Social work-based transitional care intervention for super utilizers of medical care
An Evidence-Based Practice
Description
The Bridge Model for Super Utilizers adapted the Bridge Model (see Alvarez et al., 2016) by intensifying patient engagement with an average of 40 patient contacts over 6 months following an index admission.
Goal / Mission
The goal of this study is to evaluate the effectiveness of a social work intervention aimed to address the medical and social needs of inpatient super-utilizers.
Impact
This intervention was modeled after the "Bridge Model" by intensifying patient engagement with an average of 40 patient contacts over 6 months following an index admission. This intervention has the potential to reduce health services utilization and cost among inpatient super utilizers.
Results / Accomplishments
A comparison of utilization 12 months before and 12 months after the intervention found a 59% reduction in the number of hospital admissions, from 5.75 per patient (95% CI = 95% CI = 5.64–5.88) to 2.38 per patient (95% CI = 2.17–2.59), a 37% reduction in the number of ED visits (from 5.39 to 3.38 per patient), and 47% reduction in the 30-day readmission rate (from 25.5% to 13.4%).
About this Promising Practice
Organization(s)
University of Michigan, Rush University Medical Center
Topics
Health / Intervention Data
Organization(s)
University of Michigan, Rush University Medical Center
Date of publication
Nov 2018
Geographic Type
Urban
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