Social Work Intervention Focused on Transitions

Stroke Clinical Trial

— SWIFT  

Official title:

Social Work Intervention Focused on Transitions Among At-Risk Older Adults

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02232126
• Other study ID #: UP-10-00372
• Secondary ID: 5R21AG034557-02
• Status: Completed
• Phase: N/A
• Start date: February 2011
• Est. completion date: October 2013

Study information

• Verified date: November 2023
• Source: University of Southern California
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

In response to Program Announcement (PA)-09-164, "NIH Exploratory/Developmental Research Grant Program (R21) a randomized pilot study testing the efficacy of SWIFT: Social Work Intervention Focused on Transitions among at-risk older adults following hospital discharge to home. This study is drawn from several observations. First, transitions between care settings create elevated risk for poor outcomes and for readmission among older adults leaving the hospital for home largely due to fragmented care and poor communication. Next, while few studies exist that test methods to improve transitions, those available are largely medically focused, using a nurse or advanced practice nurse in their approach. Although evidence exists to support the effectiveness of these models, few have been replicated and none have been integrated into standard health care practice. This may be attributed to several factors including the availability of the needed staff, the lack of existing structures to support these roles, and the costs of implementing these interventions. Finally, a social work driven intervention may provide a replicable mechanism for bridging medical care, addressing psychosocial needs as well as medical needs, and improving linkages with community services while reducing care duplication. This study aimed to test a structured social work transition intervention model to reduce rates of hospital readmission and medical service use while improving patient satisfaction with the care transition process. A randomized pilot study was used to test a social work transitions model designed to improve care provided to frail older adults being discharged from the hospital to return to the community. Eligible patients consenting to participate (n=181) were randomly assigned to either the social work transitions model intervention or usual care. This project was conducted at Huntington Hospital, a 525-bed, nonprofit, community hospital located in Pasadena, California. In an average year, Huntington Hospital has approximately 10,000 older adults discharged from their facility, 44% of who are 80 years old or older. Those randomized to the intervention arm received up to six sessions from the social worker, at least one provided in the home. The social work intervention was designed to overcome common problems following hospital discharge including medication review, discussion and planning around discharge instruction, assistance in scheduling follow up appointments, assessments of psychosocial and other support service needs and provision of linkages to address those needs. Outcomes were measured three and six months following arrival at home, with an interim measure of satisfaction at 10 days following arrival at home, with measures including patient level of depression, pain, physical functioning, self-efficacy with disease management, and medical service use.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 181
• Est. completion date: October 2013
• Est. primary completion date: October 2013
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 65 Years to 110 Years

Eligibility

Inclusion Criteria:

• Age 65 or more

• English-speaking

• Community dwelling (own home, vs. assisted living facility/skilled care)

• Living within specified service net

• Cognitively intact (as measured by a score of 5 or more on the SPMSQ)

• Meeting at lease one or more of the following:

• Age 75 or more

• Taking 5 or more prescription medications

• Had at least one inpatient admission or emergency department visit in previous 6 months

Exclusion Criteria:

• Age 64 or younger

• Non-English speaking

• Diagnosed with end-stage renal disease

• Hospice recipient

• Diagnosis of Alzheimer's disease or severe dementia

• Residing in assisted living or skilled care facility

• Homeless

Related Conditions & MeSH terms

• Asthma
• Cancer
• Chronic Heart Failure
• Chronic Obstructive Pulmonary Disease
• Depression
• Diabetes
• Heart Disease
• Heart Diseases
• Hypertension
• Lung Diseases, Obstructive
• Pulmonary Disease, Chronic Obstructive
• Stroke
• Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention

Intervention

Other:
• SWIFT home intervention
1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts

Locations

Country	Name	City	State
United States	University of Southern California	Los Angeles	California
United States	Huntington Hospital	Pasadena	California

Sponsors (3)

Lead Sponsor	Collaborator
University of Southern California	Huntington Hospital, National Institute on Aging (NIA)

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	30-day Hospital Readmission	The outcome measure is the number of readmissions experienced by participants in the Usual Care and Intervention groups within 30-days of their index discharge.	30-days post hospitalization
Secondary	30-day Readmission Among Intervention Participants	The outcome measure is the rate of 30-day readmissions among Intervention group participants that declined to receive the in-home social work intervention versus those Intervention group participants that received the in-home social work intervention.	30-days