title: Social work and transitions of care: observations from an intervention for older adults.
abstract: 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. Concepts developed and discussed identify the role of surprises after discharge, an expanded view of the client system, and relationship building as instrumental in carrying out effective care transitions.
authors.affiliation: School of Social Service Administration, University of Chicago, Chicago, Illinois 60637 USA. fabbre@uchicago.edu
authors.forename: Vanessa D
authors.initials: VD
authors.lastname: Fabbre
authors.forename: Anne S
authors.initials: AS
authors.lastname: Buffington
authors.forename: Susan J
authors.initials: SJ
authors.lastname: Altfeld
authors.forename: Gayle E
authors.initials: GE
authors.lastname: Shier
authors.forename: Robyn L
authors.initials: RL
authors.lastname: Golden
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration*; D006699:Home Care Services / Q000458:organization & administration; D006801:Humans; D033183:Interdisciplinary Communication; D010351:Patient Discharge; D011369:Professional-Patient Relations; D012947:Social Work / Q000458:organization & administration*