Transitions coach helps patients return home, stay there From Spotlight on Health - Winter 2013

Medication instructions — which one to take, when and how much — can be confusing. When you are being discharged from the hospital and not feeling your best, it can be overwhelming.

St. Cloud Hospital Transitions Coach Mary Eisenschenk, RN, BSN, provides information and guidance to patients to help them better understand their health conditions so they can live independently and safely at home. The transitions coach helps empower patients to use the tools and education they were given during their stay at St. Cloud Hospital to manage their medications, diet and fluid intake. Mary helps them recognize signs of declining health so they call a doctor, or another member of their health care team, before they are in crisis. She also stresses the importance of keeping clinic appointments — and helps patients set personal goals, which provide motivation.

Transition coach, Mary Eisenschenk, RN, BSN, helps St. Cloud Hospital patients transition from the hospital to home, helping to avoid readmission.

The coach visits patients in the hospital before they are discharged, makes follow-up home visits and phone calls for 30 days after discharge.

The Transitions of Care pilot program kicked off in January 2012. The goal was to decrease the readmission rate for patients with heart failure, by focusing on the patients’ transition from hospital to home.

For patients who received a transitions coach visit, readmission rates decreased by 15 percent.
St. Cloud Hospital plans to offer this program to all heart failure, chronic obstructive pulmonary disease (COPD) and pneumonia patients at high risk for readmission. For more information, call (320) 251-2700, ext. 28827. This service is provided by St. Cloud Hospital at no additional cost to the patient. The pilot program was made possible by a grant through the CentraCare Health Foundation.