Care Transitions - Stepping Stones Project

Addressing the high cost of Medicare hospital re-admissions

In early 2009  Qualis Health, a private, non-profit “Quality Improvement Organization,” initiated the three-year “Stepping Stones: Bridging Healthcare Gaps” project in Whatcom County.  Local project co-sponsors are St. Joseph  Hospital / PeaceHealth Whatcom Region, the Northwest Regional Council, and the Critical Junctures Institute.

One of only fourteen such projects in the United States, The Care Transitions Project of Whatcom County aims to eliminate unnecessary readmissions of Medicare beneficiaries to St. Joseph Hospital, while improving the overall quality of the Hospital’s discharge planning process.

Why is reducing readmissions of Medicare beneficiaries important?

A recent article in the New England Journal of Medicine found that approximately 20 percent of Medicare beneficiaries discharged from a hospital were rehospitalized within 30 days. The authors estimate rehospitalizations accounted for about $17.4 billion of the $102.6 billion in hospital payments from Medicare in 2004. In Whatcom County, the 30 day hospital re-admission rate for Medicare patients is 11 percent, nearly half of the national rate.

Many re-hospitalizations can be prevented. For example, the study documents an alarming lack of physician follow-up visits after discharge from a hospital. Indeed, about half of the patients who were rehospitalized within 30 days of being discharged had no bill for an outpatient physician visit between the time of discharge and rehospitalization. The lack of follow-up could contribute to unnecessary rehospitalizations.

To address factors contributing to potentially avoidable Medicare hospital re-admissions such as medication errors, and patient and caregiver misunderstandings about the likely course of their conditions, a major component of Stepping Stones is providing nurse coaching to patients prior to and during the four weeks following hospital discharge.

The primary role of a transition coach is to empower the patient and/or caregiver to take a more active role during healthcare transitions and to develop lasting self-management skills. The “care transitions coaching model” was developed by Dr. Eric Coleman at the University of Colorado Health Sciences Center.

Learn more about the Care Transitions Coaching Model.

View a video of  Care Transitions coaching.