RN health coaches work at White Plains Alicare Medical Management, an affiliate of insurance company Amalgamated Life, to help patients after they are discharged from the hospital. Although initiated informally about two years ago, AMMs telephonic Patient Transition Coaching Program was officially launched in March and addresses post-discharge needs of patients who are at risk for hospital readmission.
In collaboration with the patient, family and healthcare provider, an RN health coach works with the patient at-risk immediately after discharge by telephone to assess his or her health status and identify any concerns or problem areas. Nurses ensure patients understand their necessary follow-up and self-care responsibilities, which may include knowing about specific signs and symptoms related to their disease, medications and medication administration, what to do in an emergency and when to call the physician.
This program answers the need for those individuals who were falling through the cracks and were all too often ending up back in the hospital, said Claire Levitt, president of AMM. These patients might be post-surgical patients, or those with heart failure, chronic obstructive pulmonary disease, asthma and other respiratory and cardiac conditions who can benefit from postdischarge health coaching.Claire Levitt
We followed a middle-aged gentleman with diabetes and cellulitis of the foot who had experienced failed outpatient conservative treatment. As a result, he was admitted to the hospital for IV antibiotics, said Barbara Shaffer, RN, case manager. Working with a limited benefits plan, Shaffer was able to work with hospital case management, the physician and the payor to come up with a proposal that used his remaining benefits cost effectively. The patient was discharged in four days after admission with IV antibiotics, wound care and ongoing telephonic patient education. His wound healed, he returned to work and he was not readmitted to the hospital, Shaffer said.
Our patients can call us at any time 24 hours a day, seven days a week, so we can give them the education and support that they need, said Julie OBrien, RN, vice president/COO of AMM.
We had a patient who was referred to us because of recurring abdominal pain that resulted in frequent admissions through the ED, Shaffer said. After talking with the patient and recommending a specialty provider, the patient was diagnosed with diverticulitis and given appropriate medications and dietary recommendations. Working with a health coach, he followed his prescribed medication and dietary regimen and did not return to the ED, Shaffer added.
Several nurses work telephonically from the Salem, N.H., office and several work telephonically from the Norristown, Pa., office on this program, which is part of AMMs case management program. All of them are certified in case management and have a minimum of five years of case management experience. Besides the telephone, these nurses depend on the computer for case management system applications, which help identify the appropriate patients for this program. AMMs website also offers a plethora of information for patients, including health-risk assessments and client resources, which the nurses use and refer to when working with their clients.