It's a Monday morning in the spring of 2008. Humboldt State University nursing student Janis Grant looks over a referral list from the outcomes coordinator at St. Joseph Hospital in Eureka, then prioritizes her tasks and plans her day.

Two patients are to be discharged from the patient care unit while another, who had been discharged home the past week, was re-admitted through the emergency department over the weekend. Four clients need follow-up phone calls and a home visit to an older gentleman and his 83-year-old spouse/caregiver is scheduled for the afternoon.

Grant goes over her plan with her instructor, checks her field bag to make sure pamphlets and health education materials are stocked, then makes the short walk over to the hospital to see her first client. Part of the university's BSN program, it's her introduction to community/public health nursing.

Pioneering a Program

Grant, now BSN, RN, was one of eight pilot team members in the Care Transitions Program, a student-run, faculty-coordinated, hospital-sponsored community/public health initiative. The program is a collaborative effort between the St. Joseph Health System-Humboldt County (SJHS-HC), Humboldt State University's department of nursing, the California HealthCare Foundation and the Robert Wood Johnson Foundation to improve the transitional experience and care outcomes as clients move from the acute care or outpatient setting to home.

The original program model was developed by Tory Starr, MSN, RN, CIC, St. Joseph Health System-Humboldt County's regional director of performance improvement and quality management, during his graduate work. Based on an RN-led case management model, Starr customized the program to use senior-level BSN students as disease managers. With assistance from Humboldt State University senior level nursing faculty Michelle Kelly, MN, RN/PHN, FNP, the model also created a new placement option for the university's expanding community/public health rotation, which was limited by the rural location and potential clinical placement sites.

When the California HealthCare Foundation in 2007 was looking for participants for a research project, the use of student nurses as coaches was a key factor in why the budding Care Transitions Program was selected. The program was tapped as one of 10 statewide nonconventional models to implement the Coleman Transition Intervention, a method designed to promote client empowerment and self-advocacy skills through a "coaching" intervention model. In the Care Transitions Program, the model creates opportunities for students to develop skills in client advocacy and empowerment modalities essential for current clinical practice. As today's healthcare paradigm shifts patients toward shared decision making with their providers, the next generation of nurses will need specific competencies that facilitate their clients' empowerment of their personal healthcare management.

"Being a coach was very useful for us as students," said Katie Knapp, now BSN, RN. "This gave us a great opportunity to practice patient teaching in a pretty safe environment and gave us hands-on time with patients."

The Care Transitions Program adapted the Coleman Transition Intervention and established its model based on four "pillars" - a personal health record (PHR), medication list, "red flag" warning signals and discussion items for clients to utilize with their primary care provider. Student coaches meet with potential clients in the hospital prior to discharge to initiate the PHR, including the reconciled medication list, and arrange for the initial home visit. They initiate the client's care plan including the frequency and timing of the face-to-face and telephone follow-up coaching visits.

Community Impact

The program's goals include strengthening the partnership between the health system and the community and extending service beyond the hospital walls into the community - it's in providing that bridge where the program truly shines.

The program's target group is relatively broad and includes anyone at risk for readmission, such as those recently hospitalized or seen in the ED with chronic disease, people on five or more medications and those not referred to home health or long-term care. Any adults or their caregivers interested in and capable of working with a coach are eligible; services provided are voluntary and free of charge.

Joan Kaschube of McKinleyville has been a client of the program since her discharge from St. Joseph's Hospital. She credits the program for her steady recovery.

"It made a big difference to me going home," Kaschube said. "My coach came to see me in the hospital before I was discharged, then came to my home several times over a 3-week period. When I wound up back in the hospital, she came to see me there, and then started coming back to my home when I returned.

"She made me feel safer when I went home," she continued. "I knew she was always available if I had a question or concern, or needed her to explain something to me. In fact, I know I can still call if I have a problem."

Kaschube's coach, Karis Hassler, now BSN, RN, also realized the impact of the connections she made with patients through the program. "So many clients don't really understand much about their condition when they leave the hospital," she said.