[Show abstract][Hide abstract] ABSTRACT: In this issue of JCHIMP, Meade et al., publish the results of qualitative analysis regarding a second-year rotation in tracing the outcome of discharged patients. They report that their residents develop remarkable insights into the types of failures and miscommunications that plague our discharge processes. This perspective piece places this article in the context of literature seeking to understand why these problems are endemic and how we must prioritize efforts to address and prevent them.
[Show abstract][Hide abstract] ABSTRACT: It is widely recognized that vulnerable patients and caregivers attempting to navigate the transition from hospital to home are likely to encounter a stressful period fraught with a high risk of adverse events, rehospitalization, and often unsuccessful follow-up.1,2 Quality improvement specialists and administrators have identified this care transition as a target for improving outcomes, particularly for elderly patients with multiple comorbidities, and as a financial risk for hospitals, given the Hospital Readmissions Reduction Program (HRRP) penalty contained within the Patient Protection and Affordable Care Act.3 Not surprisingly, researchers have sought to identify interventions that might reduce the rate of rehospitalization, though they have often targeted specific diseases.4 Several evidence-based transitional care models or intervention bundles have been shown to reduce 30-day readmissions,5 but research has not delineated which components of these transitional care approaches ...
Journal of General Internal Medicine 02/2015; 30(5). DOI:10.1007/s11606-015-3225-6 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: High 30-day readmission rates are a major burden to the American medical system. Much attention is on transitional care to decrease financial costs and improve patient outcomes. Social workers may be uniquely qualified to improve care transitions and have not previously been used in this role. We present a case study of an older, dually eligible Latina woman who received a social work-driven transition intervention that included in-home and telephone contacts. The patient was not readmitted during the six-month study period, mitigated her high pain levels, and engaged in social outings once again. These findings suggest the value of a social worker in a transitional care role.
Social Work in Health Care 03/2015; 54(3):177-92. DOI:10.1080/00981389.2015.1005273 · 0.62 Impact Factor
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