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Springwell and Newton Wellesley Hospital

This success story was featured in IHI's STAAR Learning Session on February 2-3, 2011

In October of 2010, Springwell received a referral from Newton-Wellesley Hospital for Transitions Coaching for an
81 year old female (Mrs. A*) with a new diagnosis of arterial fibrillation. Springwell’s Coach visited the patient in
the hospital and made arrangements to follow up after discharge.

The next morning, Mrs. A called the Springwell Coach to say she had been discharged yesterday. She stated
that there had been some medication changes made and she was” very confused” as to what she should be
taking. She explained that she took her “regular” medications last night when she got home, but because she was
unsure about what she should be taking, she hadn’t yet taken any meds today. The Springwell Coach arranged to
immediately visit Mrs. A at home.

During the home visit with Mrs. A, she shared with the Coach that her goal was to get well enough to attend
her granddaughter’s wedding in the spring, which would be held out of the country. She shared again with
the Coach that she was confused about her medications – both what she should be taking and why she was
being prescribed particular medications. The Coach supported Mrs. A through the process of doing her own
medication reconciliation, using the Personal Health Record (PHR). When this was completed, Mrs. A stated that
she better understood her medications but that still didn’t understand why she had been prescribed something for
anxiety. She shared with the Coach that this was not a new medication, and in fact she actually did not take it as

The Coach discussed with Mrs. A why it was so important that Mrs. A let her doctor know right away about this. At
first Mrs. A was reluctant to have that conversation with her doctor because she found it “difficult to talk to him”.
The Coach and Mrs. A did a role playing exercise to build Mrs. A’s confidence to speak honestly with her doctor.
With the Coach’s support, Mrs. A called the office and arranged to be seen by her doctor that day, as she had not
yet scheduled any follow-up appointments.

Mrs. A then informed the Coach that she was also supposed to make an appointment for a PT evaluation. Mrs. A
shared that she hadn’t planned on making the appointment because she had received PT in the past, and “hadn’t
found it helpful”. The Coach reminded Mrs. A of her goal to attend her grandchild’s wedding, and that improving
her walking would be important to her ability to achieve that goal. Mrs. A t agreed to try PT again and would make
the appointment.

The Coach followed up by phone with Mrs. A as planned. She stated that she is “doing well and noticing some
improvement”. She kept her PCP appointment, and brought her PHR with her. She discussed her questions with
her doctors, and told him she was not taking the anxiety medication. Mrs. A told the Coach that she felt for the
first time she understood why her doctor wanted her on that medication and that she had agreed to take it.

Mrs. A also told the Coach that she had called her cardiologist’s office and requested appointment and was told
she could not get appointment until the very end of November. Mrs. A then informed the office that she needed
an appointment sooner as she had been hospitalized recently. She was waiting to hear back from them. The
Coach urged her to call again if she didn’t hear back today or tomorrow and Mrs. A agreed that she would. Mrs.
A had made the appointment for the PT evaluation, explaining that her grandchildren “mean the world to her and
this is motivating her to keep moving forward”.

Mrs. A shared that she was “deeply thankful for the support completing PHR and the encouragement” for self
advocacy. She stated that she “feels much more in control of her own health and body” as a result. The Coach
praised her for all her efforts and encouraged her to continue advocating for herself.

At the next follow up call, Mrs. A stated she was doing well, ambulating with more ease and going for regular
walks. She continues to take her anxiety medication and acknowledged it seemed to be helping her. She shared
that she feels “much more confident” managing her medications now.

At the final follow up call, Mrs. A shared that she is feeling “better by the day”, taking all her meds as prescribed,
and is walking at least 25 minutes a day. The Coach inquired about the cardiology appointment and Mrs. A
explained she was able to get an earlier appointment. Mrs. A explained she is using her PHR regularly and taking
it with her to all appointments. Mrs. A shared that she wants to remain out of the hospital and make it to her
grandchild’s wedding. Mrs. A told the Coach that she had just renewed her passport last week and she was more
hopeful than ever that she’d be able to attend.

*some details, including the patient’s name, have been changed to protect patient confidentiality
Springwell Transitions Coaching case study