Transitioning Patients to Independence.
Diane Arcilla1, Debra Levin, Marie Sperber
1Diane Arcilla, DNP, RN, is a Clinical Assistant Professor, Rutgers School of Nursing, Newark, New Jersey. Debra Levin, BSN, RN, is a Chronic Care Manager, Visiting Nurse Association of Somerset Hills, Basking Ridge, New Jersey. Marie Sperber, MS, is V.P. of Business, Development and Philanthropy, Visiting Nurse Association of Somerset Hills, Basking Ridge, New Jersey.
Home Healthcare Now
|May 7, 2019
Summary
This program reduced hospital readmissions for chronically ill patients. Telehealth and coaching support empowered patients, significantly decreasing 30-day rehospitalization rates.
Area of Science:
- Gerontology and Geriatric Medicine
- Health Services Research
- Chronic Disease Management
Background:
- High rates of 30-day hospital readmissions affect 20-25% of patients post-discharge.
- Chronic conditions like congestive heart failure, COPD, and diabetes are major contributors to rehospitalizations.
Purpose of the Study:
- To evaluate a novel program aimed at reducing 30-day hospital readmissions for patients with chronic conditions.
- To assess the impact of telehealth, coaching, and nutritional support on patient rehospitalization rates.
Main Methods:
- Implementation of a program utilizing telehealth introduced by transitions coaches in the inpatient setting.
- Provision of three coaching visits, daily vital sign monitoring, and daily symptom exacerbation checks.
- Disease-specific education, role-playing, and dietitian-led grocery shopping assistance were provided.
Main Results:
- The program achieved a 30-day rehospitalization rate of 7.8% among 102 participating patients.
- A statistically significant reduction in hospitalizations was observed, with 126 hospitalizations in the 90 days prior versus 36 in the 90 days post-program admission (p < .0001).
Conclusions:
- Empowering chronically ill patients with self-care tools and support through a structured program significantly decreases hospitalizations.
- The integrated approach combining telehealth, coaching, and nutritional support proved effective in managing chronic conditions and reducing readmissions.
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