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Promising Practices

The Promising Practices database informs professionals and community members about documented approaches to improving community health and quality of life.

The ultimate goal is to support the systematic adoption, implementation, and evaluation of successful programs, practices, and policy changes. The database provides carefully reviewed, documented, and ranked practices that range from good ideas to evidence-based practices.
Learn more about the ranking methodology.

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Social work-based transitional care intervention for super utilizers of medical care

Filed under Evidence-Based Practice, Health / Intervention Data, Urban

Goal: 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.

An Effective Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success and/or promise in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures of improvement in outcome of interest (i.e. increase in voter registration, not just delivery of voter registration drive) and/ or the outcome measure is increased or improved compared to the baseline measurement or the control group but the difference is not statistically significant.

A Good Idea meets the following HCI criteria:

  1. The program description includes: the sponsoring organization, program goals, program funding source, program implementation steps and outcomes.
  2. The program evaluation is limited to descriptive measure(s) of success/accomplishment (i.e., program participation rates, number of services/education sessions/radio messages provided). Note: oftentimes, the program has been newly implemented and a program evaluation has not yet been conducted. Programs that have not yet been evaluated, but which show promise in improving health or quality of life, are classified as Good Ideas until an evaluation is conducted.

An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.

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