Clinical trial NCT02232126: Social Work Intervention Focused on Transitions
Official title: Social Work Intervention Focused on Transitions Among At-Risk Older Adults
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: 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
Keywords: Hospital readmissions
Randomized controlled trial
Older adults
Care transitions
Social work
Lead sponsor: University of Southern California
Sponsor class: OTHER
Collaborators: name: Huntington Hospital
name: National Institute on Aging (NIA)
First posted: 2014-09-05
Enrollment: 181
Sex: ALL
Minimum age (years): 65
Maximum age (years): 110
Standard ages: OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief 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.


Eligibility criteria: Inclusion Criteria:

* Age 65 or more
* English-speaking
* Community dwelling (own home, vs. assisted living facility/skilled care)
* Living within specified service net
* Cognitively intact (as measured by a score of 5 or more on the SPMSQ)
* Meeting at lease one or more of the following:
* Age 75 or more
* Taking 5 or more prescription medications
* Had at least one inpatient admission or emergency department visit in previous 6 months

Exclusion Criteria:

* Age 64 or younger
* Non-English speaking
* Diagnosed with end-stage renal disease
* Hospice recipient
* Diagnosis of Alzheimer's disease or severe dementia
* Residing in assisted living or skilled care facility
* Homeless

Primary outcomes:
measure: 30-day Hospital Readmission
timeFrame: 30-days post hospitalization
Secondary outcomes:
measure: 30-day Readmission Among Intervention Participants
timeFrame: 30-days
Other outcomes:
Locations:
city: Los Angeles
country: United States
facility: University of Southern California
state: California
city: Pasadena
country: United States
facility: Huntington Hospital
state: California
Study officials:
References: