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Social Workers Make Effective Discharge Supervisors

July 29, 2009
The lack of aftercare for older adults transitioning from hospital to home has been implicated in the high percentage of readmissions in the days following a hospital stay. Two years ago, Rush University Medical Center in Chicago instituted a discharge plan implemented by social workers rather than nurses. "Patients who have been enrolled in our enhanced discharge planning program are extremely pleased with the service," says Robyn Golden, LCSW, director of the older adult programs at Rush. "We now need to formally evaluate the program in a randomized, controlled study to determine whether our model not only reduces readmissions, but also reduces emergency room visits, avoids nursing home placements, and improves quality of life." Even before such a study, Rush social workers have pointed out, and fixed, key problems faced by patients. In the Rush plan, within 48 hours of the hospital discharge, the patient receives a call from a Rush social worker whose responsibility is to ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments and intervene around any issues that might arise, from transportation to meals and in-home care. The Rush social workers have found several common themes in post-discharge care: Patients reported difficulty getting around, particularly if their illness affected their mobility, difficulty scheduling medical appointments and getting to their physicians’ offices and delays in home health care services. According to Golden, research has shown that 40 to 50 percent of hospital readmissions are linked to social problems and lack of community services, issues that social workers are trained to address. "Social workers possess extensive knowledge of community resources, expertise in navigating complex social systems, experience using a framework of practice that focuses on the person in the environment, and training in case management and care coordination," Golden says, explaining why the Rush model is so effective. "Social workers are also able to use psychosocial assessment skills to explore family dynamics or resources that may affect the success of the discharge plan."