Hospital and Health System

Inpatient Transitions Coaching Reduces Readmissions by 80 Percent

A pilot program that provides transitions coaching to patients hospitalized for heart attack, CHF or pneumonia has reduced unnecessary rehospitalizations at five Baton Rouge hospitals by 80 percent, according to early feedback from the program. The CMS-funded pilot targets patients 65 years and older, then pairs these older patients with a health coach. The coach works with the patients while they are hospitalized, but the real work begins once the patients are discharged.

Introduced to the patient upon admission, the health coach establishes a relationship, letting the patient know what to expect while in the hospital and after they are discharged. By the time they are ready to leave the hospital, the patient has been given advice and information about how to manage their own care. This includes information about rest and exercise, managing medicines and their potential complications, using a personal health record (PHR), when to schedule an appointment with their primary care doctor and what to do if something goes wrong.

Gary Curtis, president of the Louisiana Health Care Review (LHCR), said he is pleased with the results of the program after its first six months, which is in place at Baton Rouge General Medical Center, Lane Regional Medical Center, Ochsner Medical Center – Baton Rouge, Our Lady of the Lake Regional Medical Center and St. Elizabeth Hospital in Gonzales. “We’ve worked with about 93 patients and have only had four readmissions, a 4 percent rate, and an almost 80 percent improvement.”

The push to reduce these unnecessary hospital readmissions is also one of the many ideas found in pending healthcare reform legislation.

“The project is helping to quickly identify interventions that work. These successful strategies can then be put in place in other communities. Then, we should begin to see real and substantial improvements in this key measure of healthcare quality,” said Scott Flowers, quality improvement director for LHCR.

Source: Louisiana Health Care Review, December 2009