An Emergency Department-To-Home Intervention to Improve Quality of Life and Reduce Hospital Use

The Area Agency on Aging coach's role is to build self-management capabilities for the patient and their caregiver. During each contact, the coach reviews the four components of the Care Transition Intervention: 1: Follow-up Medical Visit. 2: Knowledge of Red Flag Symptoms. 3: Medication Reconciliation. 4: The Personal Health Record (PHR). The coach assists patients use the PHR to document and maintain vital information and to communicate with providers.

Patients randomized to usual care will receive verbal and written discharge instructions from the treating ED physician and nurse as is the standard of care.