Transitioning elderly from hospital/home

CHICAGO, July 30 (UPI) -- U.S. researchers have set up a study to determine how seniors may best avoid hospital readmission.

The program in effect at Rush University Medical Center in Chicago for two years uses social workers, rather than nurses, to coordinate the after-hospital care.

"Patients who have been enrolled in our enhanced discharge planning program over the last two years are extremely pleased with the service," Robyn Golden a social worker at Rush said in a statement. "But beyond patient satisfaction, we now need to formally evaluate the program in a randomized, controlled study to determine whether our model -- using social workers rather than nurses -- not only reduces readmissions, but also reduces emergency room visits, avoids nursing home placements and improves quality of life."

During the two years of the Rush program, the social workers have noted several common themes in post-discharge care.

Patients report having difficulty with mobility, scheduling medical appointments and getting to their physicians' offices. Also, there were reports of delays in home healthcare services and caregivers saying they were often overwhelmed in caring for someone discharged from the hospital.