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Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an AAA in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Review the AHRQ study that gave the program a moderate evidence rating for improving outcomes, decreasing cost of care.
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Short URL: http://www.advancingstates.org/node/65596