Hour-Long Home Coaching Decreases Readmission for Medicare Patients

An hour-long educational coaching session and two or three follow-up phone calls after a hospital stay are enough to reduce readmission odds by 39 percent among Medicare patients, according to a study by Cleveland-based University Hospitals Case medical Center. The study, which is published in the Journal of General Internal Medicine, also found that the average cost of care was reduced by $3,700 per patient for those patients who received the education session versus those who did not.

The study was conducted with 1,300 Medicare patients at six hospitals in Rhode Island. Out of the 1,300 patients, 321—the intervention group—received the home training and 919—the internal control group—who were eligible but declined the training, or if they had agreed, never scheduled a home visit or were not home when the coach visited. (To balance for a potential bias in selecting patients, the researchers also constructed an external control group of about 11,000 Medicare patients from the same hospitals who would have been eligible for participation, but who were not approached.)

The study found that the intervention group had significantly lower utilization in the six months after discharge and lower mean total health care costs ($14,700 vs. $18,700). An average of $3,700 was avoided for each patient who received the intervention compared with the internal control group, and more costs were avoided when compared to the external control group.

“Although outpatient costs were up a little, they were dramatically offset by savings in later hospital care,” Stefan Gravenstein, M.D., interim chief of the Division of Geriatrics at University Hospitals Case Medical Center in Cleveland, who is senior author of the study. The intervention began in the hospital with a brief introduction, and continued into the month following discharge, including one home visit and two to three phone calls. The home visit was a patient-centered coaching intervention to empower individuals to better manage their health. It was developed around four points:

1. Ensuring that the patients knew their clinical conditions from their personal health record.
2. Making sure that patients knew their medications, what they were, when to take them, and for which symptoms.
3. Knowing the signs or symptoms of when to reach out for help.
4. Empowering the patient to know how to reach out for help when one of those red flags came up.