Social Work and Transitions of Care: Observations from an Intervention for Older Adults

Fabbre, Vanessa D.; Buffington, Anne; Altfeld, Susan; Shier, Gayle; Golden, Robyn

doi:10.1080/01634372.2011.589100

Cited by 36 publications

(35 citation statements)

References 14 publications

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“…However, interventions that explicitly acknowledge caregivers' roles and emotional and tangible needs, such as the Enhanced Discharge Planning Program, have been shown to relieve the stress and burden associated with caregiving. 28 In this program, questions about the caregiver's needs, wellbeing, and ability to carry out necessary caregiving tasks are included in the baseline assessment. The plan developed from this assessment then includes services and strategies to address the caregiver's needs as well as the patient's.…”

Section: Current Evidence: Promise and Gapsmentioning

confidence: 99%

Strong Social Support Services, Such As Transportation And Help For Caregivers, Can Lead To Lower Health Care Use And Costs

et al. 2013

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A growing evidence base suggests services that address social factors with an impact on health, such as transportation and caregiver support, must be integrated into new models of care if the Institute for Healthcare Improvement's Triple Aim is to be realized. We examined early evidence from seven innovative care models currently in use, each with strong social support services components. The evidence suggests that coordinated efforts to identify and meet the social needs of patients can lead to lower health care use and costs, and better outcomes for patients. For example, Senior Care Options--a Massachusetts program that coordinates the direct delivery of social support services for patients with chronic conditions and adults with disabilities--reported that hospital days per 1,000 members were just 55 percent of those generated by comparable patients not receiving the program's extended services. More research is required to determine which social service components yield desired outcomes for specific patient populations. Gaining these deeper insights and disseminating them widely offer the promise of considerable benefit for patients and the health care system as a whole.

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Section: Current Evidence: Promise and Gapsmentioning

confidence: 99%

Strong Social Support Services, Such As Transportation And Help For Caregivers, Can Lead To Lower Health Care Use And Costs

et al. 2013

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“…Although social workers have recognized the efficacy of care transition models and the importance of their role in care transition, few social work researchers have examined the effectiveness of health care (Berkman, 1996;Berkman & Abrams, 1986;Cherin, Simmons, & Hillary, 1998;Claiborne, 2006;Fabbre, Buffington, & Altfeld, 2011).…”

Section: Interdisciplinary Collaboration and The Social Worker's Rolementioning

confidence: 99%

Factors Associated With 30-Day Hospital Readmissions Among Participants in a Care Transition Quality Improvement Program

Park

Hain

Tappen

et al. 2012

Journal of the Society for Social Work and Research

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Discharge from hospital to home is a vulnerable period for older adults who have multiple care needs. The Safe Transitions for Elderly People (STEP) program is a care transition program for Medicare fee-for-service patients 75 years and older discharged to home from a community hospital. This quality improvement project (a) compares 30-day hospital readmission rates between 498 STEP participants and 722 patients eligible for STEP but not participating in the program, and (b) determines factors associated with readmissions during STEP. The STEP participants received intervention in 1 of 2 formats: 395 received a telephone-only intervention and 103 received a telephone plus home visit intervention. STEP participants had a lower 30-day hospital readmission rate than nonparticipants (i.e., those who could not be contacted for STEP participation; those who declined to participate). Results of binary logistic regressions showed 2 variables were significant predictors of readmissions: for the group of all STEP participants and the telephone-only intervention group, the (a) hospitalization within the previous year predicted readmission; for the telephone plus home visit group, the (b) degree of assistance needed with ambulation predicted readmission. Given the multifactor nature of readmissions, interdisciplinary teams should develop tailored interventions based on individual's psychosocial and medical assessments. Reforms to the Medicare fee-for-service system have the potential to change financial incentives that currently favor hospitalization of older patients, the potential to avoid readmissions, and the potential to direct the savings to support interdisciplinary care transition interventions.

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“…These programs have many similarities with nurse-led case manager transitional models, [32, 33] including an emphasis on home-based assessments, follow-up medical appointments, patient and caregiver education, and accessing community resources. However, while nurse case manager programs focus primarily on health conditions, medication, and lifestyle changes, social workers add value by expanding patient and caregiver support for psychosocial issues, including tangible and emotional support [71, 77]. In addition to providing short-term counseling for emotional issues, social work case managers address barriers to accessing follow-up medical care and social services.…”

Section: Discussionmentioning

confidence: 99%

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

et al. 2017

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BackgroundFor some stroke patients and caregivers, navigating the transition between hospital discharge and returning home is associated with substantial psychosocial and health-related challenges. Currently, no evidence-based standard of care exists that addresses the concerns of stroke patients and caregivers during the transition period. Objectives of the Michigan Stroke Transitions Trial (MISTT) are to test the impact of a social worker home-based case management program, as well as an online information and support resource, on patient and caregiver outcomes after returning home.MethodsThe Michigan Stroke Transitions Trial is a randomized, pragmatic, open (un-blinded), 3-group parallel designed superiority trial conducted in 3 Michigan hospitals. Eligible participants are adult acute stroke patients discharged home directly or within 4 weeks of being discharged to a rehabilitation facility. The patient’s primary caregiver is also invited to participate. Patients are randomized on the day they return home using a randomized block design. Consented patients discharged to a rehabilitation facility who do not go home within 4 weeks are dropped from the study.The 2 study interventions begin within a week of returning home and conclude 3 months later. The 3-group design compares usual care to either a home-based social worker stroke case management (SWSCM) program, or a combination of the SWSCM program plus access to an online information and support resource (MISTT website). Outcomes data are collected at 7-days and 90-days by trained telephone interviewers. Primary patient outcomes include the PROMIS global 10 score (a generic Quality of Life scale), and the Patient Activation Measure (PAM). Caregiver outcomes include the Bakas Caregiving Outcomes Scale. Final analysis will be based on 214 randomized acute stroke patients. To accommodate subjects excluded due to prolonged rehabilitation stays, as well as those lost-to-follow-up, up to 315 patients will be consented.DiscussionThe MISTT study will determine if a home-based case management program designed around the needs and preferences of stroke patients and caregivers, alone or in combination with a patient-centered online information and support resource can improve stroke survivor and caregiver outcomes 3 months after returning home.Trial registrationClinicalTrials.gov: NCT02653170 (Protocol ID: 135457). Registered April 9, 2015.

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Social Work and Transitions of Care: Observations from an Intervention for Older Adults

Cited by 36 publications

References 14 publications

Strong Social Support Services, Such As Transportation And Help For Caregivers, Can Lead To Lower Health Care Use And Costs

Strong Social Support Services, Such As Transportation And Help For Caregivers, Can Lead To Lower Health Care Use And Costs

Factors Associated With 30-Day Hospital Readmissions Among Participants in a Care Transition Quality Improvement Program

Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol

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