The Texas Department of Aging and Disability Services (DADS), a CTA Tech4Impact grantee, implemented The Care Transitions Coaching Tool to facilitate the delivery and evaluation of the Care Transitions Intervention® (CTI). CTI is a care management strategy that is increasingly being used to successfully improve care following hospitalizations and to prevent avoidable rehospitalizations. The Care Transitions Coaching Tool, using an ACCESS database platform, was developed based on feedback from multiple stakeholders delivering the Care Transitions Intervention® in hospitals and community-settings. Use of the tool has resulted in a savings of up to 20 hours per week of a care transition coach’s time and up to 19 hours per week of supervisor time, which translates into a savings of approximately $969/week in personnel costs.
WHO WAS INVOLVED
Scott & White Healthcare in collaboration with the Central Texas Area Agency on Aging and the Texas Department of Aging and Disability Services
WHAT THEY DID
Problem Addressed: When evidence-based interventions are disseminated in community settings outside the realm of research protocols and evaluation, it can be difficult to capture information needed to evaluate fidelity to the original intervention and the impact of the intervention in real- world settings. This innovation emerged out of a need to enhance data collection for evaluation processes and outcome measures of hospital and community-based implementation of the Care Transitions Intervention® (Coleman et al., 2004; Coleman et al., 2006; Parish et al., 2009). The challenge was to include the enhanced data collection and evaluation components without introducing undue demands on transition coaches’ time.
Patient Population: Any hospitalized adult population
Description of the Program: The Care Transitions Coaching Tool was developed based on feedback from multiple stakeholders delivering the Care Transitions Intervention® in hospitals and community-settings, including coaches in the field, supervisors, and evaluators at several sites. A publicly available version of the tool, the “Coach database,” was used as a starting point for creation of the Care Transitions Coaching Tool.
The Care Transitions Coaching Tool runs on individual computers or as a shared file on a local server. Data is stored using methods that allow for analysis by an individual coach for a particular case, as aggregated data for reports for project managers, or extracted as raw data for evaluation purposes. Both process and outcome measures can be captured with the tool.
DID IT WORK
Summary of Results: For sites that do not currently have systems in place to track delivery of interventions, the tool is both useful and cost-effective.
HOW THEY DID IT
Context of the Program: The Care Transitions Coaching Tool supports delivery of the Care Transitions Intervention®. It does not replace training or any other aspect of program content; it is a tool to track and report on program activities and survey responses.
The Care Transitions Coaching Tool runs with Microsoft ACCESS 2007. Separate versions/datasets can be run by each person on the team or a single file stored on a secure shared folder can be accessed by several persons. It is not available in a web-application version at this time, although demand for web-based access is high. Sites are responsible for storing and accessing the data according to local and federal policies and regulations. Transition coaches generally enter data about their coaching activities and any consumer responses to surveys into the tool after face-to-face interactions and during telephone interactions.
Planning and Development Process: The Care Transitions Coaching Tool was developed based on input from experienced coaches, supervisors, and evaluators. Project teams made additional requests for changes after adopting the tool. Changes were made in “batches” to prevent loss of existing data. Local site programmers also made additional local changes as needed to customize the tool to specific site protocols and preferences.
Resources Used and Skills Needed:
Getting Started With This Program: The Care Transitions Coaching Tool is available for free to programs delivering the Care Transitions Intervention®. Details on the intervention and training to deliver the intervention are not tied to the tool and should be obtained prior to using the tool. All computers require Microsoft ACCESS 2007 to run Version 10 of the tool. It can be run in 2003 software if converted to that version. It is important to have at least one person on the team or available as a consultant who knows how to use Microsoft ACCESS.
Sustaining This Program: The Care Transitions Coaching Tool is easy to use, requires little maintenance, and promotes time and cost savings for teams implementing the Care Transitions Intervention®.
Changes to the tool require at least basic knowledge of Microsoft ACCESS. Extracting and merging data from several copies of the tool can require extensive effort. It is recommended that all users should save data into the same copy of the tool so data are stored together. Shared network drives are ideal for this purpose. Secured/ encrypted external drives can also be used for this purpose or multiple users can use the same copy of the tool on the same computer if necessary.
The data collection, merging and analysis issues could be addressed with the implementation of a web application. Creating a web application for the tool will improve access for multiple sites to track the care transitions intervention delivery. The opportunities for review of aggregate data from multiple sites would also be enhanced. In addition, a web application would promote increased adoption by allowing increased access to the tool from more locations.
Other Considerations and Lessons: It is important for coaches to continue to intervene with individual patients and caregivers as they were trained to. The Care Transitions Coaching Tool should only be used to document their activities and not to direct their coaching activities. The primary benefits of the tool exist in regular review and reporting processes where data is analyzed to determine more effective coaching activities and opportunities for assuring fidelity to the Care Transitions Intervention®.