Improving Chronic Disease Self-Management by Older Home Health Patients through Community Health Coaching.
The purpose of the study was to pilot test a model to reduce hospital readmissions and emergency department use of rural, older adults with chronic diseases discharged from home health services (HHS) through the use of volunteers. The study's priority population consistently experiences poorer health outcomes than their urban counterparts due in part to lower socioeconomic status, reduced access to health services, and incidence of chronic diseases. When they are hospitalized for complications due to poorly managed chronic diseases, they are frequently readmitted for the same conditions. This pilot study examines the use of volunteer community members who were trained as Health Coaches to mentor discharged HHS patients in following the self-care plan developed by their HHS RN; improving chronic disease self-management behaviors; reducing risk of falls, pneumonia, and flu; and accessing community resources. Program participants increased their ability to monitor and track their chronic health conditions, make positive lifestyle changes, and reduce incidents of falls, pneumonia and flu. Although differences in the ED and hospital admission rates after discharge from HHS between the treatment and comparison group (matched for gender, age, and chronic condition) were not statistically significant, the treatment group's rate was less than the comparison group thus suggesting a promising impact of the HC program (90 day: 263 comparison vs. 129 treatment; p = 0.65; 180 day 666.67 vs. 290.32; p = 0.19). The community health coach model offers a potential approach for improving the ability of discharged older home health patients to manage chronic conditions and ultimately reduce emergent care.
['Dye|Cheryl|C|0000-0003-2462-8698', 'Willoughby|Deborah|D|', 'Aybar-Damali|Begum|B|', 'Grady|Carmelita|C|', 'Oran|Rebecca|R|', 'Knudson|Alana|A|']
D000058:Accidental Falls D000203:Activities of Daily Living D000368:Aged D000369:Aged, 80 and over D002908:Chronic Disease D004636:Emergency Service, Hospital D005260:Female D006801:Humans D008019:Life Style D008297:Male D000071252:Mentoring D008875:Middle Aged D010359:Patient Readmission D010865:Pilot Projects D011634:Public Health D012424:Rural Population D000073278:Self-Management D014838:Volunteers
health coaching aging care transition chronic disease management