Impact of a Social Work Care Coordination Intervention on Hospital Readmission: A Randomized Controlled Trial

Abstract

This study assessed how a social work-led care coordination intervention would reduce the within-30-day hospital readmission rate among moderate- and high-risk patients age 50 years or older. Authors ran a randomized controlled trial to determine whether there was a significant difference in within-30-day readmission rates between patients receiving usual care post-discharge and those receiving intervention from an MSW intern (one home visit and one to two phone calls). Results were obtained using a sample of hospitalized patients with a LACE index score of 7 or higher (N = 89). Analysis suggests that the intervention improved the likelihood of not being readmitted by some 22 percent (RR = 1.222; 95% CI = 1.063-1.405). The risk improvement with the intervention was highly statistically significant (p = .003). This study shows that a time-efficient care coordination intervention by MSW interns may decrease hospital readmission rates. Replications of this study in other communities, with more diverse populations, and with larger numbers of patients will indicate whether results are generalizable.

30-day all-cause readmission rates among a cohort of individuals with rare conditions

“…Such programs to reduce readmission rates have proven successful in a variety of settings, populations, and resources. 36,37 These programs have not, however, been implemented or examined in populations of individuals with rare conditions. Inclusion of such individuals would be vital to understanding the effectiveness of these programs.…”

Expenditure Reductions Associated with a Social Service Referral Program

“…31 These findings are consistent with a growing body of literature showing that programs that coordinate multiple types of social services may reduce health care expenditures or utilization. 11 , 12 , 19 , 32 , 33 Although some programs have targeted specific social determinants of health, such as food insecurity 6 , 9 , 34–36 or housing needs, 7 , 37 , 38 almost half of studies examined in a recent systematic literature review included interventions designed to address multiple unmet social needs. 15 The wide variation of service types represented in Health Connections referral data is consistent with this multi-sector approach.…”

The LACE Score as a Tool to Identify Radical Cystectomy Patients at Increased Risk of 90-Day Readmission and Mortality

“…Bronstein et al [13] utilized the LACE score to identify high-risk hospitalized patients for targeted social work intervention, leading to a reduction in readmissions in this cohort by 22% compared to standard treatment. While Bronstein used a cutoff of LACE ≥ 7 to identify high-risk patients, in our study 95% of patients in our study had a LACE ≥ 7, offering little benefit in discriminating patient populations.…”

“…The LACE index was first externally validated in congestive heart failure patients [10,11], and has also been validated in the general population of hospitalized patients [12]. Further, based on this scoring system, Bronstein et al [13] in a prospective, randomized fashion demonstrated that social work intervention for hospitalized patients based on a LACE score ≥ 7 decreased readmission likelihood by 22% compared to standard treatment. In the radical cystectomy population, the ability to identify high-risk patients with the greatest potential for readmission or mortality would allow for targeted intervention and close outpatient follow-up.…”