Abstract
To avoid penalty through the Hospital Readmission Reduction Program, an academic practice partnership, Health Transitions Alliance, was formed with the local university, resulting in adoption of an innovative transitional care model. Key to the model was a health coach who operationalized transition care to the home setting. Health coaches, interns in their last semester of college, used motivational interviewing to help patients set disease management goals. As a result of this model, the readmission rate for program participants in the initial 7 months was reduced by 72%.