Hospitals in pursuit of excellence

Coaching for Quality Care

Poor planning. High costs. These issues helped prompt Saint Joseph-London in London, Ky., to improve care and reduce readmissions for chronically ill patients, focusing first on heart failure patients. System failures in transitioning patients from hospital to home contribute to readmissions. Variation in discharge plans and lack of patient preparation increase the likelihood for readmission. To better prepare patients for discharge, the hospital implemented a transition coach program. The coach, patient and family meet in the hospital before discharge. When the coach follows up with phone calls, "he voice becomes a face," says Mary Osborne, executive director, Innovative Cardiac Solutions, at Saint Joseph-London. The coach calls the patient at home one day after discharge to review medications and follow-up appointments and answer questions, and then calls again after 30 days. If the patient misses the week-after-discharge appointment with the HF clinic, the coach calls the patient within the same week. With this intervention, the readmissions rate for HF patients has decreased to 15.9 percent from 27.7 percent. "The transition coach is a wonderful way to meet patient needs and improve the quality of care and quality of life for these patients," adds Oborne. Contact her at mosborne@ics-cardiac.com.