Harnessing community resources to decrease ates of hospital readmission

The Division of Family Health and Senior Services(Division), as the local Area Agency on Aging, convened a forum in March 2012 to discuss ways to decrease rates of hospital readmissions. The Division partnered with the local quality improvement organization, HealthInsights, and three area hospitals. The group formed a coalition, and adopted the program name Hospital 2 Home. The Division proposed to use local volunteers to function as coaches. The Division brought to the table a volunteer workforce of 300 workers. These volunteers have a long track record of participating in the local Meals-on-Wheels program The coach's role is to visit the patient in the hospital, in the home, and to provide three follow-up telephone calls. The Division developed marketing and advertizement, developed policies and procedures, and recruited the volunteers. HealthInsights provided the coaching training based on an evidence-based homevisitation model. The hospitals cleared the way, by using internal volunteer procedures, for the volunteers to meet the patient in the hospital for the initial visit. In February 2013, the first patient was visited in an area hospital. At the time of this writing, the results of these efforts are not known. The presentation, discussion, or poster session will discuss how to form partnerships with local hospitals, involve the local community in solving issue, and how to use a volunteer workforce.