Summary 

Efforts to reduce readmissions after hospital discharge are increasingly being made to better identify and address social and logistical needs in addition to attending to post-hospital clinical challenges. A transitional care model based in the social work professional skill set may be well matched to assess and address social and logistical needs during the post-hospital transitional care period. The effect of a social work–based transitional care intervention on all-cause 30-day readmission rates for Medicare fee-for-service (FFS) beneficiaries discharged from an urban medical center was analyzed. Analyses revealed a 20% relative reduction in readmissions for 1,546 Medicare FFS discharges to home, with or without home care (a 4.5% absolute rate reduction). This model may be of interest to entities that are accountable for the care of individuals with complex social needs, such as dually eligible individuals (those eligible for Medicare and Medicaid) and adults who are newly eligible for Medicaid coverage.