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Rural Health Information Hub

Health Coaches for Care Transition

  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.


Promising (About evidence-level criteria)


The Health Coach Project of Oconee Memorial Hospital in South Carolina was developed to help reduce hospital readmissions. The target population was patients over the age of 65 with diabetes, congestive heart failure, or other heart disease who were recently discharged to home health. The program recruited and trained community members to act as Health Coaches (HCs). The HCs mentored discharged patients with the goals of reducing hospital readmissions and helping patients move from home health care to self-care.

The project ran from 2006-2010 with funding from a Federal Office of Rural Health Policy Rural Health Care Services Outreach Grant. Dr. Cheryl Dye was the Principle Investigator on this project, with co-investigator Dr. Deborah Willoughby and investigator/research assistant Dr. Begum Aybar-Damali.

Dr. Dye has continued to develop the Health Coach approach. Learn about the Health Coaches for Hypertension Control program.

Services offered

The Oconee Memorial Hospital project trained 43 lay health educators as Health Coaches. The HCs were trained in:

  • Role of the health coach
  • Safety and fall prevention
  • Communication skills
  • Psychosocial and physical aspects of aging
  • Heart and circulation
  • Stroke and congestive heart failure
  • Diabetes
  • Pneumonia and flu
  • Medications
  • Health behaviors (nutrition, physical activity, tobacco)
  • Changing and maintaining health behaviors
  • Human subjects protection
  • Community resources

The HCs provided a variety of services to reduce hospital readmissions, including:

  • Mentoring patients in chronic disease self-management
  • Assisting patients in accessing community resources
  • Discussing fall prevention strategies with patients
  • Conducting safety checks of the patient's home
  • Facilitating home modification as needed for safety

The HCs visited the patients:

  • Month 1: 2 one-hour home visits, 3 phone calls weekly
  • Month 2: 1 one-hour home visit, 4 phone calls weekly
  • Month 3: 4 phone calls weekly
  • Month 4: 3 phone calls weekly


A total of 62 patients were served by the initial project. Hospital leaders and staff were pleased with the results of the project and indicated that they would like to it to continue. HRSA's Office of Performance Review staff deemed the program a "promising practice." Participants in the Health Coach program demonstrated abilities to:

  • Monitor and track their chronic health conditions of diabetes, heart failure, or cardiovascular disease
  • Make lifestyle changes related to these conditions
  • Reduce fall risk factors
  • Access assistance from healthcare and community agencies

Compared to similar group of patients with the same diagnoses, ages and gender, the Health Coach patient group had:

  • Fewer readmissions related to their chronic condition
    • Out of the 33 program participants for whom there is complete data, 19 had no emergent care (57.6%) as compared to 17 of the 38 comparison group (44.7%).
  • Fewer new admissions for falls, pneumonia, and flu
    • HC clients had no admissions for falls and only 1 for pneumonia for total costs of $1,063 during the project period.
    • In the comparison group, there were 4 admissions for pneumonia and 1 for flu for total costs of $151,290, with 4 admissions related to falls for a total cost of $15,851.
  • When they did have a readmission, it was less costly than for the comparison patient group
    • Of those 14 program participants who did receive emergent care for their original chronic condition, the average cost was $11,161 as compared to the average cost of the 21 members of the comparison group which was $22,584.

The program not only served patients, but also assisted in developing insight and deeper understanding of the health care needs of rural elderly residents of upstate South Carolina. The Health Coaches themselves, most of whom were retired, reported that they experienced positive impacts such as role satisfaction and fulfillment of their desire to help others in a meaningful way.

For more information about the initial Health Coach project's impact:


Communities wishing to replicate this program may consider the following:

  • A clear and concise referral protocol was important for RNs referring patients to the program
  • An interdisciplinary group willing to work together, including RNs, hospital administrators and staff, health coaches, and clients made this program successful
  • A sustainability plan is highly recommended in order to continue program activities after the grant

Contact Information

Dr. Cheryl Dye, Principal Investigator
Clemson University

Aging and aging-related services
Cardiovascular disease
Chronic disease management
Community health workers
Elderly population
Home health

States served
South Carolina

Date added
January 22, 2007

Date updated or reviewed
December 9, 2019

Suggested citation: Rural Health Information Hub, 2019. Health Coaches for Care Transition [online]. Rural Health Information Hub. Available at: [Accessed 27 November 2022]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.