Chair Files

Coaching after Discharge

Salt and a jar of pickles: That's what one HealthEast (St. Paul, Minn.) transition coach found in a patient's refrigerator. The transition coach is a registered nurse specially trained to help patients after discharge, preventing readmission (and unhealthy diets). Each transition coach (1) meets with the patient in the hospital, (2) follows up the patient?s progress at the transitional care unit or rehab center, (3) calls the patient after discharge and sets up a home visit, (4) sees the patient at home to review medication and prepare for the follow-up doctor?s visit and (5) checks in weekly by phone for two weeks. HealthEast has reduced 30-, 90- and 180-day readmissions after coaching. "We integrated a documentation system to accounting and quality systems from day one," says Pennie L. Viggiano, director, government and special populations. In addition, 70 percent of patients now have personal health records, up from 20 percent before the program?s start. For more information, contact Viggiano at pviggiano@healtheast.org.

  

Additional Resources

Webinars December 13th, 2017

Equity of Care Webinar SeriesPart 2: Aligning Diversity and Inclusion, Community Engagement, Busi......

VIEW THIS RESOURCE
Webinars November 20th, 2017

Equity of Care Webinar SeriesPart 1: Aligning Diversity and Inclusion, Community Engagement, Busi......

VIEW THIS RESOURCE
Webinars November 17th, 2017

Transportation and the Role of Hospitals This AHA webinar on “Transportation and the Role of Hos......

VIEW THIS RESOURCE