by Kandi Qualls, PhD
In the United States, we spend $25 billion a year on hospital readmissions that are deemed “preventable.” Many hospital systems have identified diabetes, congestive heart failure, hypertension and coronary artery disease, as the top high risk readmission conditions. These preventable readmissions are largely driven by poor discharge procedures and inadequate follow-up care. Across all insured patients, the hospital readmission rate is 11% and the rate for Medicare patients it is 13%. By focusing on two of the primary drivers, patient self-management and adequate follow-up, we can effectively reduce and manage hospital readmissions and create effective readmission prevention programs.
Self-management and adequate follow-up ensure that each patient is educated about their condition; knows how to manage their medication; and is aware of what lifestyle behaviors positively and negatively affect their condition. These management skills have been implemented at the time of discharge or with the patient’s first call immediately following discharge. Implementation of health coaching to improve self-management and reduce the risk for hospital readmissions is a cost effective strategy to address this issue.
Health coaching is an art and a science, incorporated to bring about positive lifestyle changes. When a patient is discharged, an RN trained in health coaching methods can assist the patient in making a follow-up appointment with their primary care provider. An RN can also provide guidance on medication adherence; assess the patients’ health status to identify problem areas; and assist the patient in setting lifestyle goals to prevent their condition from worsening to reduce risk of readmission.
TeamHealth Medical Call Center takes the pressure of health coaching off of the provider by recruiting RNs who demonstrate a talent for telehealth coaching and training them in techniques that result in success. Our RN’s are dedicated to coaching. Therefore, our patient experience programs ensure that each patient has a positive and rewarding experience. As an organization, TeamHealth Medical Call Center works collaboratively with the provider and can interface with the health system’s EMR to efficiently document patient success. Along with collaboration, we also gather and evaluate patient base data to identify gaps and strategies that will comprehensively improve patient success. Our focus on providing comprehensive follow-up and patient self-management provides the best investment for health promotion and meaningful data evaluation. It is an investment that provides an ROI for the patient, nurses, providers and the entire health care system.
(References: US Department of Health and Human Services, 2012-2013 and National Quality Forum, 2011)