Social Workers Enhance Post-Discharge Care for Seniors

The Problem

Almost 20 percent of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge. Each older adult readmission costs the hospital an average of $7,400. In addition, patients may have unmet biological, psychological and social factors that impede their ability to follow up with discharge instructions.

The Solution

Staff from Rush University Medical Center's Older Adult Programs and Case Management Department teamed up to create the Enhanced Discharge Planning Program. The program calls for social workers to phone patients and caregivers after discharge to ensure they are receiving the services detailed in their discharge plan and to investigate any unanticipated needs. If necessary, social workers intervene to help patients resolve problems and connect patients and caregivers to health care providers and community-based services.