Abstract Title

Minimizing 30-Day Hospital Readmissions and Falls and Improving Quality of Life through the Safe Transitions for the Elderly Patient (STEP) Program

Presenter Name

Leigh Johnson, John Allen, Ashlee Loewen, Ashley Martin, Valerie Johnson, Kathlene Camp, Ashlee Toale, Margarita Rice

Abstract

Background: The STEP Program will provide high quality transition of care services for discharged Medicaid eligible elders of Tarrant County that includes a transition of care coordinator and in home medical care team. The in home medical care team comprises a nurse practitioner, physical therapist, social worker and physician. The foundation of the STEP Program was developed by the University of North Texas Health Science Center (UNTHSC) as part of an 1115 Waiver grant proposal approved by CMS in 2012. The STEP Program was designed to improve the coordination and continuity of care for Medicaid eligible patients 65 years of age and older transitioning from the hospital to the home setting following discharge. The primary goals of the STEP program are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among the elderly. These goals were selected because these factors-unnecessary readmissions, excessive falls, and poor quality of life-are often the result of substandard medical coordination and management. Additionally, these factors unnecessarily increase healthcare costs. 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, decreasing falls, and improving Quality of Life. The NEXTGEN EMR will be 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 will be used to regularly evaluate and re-evaluate STEP Program practices to not only meet or exceed performance metrics, but to continuously improve performance. In addition, STEP team members have worked to finalize business agreements with hospital partners (which will serve as patient referral sources) and have begun to market to and partner with community resources that will help meet the social, spiritual, financial, physical, medical and other identified needs of the STEP Program’s target patient population. STEP Team members have met with more than 15 community resources and have hosted outreach events to provide an overview of the STEP Program. Expected Results: The STEP Program must demonstrate a 5% and 10% improvement in federal fiscal years 2015 and 2016, respectively, for reducing hospital readmissions, decreasing falls, and improving Quality of Life among the elderly. Baseline data will be gathered during federal fiscal year 2014. Conclusion: By meeting or exceeding performance metrics for reducing hospital readmission, decreasing falls, and improving Quality of Life, the STEP Program can contribute to improving the quality of and reducing the costs for care transition services.

Purpose (a):

The STEP Program was designed to improve the coordination and continuity of care for Medicaid eligible patients 65 years of age and older transitioning from the hospital to the home setting following discharge. The primary goals of the STEP program are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among the elderly.

Methods (b):

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, decreasing falls, and improving Quality of Life. The NEXTGEN EMR will be 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 will be used to regularly evaluate and re-evaluate STEP Program practices to not only meet or exceed performance metrics, but to continuously improve performance. In addition, STEP team members have worked to finalize business agreements with hospital partners (which will serve as patient referral sources) and have begun to market to and partner with community resources that will help meet the social, spiritual, financial, physical, medical and other identified needs of the STEP Program’s target patient population. STEP Team members have met with more than 15 community resources and have hosted outreach events to provide an overview of the STEP Program.

Results (c):

The STEP Program must demonstrate a 5% and 10% improvement in federal fiscal years 2015 and 2016, respectively, for reducing hospital readmissions, decreasing falls, and improving Quality of Life among the elderly. Baseline data will be gathered during federal fiscal year 2014.

Conclusions (d):

Care transition models are effective in providing a safer and more successful recovery for high risk elderly patients recently discharged from the hospital.

Coordination of efficient, interdisciplinary transitional care is believed to be critical for reducing 30-day hospital readmissions, falls, and healthcare costs and increasing quality of life in patients.

Data collected during the STEP program is expected to reflect a decrease fall and hospital readmission rates and improve quality of life outcomes.

This program will demonstrate a unique transitional care model that may improve health care delivery post-hospitalization.

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Minimizing 30-Day Hospital Readmissions and Falls and Improving Quality of Life through the Safe Transitions for the Elderly Patient (STEP) Program

Background: The STEP Program will provide high quality transition of care services for discharged Medicaid eligible elders of Tarrant County that includes a transition of care coordinator and in home medical care team. The in home medical care team comprises a nurse practitioner, physical therapist, social worker and physician. The foundation of the STEP Program was developed by the University of North Texas Health Science Center (UNTHSC) as part of an 1115 Waiver grant proposal approved by CMS in 2012. The STEP Program was designed to improve the coordination and continuity of care for Medicaid eligible patients 65 years of age and older transitioning from the hospital to the home setting following discharge. The primary goals of the STEP program are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among the elderly. These goals were selected because these factors-unnecessary readmissions, excessive falls, and poor quality of life-are often the result of substandard medical coordination and management. Additionally, these factors unnecessarily increase healthcare costs. 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, decreasing falls, and improving Quality of Life. The NEXTGEN EMR will be 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 will be used to regularly evaluate and re-evaluate STEP Program practices to not only meet or exceed performance metrics, but to continuously improve performance. In addition, STEP team members have worked to finalize business agreements with hospital partners (which will serve as patient referral sources) and have begun to market to and partner with community resources that will help meet the social, spiritual, financial, physical, medical and other identified needs of the STEP Program’s target patient population. STEP Team members have met with more than 15 community resources and have hosted outreach events to provide an overview of the STEP Program. Expected Results: The STEP Program must demonstrate a 5% and 10% improvement in federal fiscal years 2015 and 2016, respectively, for reducing hospital readmissions, decreasing falls, and improving Quality of Life among the elderly. Baseline data will be gathered during federal fiscal year 2014. Conclusion: By meeting or exceeding performance metrics for reducing hospital readmission, decreasing falls, and improving Quality of Life, the STEP Program can contribute to improving the quality of and reducing the costs for care transition services.