Case study: how discharge follow-up calls work

Patient case was challenging

A hospital discharge program that has social workers make follow-up calls to patients is designed to address patients' psychosocial needs and issues, as well as their medical ones.

"Historically we've looked at patients from a medical perspective and have minimized these psychosocial and compartmental parts of their lives," says Madeleine Rooney, MSW, medical center liaison for older adult programs at the Rush Medical Center.

"So, our work has been focused on providing additional support and assistance with the transition from hospital to home," Rooney says. "Also, we've been tracking over the last three-plus years the psychosocial environmental factors that impact outcomes, including where there are gaps in services and how these impact people's lives."

Here's a case study of how it works:

"We had a case of a senior, who is in her 80s, who had been in the hospital several times," Rooney says. "She lives alone, is very anxious, and has experienced over time some increased physical problems that have made it more risky for her to live alone."

However, the woman was reluctant to receive help from community services and agencies.

While she was in the hospital, she was recommended to be placed in a skilled nursing facility or to receive department of aging services if she returned home, Rooney says.

"She wasn't willing to accept those services and insisted on going home," she adds. "But when she went home, she became very anxious about not being able to manage as she had before."

The woman sometimes calls the hospital after her discharge and eventually is readmitted.

"We had intervened with her at some point in the past, and then she was referred back to us by the inpatient case management team," Rooney says. "We spent a great deal of time talking with her to try to assess exactly what it was she wanted and to find out if there was some way that she would allow us to help her."

Also, because of her age and health issues, it was imperative that the woman receive some immediate home support.

"We were trying to prevent a crisis that would result in her returning to the emergency department unnecessarily," Rooney says.

The social worker also called the woman's primary care physician and orthopedic physician, who treated her following hip surgery.

"We asked them to agree to our recommendation, which basically was to convince her to accept some home health services," Rooney says.

The woman had been resistant to this type of help all along, but after telephone conversations with the social worker, she changed her mind.

"We got some orders in place for her to receive nursing care in her home," Rooney says.

The woman was at risk for falling, so she would also be eligible for physical therapy. And the discharge program social worker put the patient in touch with a home health care social worker to further address her psychosocial issues.

"This is where our connections come in," Rooney explains. "We recognize the limitations of our services, because they're telephonic; and we're obviously not able to be there in the home with her."

With the physicians' input, they formulated the most cohesive and best possible plan to prevent the patient from having a crisis, to stabilize her situation, and to get her to agree to home care services, she adds.