In this quasi-experimental trial of medicare beneficiaries, patients that received Care Transitions “coaching” had significantly lower 30 day readmission rates than those that did not (13% versus 20%). The coaching involved a visit near hospital discharge, a home visit within a few days, and 2 follow up phone calls before 30 days. The 4 pillars of coaching focused on medications, health conditions, follow up plans, and “red flags” requiring health care contact. This Care Transitions Intervention plan is effective in real-world settings in reducing 30 day readmission rates in a variety of disease conditions (abstract)
Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.