Family & Children’s Society recently added health coaching services in collaboration with the Care Compass Network and United Health Services. Called Care Transitions, the Delivery System Reform Incentive Payments (DSRIP) project serves to “coach” participants with independent living after hospital discharge to prevent readmission within 30 days. Eligibility is determined by hospital discharge case managers, who then generate a referral to the Care Transitions program. A Care Transitions health coach meets with the patient prior to discharge to introduce the program and onboard the patient.
Within a week after discharge, the health coach visits the patient at home to help the individual establish a personal health record that lists all their doctors, appointments, medications, etc. – which is brought to every appointment to coordinate care among disciplines and providers. The health coach also goes over basic medication management, discharge instructions and assists in arranging follow-up appointments. At regular intervals the coach checks in by phone to ensure follow-through and assess needs.
Patients who require additional help can be referred to the Community Resource Navigator for additional services. Director of Home Care Services Andrea Quezada oversees the new program along with Nurse Manager & Program Coordinator Judy Olson and Health Coach Jena Stickler.