Tablet-equipped health coaches reduce readmissions among at-risk Medicare patients

Trained health coaches supported by tablet-based software significantly reduced readmissions among at-risk Medicare patients, according to the Agency for Healthcare Research and Quality’s Innovations Exchange.

At Elder Services of Merrimack Valley, a Mass.-based agency on aging, health coaches equipped with mobile technology worked with a total of 561 Medicare patients at medium or high risk of readmission over a six month period. During the program, they visited these patients within 48 hours of hospital discharge and then called once a week for the next three weeks to monitor their health.  

During the visit and phone call, the health coaches utilized tablet software to review patients’ diagnosis and assess their risk profile. If a decline in health status was indicated, the system would send a real-time alert to a nurse care coordinator, which utilized a different component of the software to help the patient and coach to address the issue within 24 hours.

Comparing outcomes with an 18-month period of readmissions data from before the intervention, the researchers found that the tablet significantly reduced readmissions among the at-risk patients while generating cost savings for the hospitals and healthcare system. Overall, the net savings generated by the reduction in readmissions averaged $109 per patient per month, or $370,000, according to the study.

The total cost of the intervention was $205,000, including salaries and other expenses related to program services. The technology portion of the program cost $30,500, including software, tablets, data connection and training.

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