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'Health Care Coaches' Can Help Reduce Patient Bills, Rehospitalization

The transition coach works with patients and their families to improve care in four areas, referred to as “pillars”: medication self-management, the creation of a personal health record maintained by the patient, obtaining timely follow up care and developing a plan to best seek care if particular target symptoms arise. Each of these goals allows the patient to actively enhance the quality of care received.

“Despite the fact that these older individuals were recovering from their acute hospital stay, were sleep deprived and dealing with changes to their health status, they were able to learn new skills to ensure their needs were met during this vulnerable time,” Coleman said.

Beyond the benefits to the patient, the intervention lowers costs for Medicare providers who would otherwise finance the re-admissions to hospital. Because the intervention opens beds for other patients, hospitals may benefit financially. Researchers estimate that for every 350 patients who receive the intervention, hospital costs will be reduced by approximately $300,000.

The intervention was designed to be low intensity and low cost. The first meeting between the patient and transition coach was held in the patient’s home and focused on reconciling the patient’s medication, teaching effective communication skills and even role-playing. The remaining contacts between the coach and the patient were conducted by telephone and were designed to reinforce the four pillars.

The universal benefits of this program have led to its rapid spread. Coleman said, “There has been great demand for this model of care. We have successfully implemented the Care Transitions Intervention in more than 12 leading healthcare organizations nationwide.”

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