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Social work-based transitional care intervention for super utilizers of medical care

An Evidence-Based Practice

Description

The Bridge Model for Super Utilizers adapted the Bridge Model (see Alvarez et al., 2016) by intensifying patient engagement with an average of 40 patient contacts over 6 months following an index admission.

Goal / Mission

The goal of this study is to evaluate the effectiveness of a social work intervention aimed to address the medical and social needs of inpatient super-utilizers.

Impact

This intervention was modeled after the "Bridge Model" by intensifying patient engagement with an average of 40 patient contacts over 6 months following an index admission. This intervention has the potential to reduce health services utilization and cost among inpatient super utilizers.

Results / Accomplishments

A comparison of utilization 12 months before and 12 months after the intervention found a 59% reduction in the number of hospital admissions, from 5.75 per patient (95% CI = 95% CI = 5.64–5.88) to 2.38 per patient (95% CI = 2.17–2.59), a 37% reduction in the number of ED visits (from 5.39 to 3.38 per patient), and 47% reduction in the 30-day readmission rate (from 25.5% to 13.4%).

About this Promising Practice

Organization(s)
University of Michigan, Rush University Medical Center
Topics
Health / Intervention Data
Organization(s)
University of Michigan, Rush University Medical Center
Date of publication
Nov 2018
Geographic Type
Urban
For more details
https://www.tandfonline.com/doi/full/10.1080/00981...

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Related Content for: Social work-based transitional care intervention for super utilizers of medical care

An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.