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

Background: 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.

Local problem: 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.

Methods: 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.

Interventions: 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.

Results: 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%.

Conclusion: 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.