INDIANAPOLIS (WISH) — More than 34 million people will be admitted into a hospital this year throughout the United States. Although the average stay is five days, that’s just the beginning of the recovery process. The NIH reports that 15% of discharged elderly patients end up back at the hospital.

A Harvard study found half of all patients who were discharged had medication errors when they went home. That’s just one of the major hurdles patients face. Now, one hospital is hoping to change that by creating healthcare coaches to guide patients who are recovering at home.

Fly fishing has been a part of Tom Brown’s life for his entire life.

“The charm of fly fishing is that it is the pursuit of what is elusive but attainable,” said Brown.

But this year’s annual fishing trip almost didn’t happen.

“I was experiencing some dizziness and some lightheadedness,” explained Brown.

He needed immediate bypass surgery and was in the hospital for nine days.

“The most frustrating thing is that once the patients go home from the hospital, the same lifestyle behavior that could have contributed to or actually caused the chronic health condition is the same thing that they go back to,” said Rebecca Heitkam, RN, special director of congregational health ministry/nursing support at Emory Saint Joseph’s Hospital.

That’s why she is leading a new nursing program at Emory Saint Joseph’s Hospital.

“We are trying to combine our nursing experience and expertise with health coaching,” explained Heitkam.

Specially trained nurses connect one-on-one with discharged patients for 12 weeks, making sure they are taking their meds, going to all follow-up medical appointments, and providing weekly lifestyle and health coaching.

“If they would just take one small step this week, and we can help walk them through this week until they have a success,” said Heitkam.

She says re-admission rates decreased upwards of 50% so far and ER visits decreased by 60%.

“You’re constantly accountable to each other. You are calling that person, they’re calling you,” explained Kathryn Moore, MA RN, ethics nurse liaison at Emory Healthcare System.

Moore is Brown’s nurse liaison.

“He was not happy about the limitations. No cardiac patient is,” she said.

“I feel like they, that Kathryn was responsive, you know, and she knew to lean this way or push over in this direction,” Brown said.

With consistent contact, Moore was able to learn what was important to Brown, specifically, his annual fishing trip.

The new initiative is part of a larger program that began in 2017, where each year nurses are trained on post-discharge transitional care management. So far, more than 430 nurses have participated in the course.

This story was created from a script aired on WISH-TV. Health Spotlight is presented by Community Health Network.