Stepping Stones: Bridging Healthcare Gaps (The Care Transitions Project of Whatcom County) aimed to engage the community and activate patients and healthcare providers to eliminate unnecessary readmissions to PeaceHealth St. Joseph Medical Center.
Studies across the country have demonstrated that there are potential gaps in communication and coordination when patients move from one setting or aspect of care to another resulting in patient risk and increased costs. The aim of this project was to bridge those gaps and enable safer and more effective transitions.
The Centers for Medicare & Medicaid Services (CMS) contracted with Qualis Health to engage community partners including healthcare providers, patients, and families, in the project August, 2008 through July, 2011. The Stepping Stones Project was one of only 14 such Medicare demonstration projects across the US.
To guide the work, Qualis Health engaged with the Whatcom County community to form a Steering Committee comprising the target hospital, community providers, stakeholders, and patient representatives. The Steering Committee endorsed a framework to achieve sustainable progress across five strategic areas centered on the needs of the patient, as shown in Figure 1.
Working together, Qualis Health and the Whatcom County community made substantial progress across the project’s three goals:
As shown in Figure 2, a key result was a reduction in the community's hosptial readmissions (8.1% relative improvement) over a two-year period.
Read about some of the successes we had in lowering readmission rates, reducing Medicare/Medicaid expenditures, empowering patients to better manage their health, and facilitating communication between providers and patients. A complete report about the project is now available for download.
For an overview of Qualis Health's work with the Stepping Stones project during 2008-2011, see our Final Report to the Community.
The Stepping Stones project was examined in a 2013 issue of the Journal of the American Medical Association (JAMA) as part of an article focusing on QIO-led care transitions initiatives nationwide.
Selena Bolotin, LICSW
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800-949-7536, ext. 2472
Executive Director, Strategic Communications
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800-949-7536, ext. 2458