Reducing Readmissions with Patient Transition Coaching

Every year, the clinical team at Alicare Medical Management (AMM) supports tens of thousands of patients through an array of case management, nurse triage and other medical management services. Inevitably, a number of these patients end up admitted to the hospital.

After the hospital stay, many patients struggle when getting their feet back on the ground. In fact, recent studies document that as many as 20 percent of patients discharged from the hospital end up back in the hospital within 30 days. Many of these costly readmissions result from lack of follow up care or the inability of the patient to understand and follow their physician’s directions. With proper Patient Transition Coaching following discharge, many of these costly readmissions can be prevented.

As a result, AMM has begun to expand its services to patients and their families to make sure they have a more seamless transition after they leave the hospital. For example, a short-term telephonic-based Transition Coaching program can provide patients with the information and support they need for a safe and uneventful transition from hospital to home.

Our registered nurse health coaches will reach out to a selected group of patients immediately post admission to fully assess their status and identify any potential problem areas. Transition Coaches will make sure that patients and their at-home caregivers are properly informed about: follow-up care and self management requirements; the patient’s medications; complications or problems; and when to reach out to their attending physician or case manager.

Where appropriate, the Patient Transition Coach can reach out to the physician for additional information and intervention and coordinate follow-up care. Typical patients for this program often are those who are discharged post surgically, as well as those with chronic conditions such as congestive health failure, chronic obstructive pulmonary disease, and diabetes. For our utilization management clients, appropriate cases will be selected by our nurses at discharge based on system-generated triggers and nurse judgment. Other clients can work with us to develop referral criteria to identify appropriate cases.

One would think that utilization management, discharge planning, case management or disease management services already address these needs. That’s not the case. None of those programs are designed to address the post discharge needs of the patient who doesn’t require intensive management, or doesn’t require medical equipment or on-site services addressed through discharge planning. These patients can fall through the cracks of other programs and can end up back in the hospital.

If you would like to learn more about AMM’s Readmission Management Program call or e-mail us for more information at sales@alicaremed.com or 1 (800) 863-8868.