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Service Delivery Innovation Profile

Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths


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Snapshot

Summary

As part of its Enhanced Discharge Planning Program, Rush University Medical Center helps at-risk older adults transition back to their homes after hospital discharge. Hospital-based social workers call eligible patients or their caregivers within 48 hours to reinforce the discharge plan of care and to address anticipated and unanticipated needs by connecting patients to health and community-based services and providing other forms of support. The program enhanced patients' and caregivers' knowledge and ability to manage at home, improved attendance at followup appointments, and reduced readmissions and deaths.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial involving 740 patients (split roughly evenly between participants and a control group) that compared readmissions, deaths, and attendance at followup appointments over a 15-month period; additional evidence comes from a survey measuring knowledge about medications and quality of life at home, administered before and after participation in the program.
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Developing Organizations

Rush University Medical Center
Chicago, ILend do

Use By Other Organizations

Program leaders have worked with the Illinois Transitional Care Consortium (a statewide collaboration) to set up similar programs at four other Illinois hospitals: Adventist La Grange Memorial Hospital, Memorial Hospital of Carbondale, Herrin Hospital, and MacNeal Hospital. They also have consulted with officials implementing similar programs at hospitals in Pennsylvania, California, and Utah.

Date First Implemented

2007
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Patient Population

The program serves adults age 65 and older, with the average age being 75.Vulnerable Populations > Frail elderlyend pp

Problem Addressed

Older adults discharged from the hospital often have difficulty making the transition home, due in part to difficulties adjusting to new (often unpredictable) circumstances created by their recent health issues and hospital stay. Common problems include difficulties following medical instructions and obtaining needed services. As a result, these patients face increased risk of complications, costly readmissions, and death.
  • Difficulties transitioning home: Recently discharged older adult patients often face challenges managing their health after returning home, with many of these challenges being difficult or impossible to identify during routine discharge planning activities. Challenges include taking medications appropriately, understanding complex discharge instructions, finding transportation to followup appointments, dealing with paperwork and financial issues, and coordinating care among professional and family caregivers. One study found that half of older patients who were readmitted to the hospital within 30 days of a previous discharge had not seen a physician between the time of the initial discharge and the readmission.1
  • Increased risk of costly readmissions and death: Almost 20 percent of Medicare beneficiaries end up being readmitted to the hospital within 30 days of discharge, and 34 percent get readmitted within 90 days. Two-thirds of patients discharged with medical conditions and just over half (52 percent) of those discharged after surgical procedures are readmitted or die within a year of the initial discharge.1 The average readmission for an older adult costs $7,400.2

What They Did

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Description of the Innovative Activity

Rush University Medical Center helps high-risk older adults transition from the hospital back to their homes. Hospital-based social workers call eligible patients or their caregivers within 48 hours of discharge to reinforce the discharge plan of care and to address both anticipated and unanticipated needs by connecting patients to health and community-based services. Key program elements are detailed below:
  • Identification of high-risk patients: Patients qualify based on established criteria designed to identify patients most likely to need and benefit from the program. This information can generally be found in the patient's electronic medical record.
    • Standard criteria: To qualify, patients must be age 65 or older, speak English (due to absence of non-English speaking clinicians), be returning to their homes after discharge, take 7 or more prescription medications, and not have received a transplant during their hospital stay. (Transplant patients receive more intensive discharge care and support from other hospital staff.)
      • Additional criteria: In addition, patients must meet at least one of the following eight criteria:
        • Live alone
        • No source of emotional support
        • No support system in place
        • Discharged with a service referral
        • Be at high risk of falling
        • Have had an inpatient stay within the past year
        • Have a severe psychosocial need
        • Have a prescription for a high-risk medication
    • Preassessment during inpatient stay: A social worker reviews the medical charts of eligible patients to gather relevant clinical and psychosocial information and to identify potential barriers to a successful transition. The social worker also generates a list of questions about potential problem areas, such as how the patient will get to doctor's appointments, who will provide in-home support, and whether the patient is likely to take his or her medications appropriately. As part of this process, the social worker speaks with providers who have cared for the patient in the hospital. There is no direct contact with the patient or his/her caregiver.
    • Postdischarge assessment by phone: The social worker calls the patient within two working days of discharge to conduct an assessment. (If the patient cannot communicate, the social worker contacts the patient's caregiver.) The social worker first attempts to establish a rapport with the patient or caregiver, and then verifies their understanding and ability to adhere to the discharge recommendations and determines if that patient is receiving appropriate health and community-based services. In more than 80 percent of cases, the social worker identifies problems to be addressed, with about three-fourths of these problems not becoming apparent until after discharge. The three most common problems are difficulty coping with change, caregiver stress, and problems managing medical care (including medications). Other common issues include difficulties in the provision of home health, trouble obtaining community services, communication breakdowns between providers, trouble managing a new treatment or diagnosis, and difficulty understanding the discharge plan.
    • Interventions to address identified needs: The social worker contacts relevant health care and community-based providers to resolve immediate issues, and establishes a plan to address other ongoing needs. The most common interventions involve linking patients to hospital services, providing emotional support, and coaching patients on their rights and responsibilities. Other common interventions include providing information and resources related to identified problems, facilitating communication between the patient and service providers, communicating with and supporting the caregiver, and helping with decision making. Support continues until all issues identified during the assessment have been addressed. Typically, the social worker intervenes for an average of six days, during which he or she will have five or six additional contacts to coordinate care. In some cases the social worker maintains contact with the patient or caregiver for a month or longer. Patients are encouraged to call the social worker if they have problems or questions after the case has been considered closed, and about one-third do so.
    • Collaboration to resolve tough problems: The three social workers involved in the program talk daily and meet once a week to review cases and share ideas for resolving especially difficult problems. Input from other disciplines is obtained as needed.

