Safe Transitions For Elderly Patients (STEP)

Discharge Planning and Care Coordination for Medicaid-Eligible Elders (STEP) – Janice Knebl, DO, MBA

This project is implementing an enhanced transition of care program for discharged Medicaid-eligible elders of Tarrant County that includes a transition of care coordinator and in home medical care team (consisting of a Physician, NP/PA, PT, MSW/LSW, MA). The team facilitates an enhanced discharge plan, coordinates care, and provides evaluation and treatment. This model provides for collaboration between clinical and administrative representatives from a number of healthcare providers including local hospitals and utilizes support services from various community organizations.

Targeted patient population:

  • Medicaid and low-income, uninsured patients, 50 and above
  • Patients discharged from 7 community partner hospitals (JPS Health Network, Texas Heath Harris Methodist Hospital Fort Worth, Baylor All Saints Medical Center at Fort Worth, Methodist Mansfield Medical Center, PLAZA Medical Center of Fort Worth, Texas Health Huguley, and Texas Health Southwest)
  • Patients are seen in the community and patients’ homes through the utilization of mobile teams



This page was last modified on May 11, 2016