Social Work Intervention Focused on Transitions

NCT02232126 | Completed Results DMC

• 2 other identifiers: UP-10-003725R21AG034557-02
• Study Type: interventional
• Target: 181
• Locations: 1 country
• Sites: 2

Brief Summary

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.

Conditions

Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention; Heart Disease; Diabetes; Hypertension; Cancer; Depression; Asthma; Chronic Heart Failure; Chronic Obstructive Pulmonary Disease; Stroke

Keywords

Hospital readmissions; Randomized controlled trial; Older adults; Care transitions; Social work

Outcome Measures

Primary Outcomes (1)

• 30-day Hospital Readmission

  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.

  30-days post hospitalization

Secondary Outcomes (1)

• 30-day Readmission Among Intervention Participants

  30-days

Study Arms (2)

Usual Care

NO INTERVENTION

Intervention

EXPERIMENTAL

Other: SWIFT home intervention

Interventions

SWIFT home intervention OTHER

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

Eligibility Criteria

• Age: 65 Years - 110 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Older Adult (65+)

You may qualify if:

• Age 65 or more
• English-speaking
• Community dwelling (own home, vs. assisted living facility/skilled care)
• Living within specified service net
• Cognitively intact (as measured by a score of 5 or more on the SPMSQ)
• Meeting at lease one or more of the following:
• Age 75 or more
• Taking 5 or more prescription medications
• Had at least one inpatient admission or emergency department visit in previous 6 months

You may not qualify if:

• Age 64 or younger
• Non-English speaking
• Diagnosed with end-stage renal disease
• Hospice recipient
• Diagnosis of Alzheimer's disease or severe dementia
• Residing in assisted living or skilled care facility
• Homeless

Sponsors & Collaborators

• University of Southern California: lead
• Huntington Hospital: collaborator
• National Institute on Aging (NIA): collaborator

Study Sites (2)

University of Southern California

Los Angeles, California, 90089, United States

Location

Huntington Hospital

Pasadena, California, 91105, United States

Location

MeSH Terms

Conditions

Heart Diseases; Diabetes Mellitus; Hypertension; Neoplasms; Depression; Asthma; Pulmonary Disease, Chronic Obstructive; Stroke

Condition Hierarchy (Ancestors)

Cardiovascular Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases; Vascular Diseases; Behavioral Symptoms; Behavior; Bronchial Diseases; Respiratory Tract Diseases; Lung Diseases, Obstructive; Lung Diseases; Respiratory Hypersensitivity; Hypersensitivity, Immediate; Hypersensitivity; Immune System Diseases; Chronic Disease; Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases

Results Point of Contact

• Title: Dr. Susan Enguidanos
• Organization: University of Southern California

enguidan@usc.edu

213-740-9822

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: TRIPLE
• Who Masked: PARTICIPANT, INVESTIGATOR, OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Professor of Gerontology

Study Record Dates

• First Submitted: August 25, 2014
• First Posted: September 5, 2014
• Study Start: February 1, 2011
• Primary Completion: October 1, 2013
• Study Completion: October 1, 2013
• Last Updated: November 9, 2023
• Results First Posted: February 10, 2017

Record last verified: 2023-11

Locations

US (2)