    Context of the Innovation

    Rush University Medical Center is a 700-bed tertiary care hospital and academic medical center near downtown Chicago. The impetus for the Enhanced Discharge Planning Program came from a growing awareness among hospital leaders that a significant percentage of older patients were readmitted to the hospital within weeks of their initial discharge, with many of these readmissions resulting from unforeseen problems that arose at home. Additionally, there was concern that shorter lengths of stay were resulting in older adults leaving the hospital more vulnerable to adverse events, including readmissions. Additional impetus for the program came from The Joint Commission, which tracks readmission rates among older adult patients as a core measure, and alignment with the hospital's core values, including emphasis on innovation and collaboration. In 2006, the hospital hired a full-time clinical social worker to expand older adult-related programs and services within the medical center.

    Did It Work?

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    Results

    The program enhanced patients' and caregivers' knowledge and ability to manage at home, improved attendance at followup appointments, and reduced deaths and readmissions.
    • Enhanced knowledge and ability to manage at home: Surveys show that the program enhanced patients' understanding of the purpose of their medications (from 88.5 percent at baseline to 94.9 percent after completing the program) and reduced stress related to managing health care needs for both patients (from 36.8 to 30.9 percent) and caregivers (from 44.9 to 35.4 percent). The Care Transitions Measure-3 instrument was used to measure medication knowledge, and patient and caregiver stress data were based on patient self-ratings using a 5-point Likert scale.
    • Better attendance at followup appointments: Approximately 75 percent of participants scheduled and attended their first followup appointment, compared with 57 percent of nonparticipants.
    • Fewer deaths and readmissions: Only 2.2 percent of participants died within 30 days of discharge, well below the 5.3 percent that died in a group of similar patients who did not participate. Readmission rates among participants were also lower, with 13.6 percent of participants being readmitted within 30 days of discharge, compared with 16.1 percent of nonparticipants. Similar differences existed for readmissions within 90 days (26.4 vs. 34.2 percent) and 180 days (36.1 vs. 42.5 percent).

    Evidence Rating (What is this?)

    Strong: The evidence consists of a randomized controlled trial involving 740 patients (split roughly evenly between participants and a control group) that compared readmissions, deaths, and attendance at followup appointments over a 15-month period; additional evidence comes from a survey measuring knowledge about medications and quality of life at home, administered before and after participation in the program.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Creating oversight team: The dedicated social worker joined the hospital's Department of Older Adult Programs, which works with physicians, nurses, and other health professionals to coordinate each patient's discharge plan. To bolster its discharge planning services, the hospital formed an oversight team that included the director of Older Adult Programs, the director of the Case Management Department, the newly hired social worker, and several physicians, nurses, researchers, and information technology (IT) staff members.
    • Piloting the program and expanding social worker role: The newly hired social worker began contacting older patients on four units within the hospital in March of 2007. Patients were subjectively identified as being at risk by the discharge planners on those units. During this pilot, program staff tracked trends in problems areas and identified barriers across systems that seemed to affect patient outcomes. They used this information to refine the intervention and identify areas where the social worker could have the greatest impact. Once it became clear that patients benefited from the social worker's perspective and problem-solving skills, the team decided to develop a more robust discharge program centered on the expanded role of the social worker.
    • Establishing program goals: The team established patient care goals for the expanded program, as outlined below:
      • Ensure that patients understand the discharge plan, receive recommended services, and get screened for unidentified medical or social needs.
      • Connect patients to needed outpatient and community-based services (e.g., home health, in-home care, dialysis, laboratory services, specialty care, prescription drug programs), with particular emphasis on attending the first physician followup appointment.
      • Support caregivers so as to reduce their stress and burden.
      • Connect providers to each other.
    • Full program launch, clinical trial, and subsequent expansion: In 2009, after a second social worker was transferred to the program, the program was launched on a larger basis to cover the entire hospital. Concurrent with the launch, the team began conducting a clinical trial to assess the program. In 2010, data from the clinical trial were used to support the creation of a third social work position. Also, following the study's conclusion, the model was integrated into other hospital quality improvement efforts, including a collaborative care model focused on improving discharge effectiveness to reduce readmissions and improve health outcomes.

