Impact of a combined pharmacist and social worker program to reduce hospital readmissions.

Background: The Patient Protection and Affordable Care Act (2010) directed the Centers for Medicare and Medicaid Services to implement a hospital readmissions reduction program that reduces payments to hospitals for excess readmissions that began in October 2012. As such, hospitals across the country have been trying to identify and implement successful strategies for reducing hospitalizations.

Objective: To evaluate the impact of a combined pharmacist and social worker program on reducing 30-day, all-cause readmission rates to the same hospital.

Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs.

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.

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Purpose Of The Study: To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality.

Design And Methods: Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs.

Social work and transitions of care: observations from an intervention for older adults.

Making the transition from hospital to home can be challenging for many older adults. This article presents practice perspectives on these transitions, based on a social work intervention for older adults discharged from an acute care setting to home. An analysis of interviews with clinical social workers who managed 356 cases (n  =  3) and a review of their clinical notes (n =  581) were used to identify salient themes relevant to care transitions.