The Importance of a Dedicated Care Coach in the Continuity of Care 

What is Impacting Continuity of Care? 

Maximizing the continuity of care is critical in reducing hospitalizations, managing chronic disease, improving patient outcomes, and ultimately, improving financial outcomes. Although a well-understood standard of practice in healthcare, providers face difficulties in successful implementation. Nursing shortages and availability of timely appointments with health care providers, due to increased patient loads and fewer physicians, have led to a negative impact on a patient’s continuity of care, therefore affecting outcomes.  

A recent study was conducted by NYU Rory Meyers School of Nursing centering around patients receiving home healthcare after hospitalization. The study was comprised of 22,103 home healthcare patients and focused on the barriers of language and the continuity of care provided by the same medical provider who spoke the same language, for every home visit. The study revealed that having the same nurse across home healthcare visits, who also spoke the same language as the patient, had the best chance of reduced hospital readmission, but the study also revealed another fact: Having the same nurse across visits, even if they did not speak the same language as the patient, was also linked to lower hospital readmission rates.  

The study conducted by NYU highlights factors already understood by health care providers: Employing the same medical professional on every patient visit, monitoring the patient between office visits, assisting with referral coordination, and assessing social barriers, has a positive impact on the health of the patient. The challenge for the provider is being able to quickly implement an effective solution for continuity of care while facing industry challenges. 

Continuity of Care Can be Achieved 

Tools have been developed to help providers address some of the challenges in healthcare and improve the continuity of care. Since the pandemic, telehealth and remote patient monitoring (RPM) have become a standard of care, even being reimbursed by Medicare and many insurance companies. Many studies have been conducted showing the effectiveness of these tools in managing chronic conditions and reducing readmission rates, and although validating the principle of continuity of care, many studies have not focused on the impact of a consistent medical professional to care for the patient. 

“The study conducted by NYU Rory Meyers School of Nursing contributes important information to accompany the many RPM and telehealth studies now revealing the continuity of care and outcomes,” states Irina Koyfman, DNP, NP-C, RN, Chief Population Health Officer, RPM Healthcare. “Having a consistent medical professional assigned to a patient, in addition to remote patient monitoring services, can assist the health care provider in managing the patient’s health, especially patients with chronic conditions, improve the patient’s outcome, and increase the provider’s revenue stream. A consistent medical professional fosters a relationship in which trust is built leading to discovery and strengthening the continuity of care.” 

Continuity of care is at the core of RPM Healthcare. Assigning patients to a specific nurse (care coach) based on their condition and language preference has shown noticeable improvements in outcomes within the RPM Healthcare patient base. “This standard of practice gives the patient a sense of comfort and peace knowing they have someone, in addition to their health care provider showing them care and compassion,” explains Koyfman. “The trust the patient develops by having a consistent nurse leads to more open dialogue. Patients are more likely to take readings and be open to receiving education. In addition, the nurse becomes knowledgeable of additional factors that may be affecting the patient’s health and strives to work with the patient’s health care provider to resolve these challenges, improving the patient’s overall quality of life and reducing the likelihood of a hospital admission or readmission.” 

Patients and providers in the RPM Healthcare program benefit from a designated nurse, and for the most part, do not experience the effects of the nursing shortage. RPM Healthcare has less than 10% turnover. “Our patients get to know their care coach and the likelihood of the patient having to be reassigned is very low,” states Koyfman. “It was important to design a model of dedication and continuity allowing the relationship to continue to grow and benefit both the patient, the provider, and the nurse care coach.” 

In an age of nursing shortages and in the shadow of the “great resignation,” it is important for organizations to genuinely show employees their efforts are valued, and their time is important. Remote jobs became prevalent during and after the pandemic, and many companies and their employees saw the benefit. “Before the pandemic, remote working within the nursing profession, except in the management of chronic diseases and care coordination, was not common,” states Koyfman. “Remote patient monitoring services and telehealth opened that door for nurses, giving them additional opportunities and improving their work-life balance proving a benefit to patients and providers as well.” 

When the nurses feel balanced and valued, the result is minimal turnover, improved patient outcomes, and patient and provider satisfaction. “RPM Healthcare, due to the efforts of our nurses, has a 98 percent patient satisfaction rate with many compliments to accompany those ratings,” states Koyfman. “Remote patient monitoring and consistent care given by a consistent healthcare professional results in continuity of care, improved outcomes, increased revenue, and reduced healthcare costs and associated frustrations.” 

RPM Healthcare offers remote patient monitoring and care coaching services for those with chronic health conditions. The RPM365 platform and care coaches work with health care providers for consistent medical management between provider visits, provide necessary information to adapt or create care plans, and help to increase revenue streams. RPM Healthcare care coaches and apps encourage patients to take necessary readings, offer support and education, and help patients live a more active life. Visit for more information and provide your patients with access to free health webinars. 

All health content is reviewed by Irina Koyfman, DNP, NP-C, RN, Chief Population Health Officer, RPM Healthcare. 

Contact us today to learn how we can help provide better care for your patients and generate more revenue for your practice.

RPM Healthcare Highlighted in NJBIZ

Great to see our comprehensive remote patient monitoring program, including our amazing RPM Care Coaches, highlighted by our partners at Englewood Health,


RPM Healthcare Highlighted in NJBIZ

Great to see our comprehensive remote patient monitoring program, including our amazing RPM Care Coaches, highlighted by our partners at Englewood Health,

woman taking glucose reading at home rpm

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