Executive Summary

A brief home coaching intervention can save healthcare costs in high-risk Medicare patients, a new study finds.

  • It entails training transition coaches to engage patients and guide them to making decisions, such as calling their community doctor when there’s a health issue or question.
  • Patients wrote out their own personal health information, reinforcing what they’ve learned but also giving providers a chance to see what they do not understand.
  • Transition coaches met with patients before discharge and provided follow-up calls after a home visit.

Researchers found that a brief coaching intervention — often around one hour — can save thousands of dollars per Medicare patient. It’s a case management approach that can be implemented by case managers in the coaching role or as supervisors of non-skilled transition coaches.

An intervention group’s mean total healthcare costs were $3,752 lower than the control group’s costs at six months after being discharged from the hospital.1

The home coaching intervention was based on the Care Transitions Program, led by Eric Coleman, MD, MPH, based in Aurora, CO. The program was created to support patients and families and increase healthcare provider skills, says Stefan Gravenstein, MD, a senior author of the study and interim chief of the division of geriatrics at University Hospitals Case Medical Center in Cleveland.

“Our transition coaches were trained by Eric Coleman and his team,” Gravenstein says.

The goal was to meet briefly with newly discharged patients and show them how to call the doctor and not emergency services when they experienced health problems, he adds.

“This was a skill that stuck with patients,” Gravenstein says.

The study’s finding of a cost savings for the intervention took into account the cost of paying transition costs at an hourly rate, as well as all hospital admissions, emergency department visits, post-acute care costs, home health costs, and outpatient expenses, says Rebekah Gardner, MD, senior medical scientist of Healthcentric Advisors and assistant professor of medicine at Brown University in Providence, RI.

There were 321 intervention subjects in the study, so the finding of mean cost savings was thrilling, she notes.

“We looked at every cost within the six months after they were admitted to the hospital, and found that the lower cost for the intervention group was driven by mostly lower rates of hospital admission,” Gardner explains. “The coaching cost $298 per patient.”

The traditional healthcare system model, designed in silos, makes it difficult for these transitional care interventions, notes Rosa Baier, MPH, associate director of the Center for Long Term Care Quality and Innovation at Brown University.

“Some of that is starting to change in terms of how payment is provided,” Baier adds. “With bundled payment, where it’s part of an episode of care, hospitals are responsible for post-discharge outcomes in a way they weren’t previously.”

For example, hospitals under the Affordable Care Act have a number of different payment reforms happening simultaneously, including penalties to providers who do not take measures to reduce hospital readmissions, Baier explains.

So hospitals and others are becoming more interested in interventions involving care transitions, but these changes are happening gradually, Baier says.

“Devoting resources to helping patients successfully transition from hospital to home can be financially beneficial to the hospital,” she adds.

Case managers can make a business case to senior leadership that their services are important to reducing readmissions, and they will need additional resources to make it happen, Baier says.

Here’s how the home coaching intervention works:

  • Train transition coaches. The transition coaches had both healthcare and non-healthcare backgrounds. Social workers, nurses, and others were trained as coaches. Case managers are suited for this type of program, and it’s cost effective to house the coaching program under the case management umbrella and have case managers run the program, Gardner says.

The non-skilled coaches performed the coaching role very well and were also the lowest cost option, Gravenstein notes.

For organizations that choose to replicate this model, it might work best financially to have a case manager in a supervisory role while non-skilled coaches make the home visits, he suggests.

All coaches received intensive training in how to be a transitional coach.

“We did immersive training for a day and a half, and then we did additional training with motivational interviewing and so forth,” Gravenstein says.

Coaches who had a nursing or case management-type of background had to learn how to not provide care to patients, Gardner notes.

The coach’s role is to gently guide patients into making the right decisions and acting on those.

“It takes a shift to move from caring for a patient and the patient’s role to learning how I can help and empower and educate the patient,” Gardner says. “The most important message, and I can say this as a physician, is that we can often underestimate what families and their caregivers can do.”

Providers often do not give patients and caregivers the resources and education they need to self-manage their conditions, especially during their vulnerable period after leaving the hospital, Gardner says.

“By employing a transition coach, we’re giving them the tools they need to self-manage as best they can,” she explains. “Not every patient can call the physician without help, but some can, and [encouraging them] to do this is good for patients and the healthcare system as a whole.”

  • Choose patients efficiently for the service. “We’ve applied this intervention to our super utilizers — the folks using more healthcare dollars than anyone else, the top 1%,” Gravenstein says.

The enrolled patients were often in a hospital 20 times a year, but after receiving the intervention, their hospital use was cut dramatically within one week, he adds.

“We didn’t manage their medications or health conditions,” Gravenstein says. “We let them go to their primary care physician.”

The intervention’s purpose is to train high utilizers to make a different choice when they are faced with a health issue that typically lands them in the hospital. Patients with multiple health issues often get in the habit of heading to the emergency department instead of calling their family doctor. Also, they need more hope and purpose in their lives, Gravenstein says. “Ultimately, what we’re looking for is why that person wants to get up in the morning and what they can look forward to doing in their day or week — like Johnny’s baseball game,” he says.

“We ask them, ‘If you can’t make it to the game, why do you think that is?’” he explains. “They tell us why, and then we ask them how they can prevent that from happening.”

  • Connect with patients early on. Transition coaches first met briefly with patients in the hospital, mostly to help them put a face to the name, Gardner says.

Transition coaches want patients to at least meet them before they return home, so when the coaches visit patients at home they won’t seem like total strangers, she adds.

Patients rarely understand all of their discharge instructions they are given while in the hospital because they’re impatient and worried about keeping their ride home waiting too long, Gravenstein says.

“They’re anxious to get out of the hospital and figure they can catch up with it when they go home, but they don’t realize they have 50 sheets of paper to go through that they’ll never read,” he says. “There are patients who are very engaged and do it all very well, but they are not the ones who need our help.”

  • Give patients homework. Coaches give patients booklets with lines to list health problems and medications and symptoms that could be red flags. The booklets have telephone numbers and should be filled in by the patient and caregiver, Gravenstein says.

“Their job is to complete the booklet, and they can take it with them to appointments,” he adds. “Coaches let the patient or caregiver write in the booklet, as opposed to having the case manager write it. Patients will be writing truth as they know it, and if they write it down, then they will understand it.”

  • Coach — do not direct — patients on how to manage their health. “The coach’s job is to help the patient reflect on what they’ve written down and then align it with any information they have to see if it’s right or not,” Gravenstein says.

The patient or caregiver decides what information is wrong because once the coach makes this decision, he or she is a healthcare provider and not a coach, he adds.

“If the patient’s notes do not make sense, then the coach can reflect with the patient about what will happen if they didn’t get the information right, and this leads the patient to conclude to call the nurse or doctor for help,” he says. “The coach doesn’t watch the interaction between the patient and the doctor or nurse, or judge the patient for doing a good or bad job.”

The coach does encourage the patient to present the personal health record that he or she has completed to all providers.

“This gives the nurse and doctor the opportunity to see how the patient’s view aligns with actual instructions,” Gravenstein explains. “If the coach were to fix the record, then providers never get a clue that the patient doesn’t know what’s going on.”

Transition coaches also ask patients how they’re doing with their medications and whether they are having any problems and when their follow-up appointment is, Gardner says.

“They review red-flag symptoms that signal when a condition is worsening and the patient needs help,” Gardner adds.

Transition coaches provided follow-up phone calls after the home visit, reinforcing the message that patients and their caregivers could make better health decisions when crises arise.


  1. Gardner R, Li Q, Baier RR, et al. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med. 2014;29(6):878-884.