A STEP in the Right Direction: An Interdisciplinary Transitional Care Approach to Preventing Hospital Readmissions (2015)




Loewen, Ashlee
Knebl, Janice
Yarabinec, Ashley
Camp, Kathlene E.
Johnson, Valerie
Stafford, Ashley
Allen, John G.
Shoukry, Emad
Wagner, Teresa
Greenlee, Quante


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Purpose: The Affordable Care Act, calls for more focus on finding “innovative delivery systems that improve care, increase efficiency, and reduce costs” (Centers for Medicare and Medicaid Services, n.d., para. 4). The Safe Transitions for the Elderly Patients (STEP) program is a hybrid transitional care model developed to reduce readmission rates for Medicaid patients over 50 years of age in Tarrant County. Background: The STEP Program provides high quality transition of care services for discharged Medicaid elders of Tarrant County. A medical director, nurse practitioner, physician assistant, physical therapies, social workers, pharmacist, and nutritionist make up the in home care team. The foundation of the STEP Program was developed by the University of North Texas Health Science Center (UNTHSC) as part of an 1115 Waiver approved by CMS in 2012. The STEP Program is designed to improve the coordination and continuity of care for Medicaid patients 50 years of age and older transitioning from the hospital to the home setting following discharge. The primary goal of the STEP program is to identify discrepancies in transitional care and find solutions toward reducing all-cause 30-day hospital readmissions. Through the CMS 1115 waiver guidelines, we are also tracking patient BMI, smoking status, and pneumococcal vaccine status. Methods: The STEP Program will provide care transition services for 750 patients from October 1, 2013, to September 30, 2016, via referrals received from local hospital partners. STEP faculty and staff have developed evidence-based protocols and communication strategies aimed at meeting or exceeding performance metrics for reducing hospital readmission. The NextGen EMR is the primary means for gathering data for these metrics and assessing the impact of the evidence based protocols and communication strategies. Plan-Do-Study-Act methodology is used to regularly to evaluate and re-evaluate STEP Program practices to meet and exceed performance metrics, while improving overall performance. Current Results: The current 30-day readmission rate for patients enrolled in the STEP program is 9%, which is a significant improvement from the recent national readmission rate at 18.5% and Texas at 18.4% for Medicare specific beneficiaries (CMS, 2012). Conclusion: By reducing hospital readmission, the STEP Program can contribute to improving the quality of transitional care services as a sustainable practice model. This example of transitional care services can serve as a model to help reduce hospital expenditures, decrease hospital penalization for readmissions, and help provide quality outpatient management and coordinated care for this vulnerable patient population. Centers for Medicare and Medicaid Services. (n.d.). Section 1115 demonstrations. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/Section-1115-Demonstrations.html Centers for Medicare and Medicaid Services. (2012). National Medicare readmission findings: Recent data and trends. Retrieved from http://www.academyhealth.org/files/2012/sunday/brennan.pdf