Safe STEPS (Safe and Successful Transition of Elderly Patients Study) Intervention Program

Safe STEPS (Safe and Successful Transition of Elderly Patients Study) is a discharge intervention program designed to decrease the likelihood that patients over 65 years of age will return to the emergency department within 30 days of being discharged from a hospital.

Safe STEPS takes a multi-disciplinary approach by developing a care plan suited to the patient by integrating physical and occupational therapy, pharmacy, nutrition, case management, social work, and home nursing. Safe STEPS uses a team worksheet to collect input from all of the appropriate members working with the individual and includes five steps: an admission assessment, notification of the primary care physician, multidisciplinary coordination, a meeting of the physician and pharmacist, and a discharge meeting.

The goal of the program is to ensure effective discharge of patients from the hospital back to their homes, and to reduce 30-day hospital readmission.

The program evaluation involved more than 420 participants. Researchers found that one week after discharge, patients who had been exposed to the intervention were less likely to return to the emergency department or need readmission to the hospital (Odds Ratio (OR) = 0.25), more participants knew where to go for questions or concerns upon their return home (OR = 15.9), and more participants reported feeling better (OR = 2.33, 95%).

30 days after discharge, program participants were less likely to return to the emergency department (OR = 0.58), less likely to be readmitted to any hospital (OR = 0.55), and more participants reported feeling better (OR = 2.36).