EVCTP Care Transitions Coaches are trained and certified in the following evidence-based models of care:

CTP® Care Transitions Program, Dr. Eric Coleman, University of Colorado — A 30-day intervention to instill confidence and engage patients to take charge of their own health. The purpose is to focus on patients and caregivers with multiple chronic conditions to avoid costly and unnecessary returns to the hospital for treatment. The model delivers education regarding chronic diseases, medication management, red flag identification, and the importance of primary or specialty care follow-up.

Chronic Disease and Diabetes Self-Management, Stanford University — is a training model for patients with chronic health conditions or diabetes to deal with problems such as frustration, fatigue, pain and isolation. Teaches appropriate exercises for maintaining and improving strength, flexibility, and endurance as well as the appropriate use of medications, proper nutrition, effective communication skills, how to evaluate new treatments and develop good decision making.

Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors), Baylor University  A 90-day model to detect and address depression and anxiety in older adults with chronic health conditions and functional limitations. Utilizing the PHQ9 screening tool, this model assesses the severity of symptoms, educates about depression treatment and self-care, links patients to healthcare and mental health professionals if necessary and helps patients engage in behavioral activation as they pursue personal and meaningful goals.

Mental Health First Aid® — Designed to teach lay people methods, knowledge and skills to improve and respond to early-stage mental illness and mental health crisis. Methods encourage self-help and other support strategies.

Motivational Interviewing for healthcare professionals  — A method that works to facilitate and engage intrinsic motivation within the patient in order to change behavior. Motivational Interviewing is a goal-oriented, patient centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence.

Matter of Balance — A fall prevention training that emphasizes practical coping strategies to reduce the fear of falling. Methods include the increase of activity levels by promoting the view that falls are preventable, that making small environmental changes, setting goals and promoting exercise to increase strength and balance can reduce risk factors that are attributable to falls.

Home Meds — Addresses medication related problems and errors that might endanger the lives and wellbeing of an aging population. Home Meds is an individualized in-home screening, assessment and alert process to identify medication issues. The program includes computerized screening and a pharmacist review to help prevent falls, dizziness, confusion and other medication-related problems for aging and living independently at home. *Associated Pharmacist costs for the review. Average review requires 20 minutes and 30- 40% will require additional review.

Virginia Options Counseling — Options counseling is a documented plan that contains an individual’s goals along with action steps, resources needed, time lines and responsible parties to achieve the goals. Options counseling is an interactive decision-support process whereby individuals, with support from family, caregivers, and or significant others, are supported in their deliberations to make informed long-term support choices in the context of the individual’s preferences, strengths, needs, values, and individual circumstances.

Advance Care Planning — Initiates communication between patients, their family and their health care provider. Taking into consideration the patient’s relationship and culture, which will then drive specific medical treatment decisions, the coach will facilitate a referral which can lead to the Advance Directive.