A key challenge of the healthcare system is developing care models that prevent people from needing multiple hospital admissions for the same condition. Northeast Health is using a care transitions coaching program that empowers patients to become partners in their care to reduce its 30-day hospital readmission rate.
Their coaching program focuses on patients with high-risk diagnoses of congestive heart failure, pneumonia, acute myocardial infarction, chronic obstructive pulmonary disease, and diabetes. A coach visits the patient at home within 24 to 72 hours of discharge, providing medication reconciliation, education, tools to manage their illness, and follow-up telephone calls once a week for a month. The coach also ensures that a follow-up visit with the doctor is scheduled within seven days of the patient's hospital discharge.
The combined readmission rates for congestive heart failure, chronic obstructive pulmonary disease, and diabetes have decreased from 25% to 13.4% in two years as a result of this coaching program.