped him become a bold “change agent” willing to take risks and undaunted by such challenges as improving transitional care. He has spent much of his career researching the vexing and persistent problem of miscommunication and errors that crop up during, or soon after, patient transitions from one care setting to another. Then, putting that knowledge to use, Coleman pioneered a nurse-led, patient-centered model for care transitions.
Empowering Patients and Their Families
"When patients are moving across care settings," Coleman explains in a video on the MacArthur Foundation website, "say, from a hospital to a skilled nursing facility or from a skilled nursing facility to home, the process is generally very rushed. We know that 40 to 50 percent of people, especially older adults, after they leave the hospital, experience a medication error or problem. This is rather striking, given how much emphasis we've been placing in the health care delivery system on patient safety. So with direct input from patients and families, we launched what we call the Care Transitions program."
Coleman’s Care Transitions Intervention is a nurse-coaching model that aims to improve transitions between care settings and help patients assume a more active self-care role. Coleman describes the program as an "empowerment model" for patients and their families. "What we're trying to do is to encourage older adults and family caregivers to assert a more active role in their care, and the way that we do this is through simulation, practice, rehearsal," he says. "Rather than just giving them a series of instructions, we actually have them demonstrate how they would go about doing [what they need to] under the constraints of the lifestyles they lead."
The program is led by nurses and social workers, and it includes coaching and checklists for patients and their families aimed at ensuring that they have the information they need when patients are transitioning from one setting to the next. A discharge preparation checklist created as part of the program covers such topics as how to get and take prescribed medications, what side effects to look for, whom to call if problems arise, and scheduling follow-up visits and arranging transportation to get to them.
Care Transitions provides patients with a personal health record so they can track their care as they move from one setting to the next and one provider to the next. It helps them keep track of questions they have, and facilitates interdisciplinary communication among providers. Another part of the program is a medication discrepancy tool for use by multiple practitioners caring for the patient.
Coleman says the program is intended to "operationalize the spirit and reality of person-centered care—not just patients but people and their families, empowering them to assert their health care needs, particularly in a vulnerable time."
Coleman's success with the program has led to its adoption by 750 organizations across the country, and it is included in Medicare's Community-Based Care Transitions program, a national initiative testing transition models as part of health care reform.
Becoming a 'Change Agent'
Coleman sees the MacArthur award as validation of work that he recognizes is "outside of the mainstream in some respects. The validation is really about trying something very different." He credits his experience with the RWJF Clinical Scholars program for instilling that spirit of exploration. "One thing we were encouraged to do through the RWJF Clinical Scholars program was to take on daunting challenges in areas that are complex, and to become change agents.”
“The work I do is pretty high risk,” Coleman continued. “It's sort of a paradigm shift to say that maybe we should think about the end user when we design health care. But taking on the identity of a change agent, particularly with respect to underserved and disadvantaged populations, is such a key part of the Clinical Scholars program."
Learn more about the RWJF Clinical Scholars program.
Learn more about RWJF’s work to support a more highly educated, skilled nursing workforce.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.
Learn about the Future of Nursing Campaign for Action – working to transform health care through nursing at www.CampaignforAction.org.
Learn how to improve care transitions and prevent avoidable hospital readmissions, and pick up nursing and medical education con-ed credits.
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