"It's going really well," Riehle says of Fairfield's program. "Our coach did 10 home visits the first week she was here."
Although Fairfield Hospital is only a few weeks into its program, Riehle says that the pilot program that their grant was based on decreased the readmission rate for the target population to 7.5%, which is about a third of the national rate.
Also, she says nurses have already learned a lot about the challenges patients face at home.
"I think the thing that surprises them the most is how confused patients really are about their medications," Riehle says.
The focus on readmissions has also broadened nurses' view of healthcare.
"In acute care, we always lived in our own little world….and we really have to think about managing that patient across the whole continuum," Riehle says, "so they don't just bounce right back to us."
That broadened view of healthcare puts the patient in a larger context than just their hospital stay. Riehle says it also requires partnerships between a wide range of stakeholders in the larger community.
"I think we're going to have to really think about ‘how do we manage those relationships?" Riehle says.
Or, put a different way: "How do we do a good hand-off?"
Alexandra Wilson Pecci is an editor for HealthLeaders.