Social Work Intervention Focused on Transitions

Not Applicable

Completed

• Conditions: Asthma; Stroke; Heart Disease; Diabetes; Cancer; Depression; Chronic Heart Failure; Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention; Hypertension; Chronic Obstructive Pulmonary Disease
• Interventions: Other: SWIFT home intervention

• Registration Number: NCT02232126
• Lead Sponsor: University of Southern California

Brief Summary

In response to Program Announcement (PA)-09-164, "NIH Exploratory/Developmental Research Grant Program (R21) a randomized pilot study testing the efficacy of SWIFT: Social Work Intervention Focused on Transitions among at-risk older adults following hospital discharge to home. This study is drawn from several observations. First, transitions between care settings create elevated risk for poor outcomes and for readmission among older adults leaving the hospital for home largely due to fragmented care and poor communication. Next, while few studies exist that test methods to improve transitions, those available are largely medically focused, using a nurse or advanced practice nurse in their approach. Although evidence exists to support the effectiveness of these models, few have been replicated and none have been integrated into standard health care practice. This may be attributed to several factors including the availability of the needed staff, the lack of existing structures to support these roles, and the costs of implementing these interventions. Finally, a social work driven intervention may provide a replicable mechanism for bridging medical care, addressing psychosocial needs as well as medical needs, and improving linkages with community services while reducing care duplication. This study aimed to test a structured social work transition intervention model to reduce rates of hospital readmission and medical service use while improving patient satisfaction with the care transition process. A randomized pilot study was used to test a social work transitions model designed to improve care provided to frail older adults being discharged from the hospital to return to the community. Eligible patients consenting to participate (n=181) were randomly assigned to either the social work transitions model intervention or usual care. This project was conducted at Huntington Hospital, a 525-bed, nonprofit, community hospital located in Pasadena, California. In an average year, Huntington Hospital has approximately 10,000 older adults discharged from their facility, 44% of who are 80 years old or older. Those randomized to the intervention arm received up to six sessions from the social worker, at least one provided in the home. The social work intervention was designed to overcome common problems following hospital discharge including medication review, discussion and planning around discharge instruction, assistance in scheduling follow up appointments, assessments of psychosocial and other support service needs and provision of linkages to address those needs. Outcomes were measured three and six months following arrival at home, with an interim measure of satisfaction at 10 days following arrival at home, with measures including patient level of depression, pain, physical functioning, self-efficacy with disease management, and medical service use.

Detailed Description

Not available

Basic Information
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Recruitment & Eligibility
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Study & Design
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Trial Locations

Study Timeline

• Study Start: 2011-02
• Primary Completion: 2013-10
• Study Completion: 2013-10
• Study First Submitted: 2014-08-25
• Study First Submitted QC: 2014-09-04
• Study First Posted: 2014-09-05
• Results First Submitted: 2014-12-04
• Results First Submitted QC: 2016-12-19
• Results First Posted: 2017-02-10
• Status Verified: 2023-11
• Last Update Submitted: 2023-11-08
• Last Update Posted: 2023-11-09

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 181

Inclusion Criteria

• Age 65 or more
• English-speaking
• Community dwelling (own home, vs. assisted living facility/skilled care)
• Living within specified service net
• Cognitively intact (as measured by a score of 5 or more on the SPMSQ)
• Meeting at lease one or more of the following:
• Age 75 or more
• Taking 5 or more prescription medications
• Had at least one inpatient admission or emergency department visit in previous 6 months

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Exclusion Criteria

• Age 64 or younger
• Non-English speaking
• Diagnosed with end-stage renal disease
• Hospice recipient
• Diagnosis of Alzheimer's disease or severe dementia
• Residing in assisted living or skilled care facility
• Homeless

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Intervention	SWIFT home intervention	-

Primary Outcome Measures

Name	Time	Method
30-day Hospital Readmission	30-days post hospitalization	The outcome measure is the number of readmissions experienced by participants in the Usual Care and Intervention groups within 30-days of their index discharge.

Secondary Outcome Measures

Name	Time	Method
30-day Readmission Among Intervention Participants	30-days	The outcome measure is the rate of 30-day readmissions among Intervention group participants that declined to receive the in-home social work intervention versus those Intervention group participants that received the in-home social work intervention.

Trial Locations

Locations (2)

Huntington Hospital; 🇺🇸 Pasadena, California, United States

University of Southern California; 🇺🇸 Los Angeles, California, United States