Sentara Martha Jefferson Hospital recently launched a new pilot program aimed at reducing preventable readmissions. 

“Every time a senior is admitted to the hospital there are downsides to that,” said Jessica Cooper, BSN, RN, OCN, Senior Services Program Coordinator at Sentara Martha Jefferson.   “The get deconditioned, they get set back in their progress and they are more susceptible to more infections.” 

The program is evidence-based and includes a visit from a health coach while in the hospital, as well as once patients go home. 

“When I go see a patient in the hospital, I explain what the program is, that I’ll be visiting them in their home, and also give them the opportunity to say no, this is not what they want at that time,” said Amy Leider, Health Coach.  

If a patient does decide to participate, a personal health record is discussed at the home visit, and that’s when the coaching really begins. 

“We’re talking with them about all their health conditions, not just what put them in the hospital, but any that they may have,” said Leider.  “We discuss how they know that that condition is acting up, what their warning signs are, and how to make a plan for what to do.” 

The overall goal is to help patients understand, in many cases, they have alternatives to the hospital, and empower them to play a role in their healthcare. 

“Making the patients advocate for themselves really puts them in charge of their own care and tells them the right avenues to take instead of coming back into the hospital,” said Cooper.  

For more information on this topic, please call 1-800-SENTARA. If you have a question about your health you’d like us to answer, email