Social Work Intervention Focused on Transitions
Condition: Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention; Heart Disease; Diabetes; Hypertension; Cancer; Depression; Asthma; Chronic Heart Failure; Chronic Obstructive Pulmonary Disease; Stroke
MeSH terms: Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Heart Diseases
Study type: Interventional

Summary: 
      In response to Program Announcement (PA)-09-164, "NIH Exploratory/Developmental Research
      Grant Program (R21) a randomized pilot study testing the efficacy of SWIFT: Social Work
      Intervention Focused on Transitions among at-risk older adults following hospital discharge
      to home. This study is drawn from several observations. First, transitions between care
      settings create elevated risk for poor outcomes and for readmission among older adults
      leaving the hospital for home largely due to fragmented care and poor communication. Next,
      while few studies exist that test methods to improve transitions, those available are largely
      medically focused, using a nurse or advanced practice nurse in their approach. Although
      evidence exists to support the effectiveness of these models, few have been replicated and
      none have been integrated into standard health care practice. This may be attributed to
      several factors including the availability of the needed staff, the lack of existing
      structures to support these roles, and the costs of implementing these interventions.
      Finally, a social work driven intervention may provide a replicable mechanism for bridging
      medical care, addressing psychosocial needs as well as medical needs, and improving linkages
      with community services while reducing care duplication. This study aimed to test a
      structured social work transition intervention model to reduce rates of hospital readmission
      and medical service use while improving patient satisfaction with the care transition
      process. A randomized pilot study was used to test a social work transitions model designed
      to improve care provided to frail older adults being discharged from the hospital to return
      to the community. Eligible patients consenting to participate (n=181) were randomly assigned
      to either the social work transitions model intervention or usual care. This project was
      conducted at Huntington Hospital, a 525-bed, nonprofit, community hospital located in
      Pasadena, California. In an average year, Huntington Hospital has approximately 10,000 older
      adults discharged from their facility, 44% of who are 80 years old or older. Those randomized
      to the intervention arm received up to six sessions from the social worker, at least one
      provided in the home. The social work intervention was designed to overcome common problems
      following hospital discharge including medication review, discussion and planning around
      discharge instruction, assistance in scheduling follow up appointments, assessments of
      psychosocial and other support service needs and provision of linkages to address those
      needs. Outcomes were measured three and six months following arrival at home, with an interim
      measure of satisfaction at 10 days following arrival at home, with measures including patient
      level of depression, pain, physical functioning, self-efficacy with disease management, and
      medical service use.
    


Intervention name(s): SWIFT home intervention
Intervention type(s): Other
Intervention description(s): 1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Health Services Research
Keywords: Hospital readmissions; Randomized controlled trial; Older adults; Care transitions; Social work