Safe Transitions for the Elderly Patient (step)

Johnson L, Allen JG, Camp K, Johnson V, Loewen A, Toale A, Rice M, Martin A

1. Department of Internal Medicine, UNTHSC, Fort Worth, TX

Background: The STEP Program will provide high quality transition of care services for discharged

Medicaid eligible elders of Tarrant County that includes a transition of care coordinator and in home

medical care team. The in home medical care team comprises a nurse practitioner, physical therapist,

social worker and physician. The foundation of the STEP Program was developed by the University of

North Texas Health Science Center (UNTHSC) as part of an 1115 Waiver grant proposal approved by CMS

in 2012. The STEP Program was designed to improve the coordination and continuity of care for

Medicaid eligible patients 65 years of age and older transitioning from the hospital to the home setting

following discharge. The primary goals of the STEP program are to reduce all-cause 30 day hospital

readmissions, improve quality of life, and decrease falls among the elderly. These goals were selected

because these factors-unnecessary readmissions, excessive falls, and poor quality of life-are often the

result of substandard medical coordination and management. Additionally, these factors unnecessarily

increase healthcare costs.

Methods: The STEP Program will provide care transition services for 750 patients from October 1, 2013,

to September 30, 2016, via referrals received from local hospital partners. STEP faculty and staff have

developed evidence based protocols and communication strategies aimed at meeting or exceeding

performance metrics for reducing hospital readmission, decreasing falls, and improving Quality of Life.

The NEXTGEN EMR will be the primary means for gathering data for these metrics and assessing the

impact of the evidence based protocols and communication strategies. Plan-Do-Study-Act methodology

will be used to regularly evaluate and re-evaluate STEP Program practices to not only meet or exceed

performance metrics, but to continuously improve performance. In addition, STEP team members have

worked to finalize business agreements with hospital partners (which will serve as patient referral

sources) and have begun to market to and partner with community resources that will help meet the

social, spiritual, financial, physical, medical and other identified needs of the STEP Program’s target

patient population. STEP Team members have met with more than 15 community resources and have

hosted outreach events to provide an overview of the STEP Program.

Expected Results: The STEP Program must demonstrate a 5% and 10% improvement in federal fiscal

years 2015 and 2016, respectively, for reducing hospital readmissions, decreasing falls, and improving

Quality of Life among the elderly. Baseline data will be gathered during federal fiscal year 2014.

Conclusion: By meeting or exceeding performance metrics for reducing hospital readmission, decreasing