Pocono Medical Center (PMC) Chief Medical Executive Jonathan Goldner, M.D., has seen it happen too many times. Elderly patients suffering from chronic diseases are discharged from the hospital. Because they don’t follow their doctors’ orders, they soon are readmitted for more care.

That type of medical recidivism prompted Goldner to partner with area colleges on an innovative program to curb hospital readmissions and emergency department (ED) visits. College students volunteer as PMC health care coaches for chronically ill Medicare patients soon after they leave the East Stroudsburg, Pa.-based hospital. They visit patients at home to monitor medications and make sure they are eating well. 

The hospital and East Stroudsburg University (ESU) first designed the course in the fall of 2012 for students majoring in community health, exercise science, athletic training and pre-physician assistant programs. They are taught how to recognize signs that a patient might need medical help, what to look for in the home that might hamper recovery and how to coach them on following their doctor’s recommendations.

Once completing the course, students visit patients once a week. The visits begin within a week of the patient’s discharge from the hospital.

“We know when patients leave the hospital they want to get out of there, they want to get home and they don’t always hear the instructions very well,” said Goldner. He says the coaching focuses on patients who are likely to leave the hospital only to return days or weeks later. Those patients are typically elderly and suffering from chronic diseases that account for most of health care spending. 

“The students are gung ho, energetic and look forward to talking with patients,” Goldner said. “And the patients love the young person coming in and talking to them.”

Coaching StudentsESU senior Sabrina Schembeck took the health care coaching course last fall and coached an elderly woman with Chronic Obstructive Pulmonary Disease (COPD), which makes it difficult to breathe. She sees things going on in the home that might not come to light when a patient is seen in a doctor’s office. In Schembeck’s case, “it was family members smoking around the patient and that is not something you can do with a patient who has COPD.”

Because she is in the patient’s home, she can see if the patient is following diet restrictions and medication levels. She explains why it is important to follow the doctor’s instructions. After a visit, she makes the doctor aware of any problems, so when the doctor sees the patient in the office, the problems can be addressed.

“I’m there to guide them when they go off track,” says Schembeck, who is studying biology and wants to become a physician’s assistant. ”Seeing them understand what they need to do and take control of their life is very rewarding.”

PMC’s Goldner said a big reason for readmissions has to do with elderly patients’ confusion about their medication. A lot of patients are readmitted because of a mix-up with their medicine, he said.

PMC expanded the coaching program last year through a collaboration with Wilkes-Barre-based Wilkes University’s school of pharmacy that brings third-year pharmacy students into the patients’ homes. They compare a patient’s medication orders to all of the medications that the patient has been taking so they can avoid medication errors such as omissions, duplications, dosing errors or drug interactions.

“They go to the patient’s home sometimes with our East Stroudsburg University health care coaches, who are talking to the patient about diet and making sure they follow up with their doctor’s appointments and making sure their diabetic patients are checking their sugar and so on,” Goldner said. “And the pharmacy student goes through the medication part of it. That has worked out extremely well.”

The hospital last month added another component to the program. Paramedics visit patients in their homes, take their blood pressure and check their heart rate and talk to them about how they can manage their chronic illness.

PMC expects to see improvements in patients’ health and a reduction in patient readmissions and ED visits. Preliminary results are encouraging. The hospital last fall tracked the costs of caring for 20 elderly, chronically ill patients who had health care coaches. It found the program saved about $50,000 in costs related to readmissions and about $16,000 in ED visits for those patients.

The student coaches fill a need in preventive health care, said Alberto Cardelle, chairman of ESU’s health studies department. Cardelle helped design the ESU course on coaching.

“This program offers a bridge” toward more coordinated care, he said. “We are using undergraduates to do more of this population health approach at no cost other than the time and effort the hospital puts into training the students and coordinating the program. The hospital’s role is extended in the community and that is a critical component of the patient’s recovery.”

Golden said students build rapport with patients. Patients might be intimidated talking to a doctor, he said. They often find it easier to talk to the student coaches and tell them things they may not tell their doctor.      

“When I ask questions, patients kind of yes me to death and tell me everything is fine,” he said. “And here is this college kid telling patients how they should take care of themselves and the response has been amazing. The bang for the buck is getting in the patient’s home.”