The STEP program has been designed to accentuate current transition care models and provide necessary services to assist high-risk elderly patients in order to achieve a successful transition from hospital to home.
Coordination of efficient, interdisciplinary transitional care is believed to be critical for reducing 30-day hospital readmissions, falls, and health care costs while increasing quality of life in patients.
The STEP transitional care team has developed evidence based protocols and communication strategies aimed at meeting or exceeding quality improvement goals for effective healthcare delivery and patient outcomes.
Because falls are often multifactorial in nature, the STEP team is prepared to decrease falls from an interdisciplinary approach. Our physical therapists have specialized training and expertise in fall risk assessment and intervention. The STEP physical therapists work closely with the rest of the team to address any medical or psychosocial factors that may be contributing to an individual’s fall risk.
An important goal of this transitional care program is to inspire our patients to make informed decisions about their health conditions outside the hospital. The STEP program empowers Medicaid eligible elders by training them to effectively navigate within an often complicated, confusing, and misunderstood health care system. Poor understanding and utilization of the healthcare system puts these individuals at risk for functional, emotional, and physical decline.
In addition to helping patients reconnect with their primary care physician after hospitalization, the STEP team directs patients toward community resources that will provide additional support in meeting their social, financial, spiritual, physical, medical, and other identified needs.
This page was last modified on November 30, -0001