    Resources Used and Skills Needed

    • Staffing: The program has three full-time licensed clinical social workers, each of whom handles approximately 60 cases per month. The hospital plans to hire a fourth social worker in 2012. Program leaders hire social workers who have several years of experience working with older patients in health care settings, so minimal training is required.
    • Costs: The program's primary expense consists of salary and benefits for the social workers, who work on select units with older adult populations. Annual program-related costs total roughly $300,000, including program management and evaluation.
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    Funding Sources

    Rush University Medical Center
    Although the program is largely funded through the hospital's internal operating budget, the following agencies and organizations have provided financial support: the U.S. Administration on Aging, Sanofi Aventis, Cardinal Health, Community Memorial Foundation, Michael Reese Health Trust, the New York Academy of Medicine, and the Harry and Jeanette Weinberg Foundation.end fs

    Adoption Considerations

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    Getting Started with This Innovation

    • Hire social workers with relevant experience: Because this program serves patients with multiple chronic health conditions (including both physical and mental health issues), social workers need to understand the interconnectedness of medical and social factors in health and how common diseases are treated and managed. Experience in working with older at-risk adults is important. Social workers are well suited to the care coordination role due to their training in navigating complex systems, their understanding of the relationship between medical and social factors, their extensive knowledge of community resources, and a practice framework that focuses on the interconnectedness of all these factors.
    • Establish eligibility criteria: Defined criteria, referred to as "an algorithm of risk" at Rush University Medical Center, eliminate the need to discuss eligibility on a case-by-case basis.
    • Integrate with electronic medical record: Being able to determine eligibility based on data in the electronic medical record reinforces a common language to define risk across disciplines and saves significant time. To make data integration as smooth as possible, include an IT department representative on the program planning team.

    Sustaining This Innovation

    • Allow social workers to take "big-picture" approach: Social workers were found to engage patients in a way that facilitated communication about the underlying causes of their problems. It is important to structure the intervention in a way that allows time to gain an understanding of patients' general life circumstances and the issues affecting their health. In many cases, patients will divulge information they have not previously shared with other providers. Qualitative analyses conducted by Rush University of Medical Center support this idea.
    • Monitor and share data on program impact: Even if a randomized controlled trial is not feasible, track and circulate data on the program's impact on readmissions, mortality, and other important health indicators. Data can be used to identify and correct system problems and other barriers that impact patient satisfaction, safety, and quality of care. It will also reinforce the important role of social workers in enhancing patient care and can make the case for hiring additional social workers to expand the program's reach.

    Use By Other Organizations

    Program leaders have worked with the Illinois Transitional Care Consortium (a statewide collaboration) to set up similar programs at four other Illinois hospitals: Adventist La Grange Memorial Hospital, Memorial Hospital of Carbondale, Herrin Hospital, and MacNeal Hospital. They also have consulted with officials implementing similar programs at hospitals in Pennsylvania, California, and Utah.

    More Information

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    Contact the Innovator

    Madeleine Rooney, MSW, LCSW
    Coordinator, Transitional Care
    Department of Health and Aging
    Rush University Medical Center
    710 S. Paulina, Suite 424
    Chicago, IL 60612
    (312) 942-6995
    E-mail: Madeleine_Rooney@rush.edu

    Innovator Disclosures

    Ms. Rooney has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

    References/Related Articles

    Fabbre VD, Buffington AS, Altfeld SJ, et al. Social work and transitions of care: observations from an intervention for older adults. J Gerontol Soc Work. 2011;54(6):615-26. [PubMed]

    Altfeld S, Golden R, McFolling S, et al. An innovative model for transitional care: Enhanced discharge planning program. Collaborative Case Management. 2009;7(2).

    Rooney M. Rush University Medical Center Enhanced Discharge Planning Program. Aging Today Online. 2010;1(3).

    Perry A, Golden R, Rooney M, et al. Best Practice: Rush University Medical Center’s Enhanced Discharge Planning Program. In: Schrader C and Shelton P, editors. Comprehensive care coordination: Community care of chronically ill adults. Chichester, West Sussex, UK: Wiley-Blackwell; 2011. p. 277-292.

    Footnotes

    1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. [PubMed]
    2 Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61(2):225-40. [PubMed]
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: April 11, 2012.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: May 07, 2014.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: March 20, 2014.
    Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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