Improving Care Transitions Through Use of a Coaching Intervention

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97688


Preventable rehospitalizations are disconcerting for patients, contribute to high costs, and are partly due to deficiencies in patients’ ability to execute post–discharge care plans. Increasing patient engagement and self–empowerment through use of an evidence–based coaching model can improve adherence to the post–discharge care plan and may reduce preventable rehospitalizations.


To assess the feasibility of setting up a transitions coaching program in an urban teaching hospital and measurably reduce 30–day rehospitalizations and emergency department (ED) visits. Secondary goals included improving patients’ understanding of their post–discharge medication regimen, ability to communicate with their doctor at the first follow–up visit, and understanding of symptoms of clinical deterioration and how to respond appropriately.


From March through August 2011, we piloted a coaching intervention for high–risk general medicine discharges using six experienced home care professionals (non–clinicians) employed by a local community–based non–profit organization and trained in transitions coaching by the University of Colorado Care Transitions Program ( Coaches met with patients twice – once in the hospital and once in patients’ homes shortly after discharge – and made three follow–up phone calls to provide coaching in the areas outlined above. Outcomes were measured via telephone survey of patients and review of administrative records.


Of 108 patients referred for coaching, 39 completed the intervention with another 12 nearing completion (acceptance rate 47% [51/108]). Of the 39 completed cases, only 7 (18%) were rehospitalized or had an ED visit within 30 days (inclusive of admissions/visits to other hospitals). Given that only patients deemed to be at high risk of readmission were referred for coaching, a potential comparison group is patients discharged home with services; approximately 20% of such patients were readmitted (to our hospital) during the preceding fiscal year suggesting a likely reduction in readmissions with the coaching intervention. In 14 completed patient experience surveys (response rate 36% [14/39]), 93–100% of respondents agreed or strongly agreed with feeling more confident about taking all prescribed medications correctly, asking their physician pertinent questions, and identifying red flags indicating worsening health. Conducting this pilot establishes that a large urban teaching hospital can successfully collaborate with a community–based non–profit organization for the benefit of community–dwelling elders. Salient challenges addressed as part of this feasibility assessment included: understanding legal barriers to such collaboration and successfully meeting legal and regulatory standards, finding a funding source for the intervention and exploring different business models to make the intervention sustainable, and fostering a culture of collaboration with external, non–academic entities.

To cite this abstract:

Dutkiewicz C, Hasan O. Improving Care Transitions Through Use of a Coaching Intervention. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97688. Journal of Hospital Medicine. 2012; 7 (suppl 2). Accessed March 31, 2020.

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