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Staying at Home

Successful program uses RN health coaches to reduce readmissions following hospital discharge

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Reducing readmissions is one of the biggest challenges facing healthcare. While providers intend for patients to continue to recover after discharge, hospital readmissions associated with certain conditions are now tied to penalties as part of the Affordable Care Act.

Holy Redeemer HomeCare, the largest nonprofit provider of home health and hospice services in New Jersey, has programs to address readmissions flagged by ACA. HeartAssess and BreatheEasy are two fully developed clinical programs designed to help patients with chronic illnesses stay at home.

The newest innovation from Holy Redeemer is the RN Health Coach program. Launched in 2011, it is designed to resolve unnecessary hospital readmissions outside of the conditions identified by ACA. "We've been working for the past 10 years or more on reducing re-hospitalizations," said Holy Redeemer HomeCare expert Susan Grinkevich, MS, BSN, RN, administrator, HomeCare and Hospice, New Jersey North.

The RN Health Coach program in its first year outpaced national averages for keeping elderly residents from being re-hospitalized.

Thanks to a grant from the Grotta Fund for Senior Care of the Jewish Community Foundation of MetroWest, N.J., Holy Redeemer partnered with Jewish Family Service of Central New Jersey and Trinitas Regional Medical Center to put their Health Coaches into action. In October 2011, Holy Redeemer was awarded a one-year grant and it was equaled in 2012.

The Program

Basing its direction on evidence-based practices shown to reduce re-hospitalizations, Holy Redeemer looked at care transition programs and interventions for patients moving from a hospital to another setting. According to Grinkevich, RN health coaches attack three major barriers preventing a patient from successfully transitioning home: inability to purchase medications, inability to purchase specialty foods for a prescribed diet, and the lack of transportation to physician follow-up appointments.

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HEALTH COACH: Juliana Ige-Odunuga, BA, RN, a Holy Redeemer RN Health Coach, visits a patient at home following discharge.

"Nurse coaches are in the hospital and they work with the staff to identify high-risk patients for re-hospitalization," Grinkevich explained. A screening tool that looks at age, number of medications, co-existing health conditions and functional ability helps staff decide who is at risk. Factors indicating high risk include hospitalization in the past year, certain primary diagnoses, co-morbidities and the environment to which they will be discharged.

The program currently targets high-risk patients. Once patients are identified, care transition interventions begin in hospital. The health coach creates a transitional plan of care with the patient, clarifying their medications, developing a medication schedule and identifying drug allergies. The health coach sets a follow-up doctor's appointment and educates the client and family on red flag symptoms that could lead to re-hospitalization.

After the patient's discharge, the health coaches make a home visit within 48 hours and then weekly for the first month to reinforce the coaching and the flow of information between providers and family. The health coaches also accompany clients to their first doctor's visit after discharge to help advance communication between client and physician. Additionally, the health coaches remotely monitor vital signs through a telemonitoring device for up to four months. These services are provided at no charge to the patient. The staff's time is funded by the Grotta Fund for Senior Care grant.

In its first year, the program utilized two RNs trained to use a transitional care model. Each worked 20 hours. One was from Jewish Family Service and one from Holy Redeemer. Together, the coaches worked to identify patients and follow them through the community setting.

"In the second year, we identified in our grant proposal a big issue with resources and the need for a social worker to help with those needs so nurses could focus on medical aspects," Grinkevich said. The social worker assists patients who can't get to a doctor, get the right food or get their medicine.

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TECHNOLOGY & TEAMWORK: Telemonitoring nurse Carleen A. Valerio, RN, checks the health of a patient remotely. (Bottom) Leaders of the RN Health Coach program meet to discuss progress. (From left) Kathleen McMahon, MA, MEd, RN, health coach, Jewish Family Services; Juliana Ige-Odunuga, BA, RN, health coach, Holy Redeemer; Lucy Ankrah, MA, MSN, APN-BC, care transition; Susan Grinkevich, MS, RN, VP Holy Redeemer HomeCare; Thomas Beck, executive director, Jewish Family Services; Carleen A. Valerio, RN, telemonistoring nurse, Holy Redeemer HomeCare; and Marilucy Lopes, LMSW, social worker, Jewish Family Services.

Inside the Numbers

The RN Health Coach program led to zero readmissions in the first 30 days of discharge during the first year (46 patients were served by the program). As the year went on, re-admissions increased. In year two, diagnoses included in the transitional care program expanded to even more medically-compromised patients and that affected the outcomes as well.

"Results change based on the timeframe and the population served. In our first year of the program, we focused on what we thought were the highest risk patients for re-hospitalization but excluded certain diagnosis like end stage renal," Grinkevich said. "The second year, when we wrote our proposal and collaborated with Jewish Family Services, we added many of the diagnoses we excluded in year one and ended up with different results. Our results for year two have been 17% re-admitted in 30 days or less for the first nine months of the program."

Those results weren't surprising, as there were more diseases, more medications and more barriers for staying out of the hospital. "There are a lot of issues with health literacy," Grinkevich noted. "Individuals with chronic illness don't always understand the relationship between taking medications, eating low-salt foods and feeling better."

As the program continues, more challenges will be revealed and solutions implemented. "This [program] is to help the community and really find out what we can do to help patients stay at home and help more patients stay out of the hospital," Grinkevich said. "Most people don't want to return to the hospital when they leave. They want to enjoy their grandchildren or go fishing or something that is important to them. They can only do that if their chronic illness is controlled."

Keith Loria is a freelance writer.

About Holy Redeemer

Holy Redeemer Health System offers a wide range of healthcare and health-related services, including an acute care hospital, home health and hospice services, two skilled nursing facilities, personal care, an independent living community for seniors, low-income housing, an active living community, and a transitional housing program for homeless women and children. With corporate offices in Huntingdon Valley, PA, Holy Redeemer Health System is a Catholic healthcare provider, serving southeastern Pennsylvania and 12 counties in New Jersey, from Union County south to Cape May County.


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