a School of Social Work , University of Michigan , Ann Arbor , MI , US.
b Social Work and Community Health , Rush University Medical Center , Chicago , IL , US.
Soc Work Health Care. 2019 Jan;58(1):126-141. doi: 10.1080/00981389.2018.1547345. Epub 2018 Nov 14.
The present study was a retrospective evaluation of a social worker-led transitional care intervention that addresses the medical and social needs of inpatient super utilizers with ≥5 inpatient admissions in a 12-month period. Bivariate analyses revealed significant reductions in the total number of hospital admissions, 30-day readmission rates, number of emergency department visits, average hospital charges per episode, and total hospital charges per person after the intervention. This social work intervention may be of interest to providers and payers, particularly regarding addressing the psychosocial needs of complex patients who account for most of health care costs.
本研究对一名社工主导的过渡性护理干预进行了回顾性评估，该干预措施针对的是在 12 个月内有≥5 次住院经历的住院超高使用率患者的医疗和社会需求。双变量分析显示，干预后总住院人数、30 天再入院率、急诊就诊次数、每次住院平均费用和每人总住院费用均显著降低。这种社会工作干预可能会引起提供者和付款人的兴趣，特别是在解决占医疗费用大部分的复杂患者的心理社会需求方面。
