Evaluation of a nurse practitioner-led transitional care program: The effects on 30-day Medicare readmission rates and patient satisfaction scores.

Abstract

Data suggest that nurse practitioner (NP)-led transitional care models can reduce 30-day readmission rates. It remains unclear if transitional care has any impact on Press Ganey's Hospital Consumer Assessment of Health Provider and Systems (HCAHPS) patient satisfaction scores. A transitional care encounter program (TCEP) was designed and implemented by an NP at an internal medicine private practice in response to an increase in Medicare 30-day readmission rates and lower HCAHPS results. A program evaluation was carried out to determine any impact on 30-day readmissions and HCAHPS. The evaluator used CDC's Framework for Program Evaluation in Public Health for program evaluation. Quantitative retrospective data collection of Medicare 30-day readmission rates was obtained and compared preimplementation/postimplementation. HCAHPS results were collected from the data analytics department at Methodist Health System and compared preimplementation/postimplementation. All Medicare patients followed by the private practice discharged from hospital to home had a TCEP visit within 7 days of discharge. The NP extensively reviewed the hospital records, medication reconciliation, education about current medications, diagnoses, and treatment plan with the patient. Readmission rates and HCAHPS are tracked by physician name at discharge. The TCEP resulted in a 2.1% reduction in Medicare 30-day readmission rate. Physician A pre-/post-HCAHPS score was 74% increased to 81.3%. Physician B pre-/post-HCAHPS score was 75.8% increased to 78.6%. The TCEP model became an integral part of the clinic's daily operations. Transitional care has potential for decreasing Medicare 30-day readmission rate and improving HCAHPS.