About the Stepping Stones Project

Background

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.

Figure 1:
The project's key strategies were centered on the needs of the patient

Results

Working together, Qualis Health and the Whatcom County community made substantial progress across the project’s three goals:

• Connect providers throughout the healthcare system in Whatcom County to enable safe and effective transition of patients.
• Eliminate unnecessary hospital readmissions to St. Joseph Hospital.
• Enable Whatcom County patients and their families to participate fully in their health and healthcare, particularly when leaving the hospital.

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.

Figure 2:
Over the course of the project, the 30-day readmissions rate dropped

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.