Heart and Blood Diseases

All Conditions

Nervous System Diseases

Nutritional and Metabolic Diseases

Gland and Hormone Related Diseases

Respiratory Tract (Lung and Bronchial) Diseases

Immune System Diseases

Behaviors and Mental Disorders

Symptoms and General Pathology

Rare Diseases

Heart Failure

Stroke

Diabetes Mellitus

Asthma

Hypertension

Depression

Depressive Disorder

Lung Diseases

Lung Diseases, Obstructive

Pulmonary Disease, Chronic Obstructive

Heart Diseases

Respiratory Tract Diseases

Chronic Disease

Disease Attributes

Chronic Graft Versus Host Disease

1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts

SWIFT home intervention

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.

Social Work Intervention Focused on Transitions

Social Work Intervention Focused on Transitions Among At-Risk Older Adults

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.

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.

Huntington Hospital

National Institute on Aging (NIA)

University of Southern California

Associate Professor of Gerontology

Usual care for the present study constituted the usual course of care provided to older adults transitioning from hospital to home from Huntington Memorial Hospital.

Usual Care

SWIFT home intervention: 1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts

Intervention

Usual care consisted of the usual course of care provided to older adults transitioning home from a hospital stay at Huntington Memorial Hospital

Total

Age, Categorical

Age, Continuous

Sex: Female, Male

African American

Caucasian

Latino

Native American

Asian/Pacific Islander

Other

Declined to provide response

Race/Ethnicity, Customized

United States

Region of Enrollment

Married

Single

Divorced

Widowed

Marital status

Own house/apartment

Living in family member's home

Current living situation

Alone

Spouse/partner

Child

Paid caregiver

Who do you live with?

No one/self

Spouse

Significant other

Who is your primary caregiver?

Under $10,000

$10,000-$19,000

$20,000-$29,000

$30,000-$39,000

$40,000-$49,000

$50,000 or more

Refused to respond

Current annual income

8th grade or less

9th-11th grade

High school graduate

Some college

College graduate

Graduate degree

Doctoral degree

Highest grade completed in school

Cancer

Cardiac disease

Dementia/Alzheimer's disease

Diabetes

Respiratory disease

Measure NOT mutually exclusive. Inventory of conditions

Chronic condition inventory

The Patient Health Questionnaire, 9-item uses nine questions to asses for depression and has been widely and successfully used in health care research since the early 1990's, particularly in investigations among older adults aged 65 years or more.

A total score is reported at the end of the questionnaire and scores can range from 0-27 with a higher value indicating more severe or worse depression. Total scores correspond to the following: 0 no depression, 1-4 minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderate severe depression, and 20-27 severe depression.

Patient Health Questionnaire 9-item (PHQ-9)

The Number Rating Scale is a self-reported measure for pain level that is widely used in US hospitals. Patients are asked to rate their level of pain felt over the last 24-hours on a scale ranging from 0-10, where zero indicates no pain, and 10 is the worst pain imaginable.

Pain (Number Rating Scale)

The Short-Form, 12-item is a survey tool to measure physical health and functional level and an abbreviated version of this tool was used in the present study which constituted eight of the 12-items that focused on physical functioning. Response options ranged from 'not limited at all,' to 'limited a lot' and after assigning numerical values to response options, total scores ranged from 0-16 with a higher score corresponding to greater physical limitations.

Physical Functioning Index (abbreviated Short Form-12)

The Short Portable Mental Health Questionnaire (SPMSQ) is widely used tool to screen for cognitive impairment. This questionnaire consists of 10 questions and a total score is derived at the end. Scores can range from 0-10 where a low score indicates high cognitive impairment and a high score indicates higher cognitive functioning. The scale has an established cut-off score of 5 where those scoring 5 or higher are cognitively intact to participate in research, understand the study and associated activities, and provide consent. Those scoring below 5 are deemed ineligible.

Cognition (SPMSQ score)

Number of health conditions

Number of daily medications

Discharged home under self-care

Had inpatient stay or emergency department visit in previous 6 months

Has Advance Directive

Dr. Susan Enguidanos

Usual Care in the present study constitutes usual care that is delivered to older adults transitioning from the hospital to home from Huntington Memorial Hospital.

30-day Hospital Readmission

Patients randomized to the intervention group and received the intervention. SWIFT home intervention: 1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts

Spots Global Cancer Trial Database for hospital readmissions