Improving care transitions for older adults: The Enhanced Discharge Planning Program

The Rush University Enhanced Discharge Planning Program (EDPP) is a social work based transitional care model that provides telephone-based follow-up and short term care coordination for at risk older adults following hospital discharge. EDPP social workers utilize a biopsychosocial framework for assessing post-discharge problems and intervening to enhance adherence to the treatment plan including medication compliance and physician visits as well as caregiver burden and other issues that impact health and quality of life.

Mixed methods research on this intervention has shown high levels of unmet needs in this patient population. Telephone assessment within 72 hours of hospital discharge revealed unresolved problems in 83% of 360 intervention group participants. For almost three-quarters of those with issues, the problems did not emerge until after hospital discharge. Difficulties in adjusting to illness, caregiver stress and problems in obtaining home health care were problematic for significant fractions of those served. The mean duration of the intervention was 5.8 days and the mean number of contacts made by EDPP social workers was 5.4 calls.

Qualitative interviews with EDPP clinicians reinforced the concept of unanticipated challenges or “surprises” as complicating patient transitions. Another salient theme was the ability of the social workers to transcend institutional roles to resolve problems. Almost one-third of patients in the intervention group re-contacted the EDPP program for additional assistance after their cases were closed, suggesting the need for continued care coordination resources in a significant minority of older adult patients.