NY Times: Transition Coaches Reduce Readmission Rates By Up To 40%

Transition coaching — helping patients successfully discharge from hospital to home — has helped reduce hospital readmissions by 20% to 40% in some cases, according to a New York Times article.

Transitions from one care setting to another often go awry and sometimes result in a hospital readmission — as patients are sleep-deprived and medicated at the time of discharge, NYT writes. But transition coaches, research shows, have helped significantly reduce hospital readmissions for a relatively low upfront cost.

Reducing hospital readmissions has been the focus of many in the health system, as Medicare started imposing financial penalties on hospitals with high readmission rates in 2012. To reduce these rates, some hospitals began partnering with other care providers, forming accountable care organizations. Others looked to transition coaches.


The Care Transitions Intervention Program, developed by geriatrician Eric Coleman and used by more than 900 hospitals and care organizations nationwide, connects patients with coaches who visit their home after they’re discharged, helping them through the transition process. Though they’re different from home health aides, transition coaches contribute to the patient’s ability to safely remain at home.

A coach might discuss the medications the patient is on or symptoms that would indicate a problem requiring medical attention. The coach would help the patient’s spouse strategize whom to call in an emergency and what to say.

It costs $300 to $450 to train and pay transition coaches, “but the cost savings can be substantial and long lasting,” NYT writes.


In the latest study, published in the Journal of General Internal Medicine, coached patients had a 30% lower readmission rate than their non-coached counterparts. In the same study, researchers found that, after allowing for the costs of coaching, Medicare spent an average $3,752 less over six months for coached patients.

These patients had fewer emergency room visits, observation stays, doctors’ visits and nursing home stays, but what drove the cost savings was significantly reduced hospital readmissions, said Stefan Gravenstein, senior author of the study.

“We believe that when something came up, they got help before they got so sick they needed to be hospitalized,” said Gravenstein, a geriatrician now at University Hospitals Case Medical Center in Ohio.

He added, “When they discover that the things that worry them also have an urgency, it removes the hurdle. It gives them permission to ‘bother the doctor.’ ”

To read the full New York Times article, click here.

Written by Emily Study

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