A program implemented by visiting health coaches in Massachusetts, supported with mobile technology, reduced readmissions for at-risk Medicare patients by almost 40 percent and saved $370,000 during a recent six-month trial.

The program was highlighted in a recent Agency for Healthcare Research and Quality Innovations Exchange.

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Administered in partnership with area hospitals, the four-week program begins with an in-hospital visit to determine the risk of readmission.

Patients at medium or high risk for readmission receive an in-home visit within 48 hours of discharge and a weekly phone call for each of the next three weeks. During each encounter, the coach uses a tablet-based application developed by San Francisco-based Care At Hand that provides suggested questions written in lay language based on the patient's diagnoses, treatment, and overall risk profile. If the answers indicate a decline in health status, the system sends a real-time alert to a nurse care coordinator, who subsequently uses a different component of the software to help the patient and coach address the issue within 24 hours, including arranging for any needed services.

Based on hospital-generated admissions data from hospitals involved in the program, the addition of the Care at Hand software to the health coach protocol reduced 30-day readmissions by 39.6 percent among at-risk patients eligible for a health coach, as compared with the previous model in which health coaches did not have access to the software. This translates to a 5.9 percent reduction in all-cause readmissions among Medicare beneficiaries, including low-risk patients who did not get assigned a coach. In addition, an expected seasonal spike in readmissions during the winter (due to an increase in respiratory illnesses) did not occur.

The net savings generated by the reduction in readmissions averaged $109 per patient per month, with gross savings of roughly $600,000 and net savings of approximately $370,000 during the six-month trial period involving 561 patients.

 

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