A STEP in the Right Direction: An Interdisciplinary Approach to Transitional Care (2016)

Purpose: The Affordable Care Act, calls for more focus on finding innovative delivery systems that improve care, increase efficiency, and reduce costs. Background: Hospital readmissions, excessive falls, and poor quality of life are factors that unnecessarily increase healthcare costs. The Safe Transitions for the Elderly Patients (STEP) program is a hybrid transitional care model developed by the UNT Health Science Center (UNTHSC) as part of an 1115 Waiver to address these factors in a home care setting in Tarrant County. Objectives: The primary goals of STEP are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among Medicaid patients over 50 years through a collaborative and interdisciplinary approach to patient care. Methods: An interprofessional team that includes a physician/geriatrician, nurse practitioner, physician assistant, social workers, physical therapists and a dietician assess and treats the pateint in the home for up to 90 days post hospital discharge based on the individual patient needs. Conclusions: Through this model, UNT Health Science Center has the opportunity to demonstrate a unique transitional care model that will improve health care delivery post-hospitalization.