Enhanced Discharge Planning as an Innovative Model of Transitional Care

Poor care transitions from hospital to home are associated with readmission and increased health care costs. 17.6% of older adults are readmitted within 30 days of discharge, which accounts for $15 billion in Medicare spending. The Enhanced Discharge Planning Program (EDPP) at Rush University Medical Center extends the reach of an urban teaching hospital into the community by providing care coordination and community referral assistance to high risk older adults after hospital discharge. The goal of the program is to prevent post discharge complications, promote independence and enhance quality of life. EDPP helps to prevent rehospitalization by addressing major reasons for readmission: lack of coordination between care settings and psychosocial factors affecting the access to and utilization of quality post-discharge care.

The program distinguishes itself from other transitional care models in that the EDPP utilizes telephone assessment by a masters-level geriatric social worker as a core program intervention. This assessment includes review of the plan of care, barriers to compliance, social support, depressive symptoms and coping.

62% of patients referred in the pilot project (n=1057) needed additional contacts. The most common reasons for referral were: follow up for community services (81.46%), adjustment to illness or treatment (29.14%), caregiver need for emotional support (19.87%) and Issues regarding increased patient dependency (19.68%).The mean number of contacts per patient was 3.5 (range=1-42). Telephone assessments revealed that 60% of participants had needs in one of three areas: obtaining community services, following through on discharge recommendations and caregiver coping with care demands.