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No more revolving door - Can social workers reduce hospital readmissions?

No more revolving door - Can social workers reduce hospital readmissions?

Editor's Note: This is an abridged version of an article that first appeared in the Spring 2013 edition of Binghamton University Magazine. Read the full story here.

By Todd R. McAdam

A baby boomer turns 65 every 11 seconds. By the time you finish this paragraph, one will have blown out the birthday candles and applied for Medicare.

As a huge generation of Americans age, they'll pack hospitals with a variety of gerontological ailments, from acute bronchial infections to broken hips. Big boon to a hospital's bottom line? No.

Under the Affordable Care Act, Medicare won't reimburse hospitals for the cost of treating an aging patient if that patient is readmitted within 30 days. The patient could be treated for pneumonia, go home and break a hip, but the rule remains. With hospitals spending between $10,000 and $31,000 (averaging about $18,000) for a typical stay, and readmissions hovering around 35 percent, that's a big loss.

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So Binghamton University researchers from the College of Community and Public Affairs and the SUNY Upstate Medical University have teamed with a local hospital to seek new, low-cost ways to keep seniors from needing readmission while improving their quality of life.

"A big piece of making this work is making sure people follow up with their primary-care physician," Bronstein says. "There are so many conditions that people have, it's hard to tease out [what can lead to readmission]."


The two-year study, now in its final year, was designed to collect data from 100 or more patients at high risk for hospital readmission but able to live independently, says Laura Bronstein, interim dean, professor of social work and director of the University's Institute for Intergenerational Studies.

Her task was to create an interdisciplinary training program so social workers understand the medical factors that can complicate recovery and so medical providers understand the everyday living issues that can cause hospital readmission.

Making contact

Social-work students were assigned to follow up with patients released from United Health Services' Wilson Medical Center in Johnson City, N.Y.

The monthlong follow-up begins with a phone call to make sure the patient is recuperating, says Kris Marks, LCSW, manager of clinical social work at UHS. A home visit follows, and the assessment starts outside: Are the sidewalk and driveway shoveled during a cold upstate New York winter? Are steps to the door difficult to navigate for someone who may have mobility problems? Is the garage door easily opened?

Inside, the examination continues. How does the patient feel? Are there any pain- or medication-related side effects? Is the patient making follow-up appointments? If not, why not? Does the patient have adequate support - friends and relatives who can help with everyday chores such as cooking or driving?

Gaps in the recovery process can lead to a complication that can require a hospital readmission.

"A big piece of making this work is making sure people follow up with their primary-care physician," Bronstein says. "There are so many conditions that people have, it's hard to tease out [what can lead to readmission]."

Sometimes all that's needed is a tweak of available services, Marks says, such as arranging for Meals on Wheels or a short-term home-health aide. "I think some people just benefit from the contact they get," she says.

Read the rest of the story on the Binghamton University Magazine website.

HOW YOU CAN HELP
You can do some of the empowerment work that Binghamton University and United Health Services provide to keep seniors from being readmitted to a hospital, says Kris Marks, manager of clinical social work at UHS.

Keep in contact with a relative, friend or neighbor who just got out of the hospital. Look for a few things:

  • Is the patient feeling pain, disorientation or discomfort? Does supplied medical equipment work well? Suggest following up with a doctor.
  • Is the patient able to keep follow-up appointments? Patients may be able to drive, but can't get anywhere if they can't shovel the walk or open the garage door.
  • Does the patient eat well and see to the typical chores of life? Patients with mobility problems or pain may try to endure it - to their detriment - rather than get help.
  • Does the patient have an adequate support network? Do friends or family - people like you - stop by to make sure the patient is OK and essential tasks are completed?

Simple questions, simple contact, can keep a patient from needing readmission, Marks says. Beyond that, the patient will be more comfortable and healthier, too.