Department of Medicine

Care Transitions


Initiative Overview


Faculty Lead: Kathryn Agarwal, M.D.
Faculty Member: Mahveen Sohail, M.D.

Challenges: Transitions between one care setting and another, such as the transition from the hospital back home, are critical periods that impact function and mobility of older adults.

Unmet clinical need: Care transitions, a period of increased vulnerability for older adults, are especially high-risk in Houston and surrounding areas given high underinsurance and poor access to primary care. Lack of an identified primary care provider and the absence of timely intervention can lead to functional decline, mobility impairment, and other harms, prompting ED visits and avoidable hospital readmissions, which can result in greater functional decline.

Unmet education and training need: Primary care providers and interprofessional trainees have little education on falls, function screening, and recovery after care transitions.

Initiative vision: Through our partnerships, SETx-GWEP will intervene on three levels. On the population level, data from Baylor St. Luke’s Primary Care Network (BSLPCN) will be used to identify primary care providers for older adults ensuring timely post discharge follow-up. Patients without a primary care provider will receive community-based follow-up with Harris Health House Calls Program. Interprofessional trainees rotating with the house calls team will receive educational regarding successful care transitions. On an individual level, BSLPCN providers will receive training on screening for falls to document individual fall risks in patient medical records.



  • HHS House Calls Program
  • Baylor St. Luke’s Primary Care Network
  • Baylor College of Medicine