From Hospital to Home

Care Coordination Community Brings Chattanooga Hospitals Together to Reduce Readmissions

The Chattanooga Regional Health Innovation Coalition (CRHIC) brought three area hospitals together to achieve the lowest readmission rate in Tennessee among care coordination communities.

Since 2012, the Coalition has seen a reduction in the average readmission rate for all of the Chattanooga hospitals combined from 16.7 to 15.8, going from approximately 3,300 people being readmitted within 30 days of discharge in 2012 to about 2,900 in 2015. CHI Memorial Hospital is one of the hospitals that worked closely with the CRHIC to maintain and continue to reduce the rate of readmissions in Chattanooga.

In 2012, the Southeast Tennessee Area Agency on Aging and Disability (SETAAAD), with the assistance of Qsource, a partner in the Qsource, convened the CRHIC for the first time. The Coalition now consists of about 120 members from 41 different organizations, representing a wide variety of healthcare providers like doctors, nurses, pharmacists, hospital administrators, home health caregivers, nursing home caregivers, paramedics and patient advocates.

The CRHIC enlisted CHI Memorial Hospital, and two others in the area, to work together to reduce 30-day hospital readmissions by testing a two-year model for improving care transitions for high-risk Medicare beneficiaries.

Sandra Loveless, CHI Memorial Hospital

“We set aside our competitive tendencies and agreed we would achieve more by focusing on the community we serve and the benefits of collaboration,” said Sandra Loveless, outpatient care manager at CHI Memorial Hospital.

The CRHIC’s project proposal was the only one selected in Tennessee. Their plan implemented health coaches who were trained in Dr. Eric Coleman’s Care Transitions Intervention.

Tommy Preston, SETAAAD

“We wanted to help provide better patient outcomes through an improved continuum of care, using a multi-disciplinary approach of Coalition members,” said Thomas Preston, assistant director of SETAAAD. “We believed it could be accomplished by providing the patient with the knowledge, tools and encouragement to manage their disease themselves, ultimately improving their quality of life.”

Health coaches visited their assigned patients while they were still in the hospital. Then, they would make at least one home visit within seven days of discharge. Coaches continued to follow-up with the patients with at least three weekly phone calls through the 30-day post-discharge period.

The two-year Medicare demonstration project allowed for more than 2,700 patients to receive health coaching in hospitals across the city.

“It demonstrated that care coordination communities can make a big impact on healthcare quality through convening stakeholders,” said Corley Roberts, quality improvement advisor for Qsource.


Overcoming Barriers

It was not easy to get several acute-care health systems in Chattanooga to work together across competitive boundaries and share readmission data, said Preston. But the baseline data was critical for the root-cause analysis required by the Medicare demonstration project.

“We emphasized that this was a community project and for it to be successful we would have to work together and trust each other,” said Preston. “The Alliance helped us strategize the most efficient ways to get the medical organizations to convene and work together as a coalition. Alliance team members provided valuable insight on the application process, as well.”

The CRHIC members organized a root-cause analysis workgroup comprised of staff from each of the acute care hospitals involved.  The workgroup decided that the Coalition would compile and analyze the data and remove any identifying information to relieve the anxiety about sharing data with competitors.

Later in the project, Medicare generated the reports and the hospitals were identified by name.

“After having worked together for several months, trust and a sense of community had been established within the membership of the Coalition,” said Preston. “We were able to alleviate the hospitals’ reservations about sharing data.”

Integrating the health coaches into the workflow and continuum of care model for each hospital also proved to be a challenge.

“We had to make sure coaches had what they needed to be successful – a computer, a workspace and access to patients’ medical records,” said Loveless. “At CHI Memorial, we installed new software to connect what the coaches were doing to other areas of outpatient work in the hospital.”

Although the same health coaching techniques were used with every patient in the project, each hospital had their own protocols for referrals to the program and reporting within their organization.

“The CRHIC worked with each hospital to chart the workflow that best met their particular needs to reach a mutually agreeable outcome,” said Preston.


Maintaining Gains

Although the two-year project ended in 2015, the CRHIC has been able to maintain the lowest hospital readmission rate in Tennessee among seven other care coordination communities.

“We were able to grow our outpatient care management team through the project and continue it through our clinically integrated network, the Mission Health Care Network, which now has over 800 providers working together, including health coaches,” said Loveless. “We learned that most of our high-risk patients needed a health coach to guide them after being discharged.”

Health coaches help extend and personalize the transition from hospital to home to decrease the chance that the patient has complications.

“The benefits of preventing and reducing hospital readmissions are undeniable,” said Roberts.

“Reducing readmissions decreases medical costs and possible penalties for the hospital, but most importantly it improves the medical outcomes and quality of life for the patients,” said Preston. “A health coach program reaches outside the hospital to engage the patient in their home environment. The continuum of care does not end at the exit door of the hospital.”

To learn more about how Care Coordination Communities across the Qsource five-state region are helping to reduce and prevent hospital readmissions, visit

How a Health Coach Prevents Hospital Readmissions

Health coaches create smooth transitions for patients from the hospital to their home and develop working solutions to barriers to prevent medication errors and relapses that often cause patients to go back into the hospital shortly after being discharged. Here’s an example story told by a health coach. (The patient’s name and identifying information has been changed.)

“Mr. Johnson lived alone and had a history of congestive heart failure and diabetes. He is legally blind and could not see to read his glucose meter. After a brief hospital stay for heart complications, Mr. Johnson couldn’t locate any discharge paperwork. He was confused about the medications he was supposed to take after leaving the hospital.

During a home visit, I found various medication bottles that were empty because Mr. Johnson could not read the labels to have the pharmacy refill them. I contacted his Care Transitions Liaison at the hospital to discuss how to we could get his medication refilled and how to get Mr. Johnson a talking glucose meter for the visually impaired.

I programmed the pharmacy number into Mr. Johnson’s cell phone so he could contact them for needed medication refills anytime. He identified a neighbor that would pick up his medications for him, so I prepared the neighbor to help read Mr. Johnson’s glucose meter results to him until he could get a new one. After discovering that a primary care follow-up appointment had not been scheduled, I scheduled one for him so the doctor could prescribe a talking glucose meter.

Working with Mr. Johnson, I made a color-coded chart to identify each of his medications. We also color-coded the prescription bottles and labeled them with large block letters so he was able to identify them easily.

I continued to check in on Mr. Johnson to ensure that his transition from the hospital back to his home was successful.”