Researchers develop program to reduce hospital readmissions by more than half

When a Medicare patient heads home from the hospital, the last thing they want is to be part of the revolving door of readmission that costs the healthcare industry and Medicare billions of dollars each year. That's why researchers from Binghamton University's College of Community and Public Affairs and SUNY Upstate Medical University have teamed up to develop a new program using social workers to establish new community-based alternatives to keep recently discharged patients healthy and out of the hospital.

Early results reveal the approach is effective in reducing readmissions by more than half.

Laura Bronstein, chair of Binghamton University's Department of Social Work and director of the university's Institute for Intergenerational Studies, created this interdisciplinary training program so social workers and medical professionals could better understand the challenges each group faces in trying to improve patient health. Her group's just-completed two-year study collected data from approximately 100 patients living independently, but at high risk for hospital readmission. Students were assigned to follow up with patients released from nearby United Health Services' Wilson Medical Center.

"They call and arrange to visit the recently released patient," said Bronstein. "They find out how the patient feels, whether they are taking their medicine or experiencing any side effects from it, and they assess the individual's home environment to determine if there are risks of the patient falling or straining themselves."

In addition to possibly improving the patient's home environment, making sure people follow up with their primary care physician is key, Bronstein says. She presented her research, which shows that the social work intervention is effective, at the National Association of Deans and Directors of Social Work meeting in April, and is preparing it for submission to a journal, this summer. The participants in the experimental group experienced only a 7 percent readmission rate, she said.

Patients discharged from Wilson Medical Center during the same period and meeting the same criteria, but who are were in the control group experienced a 15 percent return rate. At some hospitals nationwide, the average readmission rate can be as high as 30 percent.

Dr. Shawn Berkowitz, medical director of the study, director of geriatrics at UHS and a clinical assistant professor at SUNY Upstate Medical University, says preliminary analysis of the initial participants is promising. "If other hospitals can duplicate this model, they would save hundreds of thousands, if not millions, of dollars every year," he said. "A social worker can create savings equal to his own salary and benefits just by preventing seven readmissions a year—and the patient's quality of life is improved significantly in the process."