The Community-Based Transitions Model: one agency's experience.

Area of Science:

• Healthcare delivery
• Chronic disease management
• Patient self-management

Background:

• Home care providers have over 100 years of experience in complex patient care.
• Essential home care clinician skills align with contemporary health coach roles in care transitions.
• Existing care transition models often have gaps in supporting patients with chronic conditions.

Purpose of the Study:

• To describe the development and implementation of the Community-Based Transitions Model™ (CBTM).
• To demonstrate how re-tooling home care clinicians with health coaching competencies enhances their role.
• To address identified gaps in care transitions for individuals with chronic conditions.

Main Methods:

• The Community-Based Transitions Model™ (CBTM) was developed by home care providers.
• Clinicians were re-tooled with health coaching competencies, including motivational interviewing.
• The model focuses on supporting patients throughout their chronic condition trajectory.

Main Results:

• Home care clinicians' existing skills are highly compatible with health coaching roles.
• Re-tooling equips clinicians to effectively manage complex patient needs during transitions.
• The CBTM provides a framework for enhanced support in chronic care management.

Conclusions:

• Home care clinicians are well-suited to function as health coaches.
• The CBTM effectively equips clinicians to improve care transitions for chronic conditions.
• Integrating health coaching competencies into home care enhances patient self-management and outcomes.