In-Home Health Coaching Could Lower Readmission Rates

A new pilot program in New York City is examining whether in-home health coaching can reduce hospital readmissions for Medicaid patients with congestive heart failure (CHF)—and it’s showing some promising early results.

The program launched in July as a collaboration between City Health Works, a Harlem-based non-profit organization that trains workers as health coaches, and Mount Sinai St. Luke’s (MSSL), a hospital that is part of New York City’s largest health care delivery system, The Mount Sinai Health System.

The pilot is funded through the New York State Delivery System Reform Incentive Payment Program (DSRIP) and is expected to run for one year.


MSSL’s heart failure team trained City Health Works’ health coaches on heart failure and important self-management tools for these patients. Seven health coaches from City Health Works have been trained and are involved in the pilot.

The program will provide twice weekly visits to 100 Medicaid-eligible patients in the first 30 days after they’re discharged from MSSL for CHF. Coaches educate patients on their condition and different ways to track and manage it, and, hopefully, avoid a repeat trip to the emergency room (ER), according to Jamillah Hoy-Rosas, director of health coaching and clinical partnerships at City Health Works.

Though it’s still ongoing, the pilot program has produced some positive results so far. In the two months since it began, only one participating patient has gone back to the hospital, but for an illness unrelated to CHF. About 10 patients have participated in the program so far, with all 100 scheduled to complete their first 30-day period by early next year.


Practical teaching

The coaching centers on practical guidance regarding a patient’s diet, medications, exercise and follow-up care, Hoy-Rosas says.

During each visit, coaches teach the patients how to look for the presence or absence of “red or yellow zone” symptoms that might mean their condition is worsening, such as shortness of breath, wheezing, excessive weight gain or swelling. If any of those symptoms are noted, the coach notifies MSSL and the patient’s symptoms are addressed, usually at home with a medication adjustment.

“Prior to this program, if a client noticed these symptoms, they would usually go to the ER unnecessarily,” Hoy-Rosas tells Home Health Care News.

All of the health advice is presented in an easy-to-understand, individualized manner and the coaches are culled from the same communities as their patients in an effort to foster trust and communication. The patients served reside in Harlem, Washington Heights and the Upper West Side of New York City.

That local approach is important because many CHF patients—especially those who live below the poverty line or face language or literacy barriers—don’t get the kind of guidance they need in clinical settings, says Manmeet Kaur, CEO of City Health Works.

“We place a big emphasis on providing motivational coaching in a context and an environment that feels less overwhelming than sitting in a doctor’s office,” Kaur tells Home Health Care News.

After the initial 30 days, coaches will meet less frequently with patients based on the patient’s needs and preferences. The coaches also check in by phone each month for one year after the patient was initially discharged, Hoy-Rosas says.

Home health workers might also be able to benefit from the program’s findings. City Health Works has started discussing the possibility of teaching senior home health workers and other in-home caregivers how to coach their patients about self-management care, Kaur says.

City Health Works has provided health coaching services for three other conditions: diabetes, hypertension and asthma. The organization is also exploring launching similar programs for other health areas such as chronic obstructive pulmonary disease (COPD), chronic kidney disease, palliative care, Crohn’s disease and co-morbid depression.

The pilot started with CHF because MSSL identified it as a key area in which to improve readmission rates. Currently, the readmission rate for CHF patients at MSSL is just under 20%.

Written by Tim Regan

(Featured image courtesy of City Health Works)

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