As part of our work on the 9th Statement of Work with the Centers for Medicare & Medicaid Services (CMS), Quality Partners of Rhode Island is focusing on improving coordination across the continuum of care. This work, referred to as Safe Transitions, is part of CMS’s National Patient Safety Initiative. The Safe Transitions project focuses on a patient’s discharge from the hospital to other care settings, promotes cross-setting communications, and ultimately, aims to improve patients’ transition experiences, self-management skills and outcomes. The primary role of the Care Transition Coach is to empower the patient/caregiver 1) to assert a more active role during care transitions and 2) to develop lasting self-management skills. Safe Transition Coaches will support individual patients with one of the identified diagnoses over a four-week period that will include a hospital visit, home visit and follow-up phone calls.
Quality Partners hired two additional Safe Transitions Coaches to carry out this work.
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– Evelyn Rodriguez, BSN, RN, is an experienced health coach whose previous experience includes providing telephone counseling and educational information to patients, as well as promoting health, wellness and follow-up care. Evelyn is a resident of Cranston.
– Paula Meegan, RN, CPUR, CMCN has over 30 years of nursing experience that includes case management as well as disease management and health coaching. Paula is a resident of Warwick.
The coaches will meet with patients during their hospital stay and after discharge, to help them learn self-management skills to best care for their health conditions. Some of the primary goals will be to :
• Help patients learn to track their medications,
• Visit their primary care physician in a timely manner
• Best understand their condition’s symptoms
• When and who to call if their condition worsens
About Quality Partners: Quality Partners of Rhode Island is a non-profit healthcare quality improvement agency based in Providence, Rhode Island that provides consulting, research and education services. We collaborate with national and local government agencies, healthcare providers, stakeholders, insurers, educational institutions and foundations on many healthcare quality improvement initiatives. With a staff of over thirty physicians, nurses, educators, analysts and other healthcare professionals, this agency is viewed within the healthcare industry as a local and national leader in quality improvement.
