Transitions of care present multiple biopsychosocial challenges to older adults and their caregivers. Psychosocial factors, such as limited financial or community resources, adjustment to having an illness, low health literacy, caregiver stress, the need for home care or residential placement, can contribute to problems during transitions of care and increase an older adult’s risk of medical complications. Addressing these factors is a key component of a social work approach to care and is important in preventing and addressing problems related to care transitions.
The existing literature and current research on transitional and coordinated care are dominated by medical models of care primarily staffed by nurses. Medical models of care often focus on what happens in the hospital and on medical concerns after discharge. However, studies suggest that 40% to 50% of hospital readmissions are linked to social problems and lack of community resources. While social work-based models addressing these issues have not been extensively studied, the limited research available suggests positive outcomes: A randomized control trial using social workers as case managers in a transitional care intervention for Medicare managed care recipients showed promising results. Another randomized control trial, of the Enhanced Discharge Planning Program (EDPP) at Rush University Medical Center, provides preliminary evidence for the success of a transitional care model that uses social workers to address the psychosocial needs of individuals in addition to their medical needs. Further research beyond the medical, physician, and nursing models of transitional care is imperative to further explore the best ways to mitigate the myriad factors that lead to rehospitalization, negative patient outcomes and high health care costs.