title: Hospital to home: a transition program for frail older adults.
abstract: OBJECTIVE
  This study describes a social-worker navigator transitional care model for at-risk seniors being discharged from hospital to home. The model is designed to prevent rehospitalizations so as to improve quality of life and patient outcomes. This model is different from others with its focus on the psychosocial aspects of care transitions, medical needs, and individualized needs with the provision of nonreimbursable services.
  
  
  METHODS
  Care begins in the acute care hospital or inpatient rehabilitation facility and continues in the postdischarge home environment. Participants are connected to community services to support their independent living at home.
  
  
  METHODS
  Case managers, physicians, or others refer potential participants to the navigator. Criteria for inclusion include the following: age 65 years or older, Medicare and/or Medicaid recipient, living in the same county as the hospital, and having at least 2 of a list of 11 criteria that predict readmission. After the participant agrees to enroll, the navigator recommends in-home services at discharge. Within the first 72 hr, the navigator makes a home visit to evaluate the home environment, assess medical management, and make referrals for other services. Follow-up phone calls and other home visits are made by the navigator during the participant's enrollment, which is from 30 days to 4 months.
  
  
  RESULTS
  Hospital readmissions were decreased by 61% for this high-risk population. Cost savings by preventing readmissions correlated to a cost savings of $628,202 per year. The 36-Item Short-Form Health Survey showed statistically significant improvements in quality-of-life scores for both physical and mental health summary scales and for all 8 subscales (p < .004). Almost all (99%) of respondents were satisfied with the overall Hospital to Home program.
  
  
  CONCLUSIONS
  The results of this study demonstrate the importance of extending social support and health education into the home after discharge from the hospital. Access to immediate in-home care services such as transportation, housekeeping, laundry, and light meal preparation allows patients not to experience gaps in care that could result in a readmission. The assigned navigator reinforces medical management and connects participants to appropriate community resources in order to remain safe at home.
authors.affiliation: Post Acute Services, Forsyth Medical Center, Winston Salem, NC 27103, USA. lwwatkins@novanthealth.org
authors.forename: Lynn
authors.initials: L
authors.lastname: Watkins
authors.forename: Carol
authors.initials: C
authors.lastname: Hall
authors.forename: Daria
authors.initials: D
authors.lastname: Kring
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management; D002908:Chronic Disease; D003266:Continuity of Patient Care; D005260:Female; D016330:Frail Elderly / Q000523:psychology*; D019538:Health Care Surveys; D006301:Health Services Needs and Demand; D019456:Health Transition; D006801:Humans; D008297:Male; D010351:Patient Discharge; D016730:Program Development; D015397:Program Evaluation; D011787:Quality of Health Care; D011788:Quality of Life; D012306:Risk; D012947:Social Work; D013223:Statistics as Topic