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New faith and community nursing program mixes health coaching with post-discharge care management
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Josh Brown
Senior Manager, Media Relations
Kathryn Moore

Kathryn Moore is among a group of nurses who provide post-discharge care coordination and wellness coaching to patients discharged from Emory Saint Joseph's Hospital. The new grant-funded initiative is part of the hospital's Faith Community Nursing program.

— Josh Brown

ATLANTA – Emory Saint Joseph's Hospital is launching a new nursing-led program that combines helping patients navigate post-discharge health needs with lifestyle coaching aimed at tackling some of the biggest risk factors for future hospitalizations.

Under the new initiative, nurses will work with patients discharged from the hospital for 12 weeks, guiding them through common obstacles after a hospital stay, such as ensuring medication adherence and having timely follow-ups with outpatient providers. In addition to that, the nurses will provide weekly lifestyle and health coaching, aiming to help the patient make progress on lifestyle behaviors that contribute to a patient’s overall health.

"In this program, our nurses will collaborate with patients to determine one lifestyle behavior that could be getting in the way of their overall health, such as smoking or blood glucose management, and then chart a course to make meaningful progress over those months," says Rebecca Heitkam, director of Emory Saint Joseph’s Congregational Health Ministries and Faith Community Nursing program.

The new initiative is part of the hospital’s larger Faith Community Nursing program, which began in 2017 and each year trains nurses on post-discharge transitional care management and how to, at the same time, connect with the patients on a spiritual level. The training also provides nurses with a foundation for how to engage with the community to expand awareness of healthy behaviors and provide educational programs that focus on preventive care and disease management. So far, more than 430 nurses from many faith traditions, cultural backgrounds and demographics have participated in the course.

The new program, which was launched through the help of a $60,000 grant from the Ida Alice Ryan Charitable Trust, takes the original program one step further – connecting nurses with specific patients one-on-one for 12 weeks following a discharge and adds the lifestyle coaching component.

"One of the unique aspects of this initiative is that rather than measure success only through a reduction in readmissions, we’re going to be taking into account overall outcomes for patients to demonstrate how focusing on attainable health goals can make a big difference in the lives of these patients," Heitkam says.

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