How does the Transitions CoachTM interact with the homecare nurse or case managers?
As long as the Transitions CoachTM is not billing Medicare for home visits, there is no concern over duplication of services. The patient and Transitions CoachTM often practiced or role played?the upcoming visit with the home health nurse in order to ensure that the patient was able to articulate his/her health care needs. The same was true for the case manager. However, often the case manager was not aware that the patient had been hospitalized and one of the actions for the Transitions CoachTM was to re-unite the patient with his/her case manager or to make a referral if longitudinal case management was indicated. In many respects, it would be natural for the home care nurse to assume some of the roles of the Transitions CoachTM, engaging the patient and family members to promote greater participation in the process. Disease management and case managers could also take on some of the Transitions CoachTM functions.
