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Home > Disease Management
Reducing Readmission Risk for the Elderly through Care Transition Coaching
Reducing Readmission Risk for the Elderly through Care Transition Coaching
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With the healthcare industry focused on reducing the high numbers of Medicare patients readmitted to the hospital within 30 days of discharge, landmark studies of transitions in older adults at high risk for readmission upon discharge are transforming care management approaches across the country.

Reducing Readmission Risk for the Elderly through Care Transition Coaching presents new models of care coordination for the elderly, including an Oxford Health Plan care transition coach program. This book also reports on Inspiris's care team approach to managing care transitions for the frail elderly — adults 65 and older who comprise 40 percent of elderly hospitalizations and who are particularly vulnerable during transitions from one care site to another.

Part of the Reducing Hospital Readmissions Toolkit, a four-volume set with case studies from a variety of programs aimed at reducing unnecessary hospital readmissions, from discharge planning, transition coaching, transitions in care case management, medication reconciliation, community partnerships, home visits, assessments to identify high-risk patients and patient and caregiver education. Click here to save 25% when you order the Reducing Hospital Readmissions Toolkit.

Reducing Readmission Risk for the Elderly through Care Transition Coaching examines four coaching-based approaches to coordinating care across healthcare settings from Oxford Health and the impact that these programs are having on healthcare utilization:

  • Transition coach program for Medicare beneficiaries that includes patient education and empowerment, health record creation, medication management, communication with physicians, and home visits and follow-up;
  • Advanced illness and coordinated care program for seriously ill patients who do not yet meet hospice criteria but require assistance with medical symptom management as it impacts end-of-life comfort care and proactive decisions about end-of-life healthcare services;
  • Health coaching and pharmacy outreach for Medicare members designed to break down barriers to medication adherence — drug and food interactions, functional issues and socioeconomic factors; and
  • Options for Living self-management classes for Medicare members living with diabetes, lung conditions and chronic pain.

Beyond Oxford Health's coaching-based approaches, this 30-page special report presents an analysis of vulnerabilities in care transitions for the frail elderly — a population whose numbers are expected to more than double by 2023 — from Inspiris, Inc. Since self-care, self-management or behavior modification is not an option for the majority of the frail elderly due to some degree of cognitive impairment, Inspiris proposes a care team-centered approach: identifying the at-risk population, developing the care plan and providing ongoing health maintenance and acute problem management.

In this special report, these respected thought leaders share their unique approaches to care transition management that positively impact cost and engage the patient and support team in their care decisions:

  • Danielle Butin, former director of Northeast Health Services for Secure Horizons, United Healthcare;
  • Gregg Lehman, Ph.D, president and CEO of Health Fitness Corp., who contributed to this report in his former position as president and chief executive officer of INSPIRIS.

Table of Contents

  • Integrating Health Coaching Into a Comprehensive Health Management Effort
    • Using Health Coaching to Better Manage Transitions and Improve Empowerment
    • Implementing Health Coaching Programs
    • Results of Health Coaching in Managed Care
    • Transition Coach Program
    • Advanced Illness and Coordinated Care Program (AICC)
    • Polypharmacy Transitions
    • Options for Living Self-Management Programs
    • Results of Living Self-Management Programs
  • Managing Transitions for Medicare Patients to Avoid Costly Inpatient Admissions
    • The Frail Elderly: Growing Need, Growing Problem
    • The Changing Role of Family Caregivers
    • Ten Most Common Reasons for Hospitalizations Among the Elderly
    • How and When Breakdowns Occur
    • Acute Problem Management
    • Physician Relationship Management
    • Utilization and Cost Outcomes
  • Q&A: Ask the Experts
    • Predicting Inpatient Acute Utilization
    • Managing Fractures on an Outpatient Basis
    • Criteria for Identifying Pre-Hospice Patients
    • Acute Problem Management
    • Geriatric Depression Scale and Mini Mental Status Exams
    • Funding & Reimbursement
    • Interventions for Self-Management Disease Programs
    • Health Coaching in Pharmacy Outreach Programs
    • Determining the Frequency of Maintenance Visits
    • Components of the Home Visit
    • Training Transition Coaches
    • Training Nurse Practitioners
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: October 2009
Number of Pages: 30
ISBN 10: 1-936186-85-3 (Print version); 1-936186-86-1 (PDF version)
ISBN 13: 978-1-936186-85-3 (Print version); 978-1-936186-86-0 (PDF version)
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