Transition Health Coach Essential for Continued Care
Hospitalization is a distressing time for patients with chronic conditions. Once their health has stabilized, they are more than relieved to get discharged and move to the familiar comfort of their own home.
However, an unanticipated struggle ensues once they are back home. The patients have to strictly follow the doctor’s instructions on medication and treatment. They also have to monitor their health and watch for any signs of relapse or decline.

Unfortunately, many chronic condition patients either do not understand the instructions or otherwise fail to comply with the required care. The rate of readmissions is perplexingly high and the regrettable news is that most of them could have been avoided.
This is why the role of a transitional health coach is gaining prominence. This healthcare individual is charged with guiding and assisting patients in transitioning from the hospital to their home.
What does a transition coach do?
There are many factors that come into play when a patient with diabetes, congestive heart failure, obstructive pulmonary disease or other chronic condition moves from the hospital to his or her own home. The patients are generally required to take the prescribed medications at set times of the day and keep a watchout for warning signs of any deterioration in their health. The physician will advise them on the likely red flags and may even require them to maintain a record of the day-to-day health. Some follow-up consultations with a health care specialist may also be in order.
However, the patients most often leave the hospital without a clear understanding of what all they are supposed to do. Some may not even be aware of how to test their blood sugar on a glucometer, let alone how to interpret the readings in relation to their eating and exercising habits.
It is at this crucial conjunction that a transitional health coach comes into the picture. In fact, he or she will start interacting with the patients prior to the discharge itself so as to prep them for their self-care. This is followed by in-person visits to the patients’ home and slowly moves to periodic phone calls till the patients are completely empowered to take care of themselves.
The underlying focus of the initial meeting is to establish a personal rapport with the patient and delve into his or her health goals. Through every subsequent interaction, the transitional health coach promotes self-care in the patient by linking the necessary treatment with the goals. The coach will guide the patient on everything from when and how to take the medications to making them aware of the early warning signs that can escalate into major health issues later. The patient also gains the skills to deal with any emergencies through practice and role-playing.
Apart from promoting healthy behavior in the patient, the transitional health coach also strives to provide emotional support to help the patient cope with the chronic illness.
In sum, a transitional health coach has emerged as a key link between the physician and the patient. The coach ensures continuity of treatment and good health even after the patient has left the hospital!
