Objective:

The objective was to identify if the intervention would reduce hospital utilization.

Design:

We used a retrospective, single group, pre-post design to provide a preliminary evaluation of Bridge-SU.  

Setting:

Teaching Hospital, West Chicago

Participants:

Individuals 18 years or older with more than 5 inpatient admissions in a 12-month period.

Intervention:

Social worker-led transitional care intervention that addresses the medical and social needs of inpatient super utilizers, defined as those with more than 5 inpatient admissions in a 12-mont period.

Measurements:

Number of hospital admissions, 30-day readmission rates, average length of stay and number of emergency department (ED) visits.

Results:

In the 12 months after the intervention, hospital charges per patient were reduced by nearly $200,000, ED visits decreased by two visits per patient, and 30-day readmission rates were halved among a racially diverse population of inpatient super utilizers. For the six, three, and one months following the intervention, there were significant decreases in the use of health services and associated costs. Following the intervention, the average length of stay did not change significantly.

Conclusion:

There is a chance that an intervention in transitional care spearheaded by social workers will lower the cost and use of health services among inpatient superusers by addressing the complicated social and medical requirements of patients. Further research is required to evaluate its cost-effectiveness, processes of change, potential modifiers, as well as implementation techniques after they have been proven successful.