When an older patient
is discharged from the
hospital, within 48 hours
a Rush social worker
will phone the patient

Rush University Medical Center Studies Program to Help Elderly Transition From Hospital to Home

July 29, 2009
by Joan Trombetti, Writer
Rush University Medical Center has placed its program to research ways to help older adults transition from hospital to home as a top priority under new health care imperatives to reduce the rate of 30-day readmissions.

The study's goal is to see if the program, which was implemented two years ago is working to reduce readmissions within 30 days for elderly patients. If results are positive, the program could serve as a model for hospitals across the country.

DOTmed learned that on average, one in five Medicare beneficiaries who are discharged from a hospital, are readmitted within a month. Key components of President Obama's health care reform agenda are to reduce rates of hospital readmissions, improve quality of care and achieve savings. Hospital readmissions can cost Medicare as much as $12 billion annually.

"Patients who have been enrolled in our enhanced discharge planning program over the last two years are extremely pleased with the service," said Robyn Golden, LCSW, director of the older adult programs at Rush. "But beyond patient satisfaction, we now need to formally evaluate the program in a randomized, controlled study to determine whether our model--using social workers rather than nurses--not only reduces readmissions, but also reduces emergency room visits, avoids nursing home placements, and improves quality of life."

When an older patient is discharged from the hospital, within 48 hours a Rush social worker will phone the patient, ensuring full implementation of the discharge plan and to assist with coordinating community resources and follow-up appointments as well as intervene in any issues that might arise like transportation, meals and in-home care for the patient.

During the past two years, social workers at Rush have found that several common problems arise in post-discharge care including difficulty getting around, difficulty scheduling medical appointments and getting to a physician's office and delays in home health care services because caregivers are often overbooked. Golden believes that unlike other programs where nurses initiate and coordinate after-hospital care, Rush social workers are ideally trained for the role. She states that research has shown that 40 to 50% of hospital readmissions are related to social problems and lack of community services. These are issues that social workers are trained to address.

In its efforts to find new ways to help patients transition from hospital to home, Rush is also participating in Project BOOST (Better Outcomes for Older Adults through Safe Transition), a national project involving 30 hospitals to redesign the discharge process. Rush is the only hospital in Illinois included in the project. Like Rush's enhanced discharge planning program, Project BOOST, sponsored by the Society of Hospital Medicine, is aimed at reducing readmissions. For more information see www.rush.edu.