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Hospital-to-Home Program Aims to Reduce Readmissions

Alexandra Wilson Pecci, for HealthLeaders Media, June 19, 2012

"I think we in acute care don't speak the same language as a patient at home trying to take their medications," Riehle tells HealthLeaders Media. "We don't even call them the same things."

According to Riehle, the coaches help set up patient-specific programs for successfully caring for themselves at home, teaching them everything they need to know, from taking their medications correctly to helping them make follow-up appointments. They also teach patients how to monitor their own symptoms and solve problems based on what they're experiencing.

"Whatever their condition is, [they learn] the top things that they need to be looking for that they need to call their doctor about," Riehle says.

She adds that in addition to preventing readmissions, the program aims to teach patients to be proactive in their own healthcare, helping them do things for themselves.

"At the end of that 30 days, the patient is better able to manage their own healthcare," she says.

So far, so good.

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2 comments on "Hospital-to-Home Program Aims to Reduce Readmissions"


Miguel Ortiz (6/20/2012 at 8:44 PM)
In Ecuador, South America, 25 years ago, we had a coverage-extension pilot program with participation of physicians and nurses training community leaders to work at home with new mothers and their babies right after discharge plus family training. Any problem was immediately referred to the health team. The results were noticed immediately, with increased activity in the outpatient clinics and remarkable reduction of emergency room visits. The impact on breast feeding length was beyond initial expectations. The program, financed in part by UNICEF, was so successful that scholars from around the world visited the city of Guayaquil to see the program in action. The concept works.

Kristin Baird, RN, BSN, MHA (6/19/2012 at 11:55 AM)
Alexandra, thanks for a great article. This is such an important topic on many levels. There are important clinical implications as well as patient experience implications that determine outcomes, loyalty and reputation. I'm glad to see more attention being focused on the transition of care. It's no longer a nice thing to do. It's absolutely necessary that hospitals do post-discharge follow up.