Nursing Notes

August 13, 2010

RN Health Coaches Coordinate Smooth Transitions, Prevent Readmissions

Health coaching is an up and coming area for nurses to explore.  I have been interested in this area for quite some time now and I am finally seeing the implementation of a type of health coaching by nurses in the news.  This is exciting news for those of us looking to get out of hospital nursing.  Readmission rates are sky-high in all areas of the country and here is an under-served population that could certainly benefit from good old fashioned nursing expertise.

This is from Nusing Spectrum, so you may have already seen this, but I want every one of us to take another look at this exciting avenue for nurses.


Julie O’Brien, RN

RN health coaches work at White Plains’ Alicare Medical Management, an affiliate of insurance company Amalgamated Life, to help patients after they are discharged from the hospital. Although initiated informally about two years ago, AMM’s telephonic Patient Transition Coaching Program was officially launched in March and addresses post-discharge needs of patients who are at risk for hospital readmission.

In collaboration with the patient, family and healthcare provider, an RN health coach works with the patient at-risk immediately after discharge by telephone to assess his or her health status and identify any concerns or problem areas. Nurses ensure patients understand their necessary follow-up and self-care responsibilities, which may include knowing about specific signs and symptoms related to their disease, medications and medication administration, what to do in an emergency and when to call the physician.

“This program answers the need for those individuals who were falling through the cracks and were all too often ending up back in the hospital,” said Claire Levitt, president of AMM. These patients might be post-surgical patients, or those with heart failure, chronic obstructive pulmonary disease, asthma and other respiratory and cardiac conditions who can benefit from postdischarge health coaching.

Claire Levitt

“We followed a middle-aged gentleman with diabetes and cellulitis of the foot who had experienced failed outpatient conservative treatment. As a result, he was admitted to the hospital for IV antibiotics,” said Barbara Shaffer, RN, case manager. Working with a limited benefits plan, Shaffer was able to work with hospital case management, the physician and the payor to come up with a proposal that used his remaining benefits cost effectively. The patient was discharged in four days after admission with IV antibiotics, wound care and ongoing telephonic patient education. “His wound healed, he returned to work and he was not readmitted to the hospital,” Shaffer said.

“Our patients can call us at any time 24 hours a day, seven days a week, so we can give them the education and support that they need,” said Julie O’Brien, RN, vice president/COO of AMM.

“We had a patient who was referred to us because of recurring abdominal pain that resulted in frequent admissions through the ED,” Shaffer said. After talking with the patient and recommending a specialty provider, the patient was diagnosed with diverticulitis and given appropriate medications and dietary recommendations. “Working with a health coach, he followed his prescribed medication and dietary regimen and did not return to the ED,” Shaffer added.

Several nurses work telephonically from the Salem, N.H., office and several work telephonically from the Norristown, Pa., office on this program, which is part of AMM’s case management program. All of them are certified in case management and have a minimum of five years of case management experience. Besides the telephone, these nurses depend on the computer for case management system applications, which help identify the appropriate patients for this program. AMM’s website also offers a plethora of information for patients, including health-risk assessments and client resources, which the nurses use and refer to when working with their clients.

Janice Petrella Lynch, RN, MSN, is a regional reporter for Nursing Spectrum. Send letters to or comment below.

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  1. […] RN Health Coaches Coordinate Smooth Transitions, Prevent … […]

    Pingback by Latest Health, Insurance, Health Insurance Auctions | Health Insurance Products — August 13, 2010 @ 5:51 am | Reply

  2. Hi! I have followed your blog for a few weeks now. I am an RN Health and Wellness Coach, and I am finishing up training through the Wellcoaches Corportation. I have three websites that I am currently developing. My most developed as far as content is I have NEW look coming in the next few days that is goin to make this site look very exciting. I also have a site that is just for nurses, and I have a site where I target those individuals that work night shift, and the difficulties they experience. My plan is to visit physicians locally for clients, and also to get contracts for group coaching through local businesses that are too small to have their own internal health clinic. It is something for nurses whose time has come! I also am working with a team of 5 individuals with another website that is targeted just for nurses in the areas of wellness. I am excited to be a part of this movement, and I am glad others are doing this as well! Thanks for the great information you provide!

    Comment by Joyce Harrell — August 13, 2010 @ 9:47 am | Reply

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