Coaching patients post-discharge

March 30th, 2015

Joy Daughtery Dickinson is executive editor of the Hospital Group of publications at AHC Media in Atlanta and long-time editor and writer of Same-Day Surgery. She has won nine national awards from the Specialized Information Publishers Association and the Association of Business Information & Media Companies for her writing and editing. She makes her home in southwest Georgia.

My daughter has played almost every sport at some time in her 15 years of life. Her coaches, almost all volunteers, would encourage and guide her to a win, if possible, or good sportsmanship if not. Coaches help guide you to the best result by giving you information about what you need to do at the time you need it.

That thought is the incentive behind “transition coaches” at Wyoming Medical Center in Casper. The rural hospital has participated in a statewide effort to improve the transition of care from hospital visits to primary care. The hospital has set up five transition coaches who help patients who are ill and about to be discharged and their families. They’ve focused on 10 diagnoses in order to reduce readmissions, and they’ve had success with acute myocardial infarction, congestive heart failure, and pneumonia. Reducing such readmissions is critical in the current system in which your reimbursement gets reduced when patients are readmitted.

For these patients to receive appropriate and timely follow up, the hospital needed partners: public health and community organizations. The hospital also is building more primary care practices and is having those practices work with the transition coaches. Future plans include having coaches take on a more hand-on role with patients post-discharge, such as taking them to their first doctors’ appointments and providing care planning.

The hospital isn’t stopping there. It’s trying to raise $1.2 million to build a wellness center located on the campus. The center would include consultation rooms for health coaches, integrative medicine practitioners, and nutritionists, as well as a fitness facility.

The role of the transition coaches has been described as the “glue” between hospital visits and primary care. Here’s hoping the process sticks, with patients and hospitals being the beneficiaries.