Getting Motivated: Emory Saint Joseph's Mixes Post-Discharge Care Management with Health Coaching

New initiative is expected to avert costly rehospitalizations while helping patients get and stay healthy.

Emory Saint Joseph's Hospital in Atlanta has launched a nursing-led program to help patients navigate post-discharge health needs with one-on-one lifestyle coaching to fend off future hospitalizations and the costs they incur.

More than $52.4 billion is spent annually to care for patients readmitted to the hospital within 30 days for a previously treated condition, according to a 2022 study.

At Emory St. Joseph’s, nurses not only will work with newly discharged patients for 12 weeks to ensure they properly take their medication and keep timely medical appointments, but they’ll also provide weekly lifestyle and health coaching to help them establish and maintain healthy behaviors that will keep them out of the hospital.

"In this program, our nurses will collaborate with patients to determine one lifestyle behavior that could be getting in the way of their overall health, such as smoking or blood glucose management, and then chart a course to make meaningful progress over those months," says Rebecca Heitkam, director of Emory Saint Joseph’s Congregational Health Ministries and Faith Community Nursing program.

The new initiative is part of Emory St. Joseph’s larger Faith Community Nursing program, which trains nurses on post-discharge transitional care management while connecting with the patients on a spiritual level, but it takes the original program one step further by connecting nurses with specific patients one-on-one for 12 weeks following a discharge and adds the lifestyle coaching component.

The nurses call patients once or twice a week either by phone or on Zoom for up to 90 minutes to help them determine small-step goals and actions for the next week, and help them stay motivated to accomplish the goal, she says of the program launched with the help of a two-year $60,000 grant.

"With the original program, the patients seemed to become almost co-dependent on their nurses to tell them what to do each step of the way, make calls for them to obtain resources they needed instead of doing it themselves, and be the go-between for the patient and physician provider, but few patients were really strengthening their skills on managing their own chronic conditions or better yet, making a change in the chronic condition through lifestyle behavior change, where appropriate," Heitkam tells HealthLeaders.

"I had recently taken a course and become board-certified in health and wellness coaching, and I was convinced that the nurses’ time might best be spent coaching willing patients into making lifestyle changes using SMART [Specific, Measurable, Achievable, Relevant, and Time-Bound] goals and positive coaching techniques rather than being so prescriptive for the patients’ outcomes," she says.

Some patients more readily accept post-discharge care management than others, she says.

"Once patients realize that they have a good bit of control over their health outcomes if they are willing to make some crucial behavior changes, they get very excited and are on board with being coached and supported to success," she says, "or they decide that the lifestyle changes are not worth it, and they keep doing the very same things that continue to get them readmitted to the hospital."

"We have learned to be a little more intentional with choosing patients to offer the program to, and we always leave space open for patients who didn’t appear to be receptive to change, but who surprised us and made incredible changes for their own benefit," she says.

The initiative is expected to do more good than saving rehospitalization costs, Heitkam notes.

"One of the unique aspects of this initiative is that rather than measure success only through a reduction in readmissions," she says, "we’re going to be taking into account overall outcomes for patients to demonstrate how focusing on attainable health goals can make a big difference in the lives of these patients."