title: A role for social workers in improving care setting transitions: a case study.
abstract: High 30-day readmission rates are a major burden to the American medical system. Much attention is on transitional care to decrease financial costs and improve patient outcomes. Social workers may be uniquely qualified to improve care transitions and have not previously been used in this role. We present a case study of an older, dually eligible Latina woman who received a social work-driven transition intervention that included in-home and telephone contacts. The patient was not readmitted during the six-month study period, mitigated her high pain levels, and engaged in social outings once again. These findings suggest the value of a social worker in a transitional care role.
authors.affiliation: a Davis School of Gerontology, University of Southern California , Los Angeles , California , USA.
authors.forename: Ruth D
authors.initials: RD
authors.lastname: Barber
authors.forename: Alexis
authors.initials: A
authors.lastname: Coulourides Kogan
authors.forename: Anne
authors.initials: A
authors.lastname: Riffenburgh
authors.forename: Susan
authors.initials: S
authors.lastname: Enguidanos
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration*; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D059065:Medication Reconciliation; D019982:Organizational Case Studies; D010146:Pain / Q000175:diagnosis; D010348:Patient Care Team; D010351:Patient Discharge; D012947:Social Work / Q000458:organization & administration*; D013689:Telephone
keywords: care transitions; case study; hospital readmissions; older adults; social work