This study is the first to report on a more comprehensive picture of healthcare use in the six months following the patient-centered coaching, called Care Transitions Intervention (CTI), and to estimate costs avoided using the data.
"When patients are discharged, they are often ill-equipped to self manage," said Stefan Gravenstein, MD, senior author of the study and Interim Chief of the Division of Geriatrics at University Hospitals (UH) Case Medical Center. "Typically, in the Medicare population, nearly one in five patients, or 20 percent, is re-admitted within the 30 days following discharge from the hospital. For all patients, 30-day re-admission is only about one in seven or eight patients instead of one in five.
"With this study, we found that sending someone to the patient's home who helped the patient (or their caregiver) gain confidence in recounting the patient's medical issues, medication, and when and how to reach out for help significantly reduced re-hospitalization and costs. And the teacher did not have to be a health care professional such as a doctor or a nurse, but just needed to be specially trained for this coaching activity," said Dr. Gravenstein who is also a Professor of Medicine at Case Western Reserve University School of Medicine and was at Brown University Medical School and School of Public Health during the time of the study.