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Social Work Intervention Focused on Transitions (SWIFT)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02232126
Recruitment Status : Completed
First Posted : September 5, 2014
Results First Posted : February 10, 2017
Last Update Posted : February 10, 2017
Huntington Hospital
National Institute on Aging (NIA)
Information provided by (Responsible Party):
Susan Enguidanos, University of Southern California

Brief Summary:
In response to Program Announcement (PA)-09-164, "NIH Exploratory/Developmental Research Grant Program (R21) a randomized pilot study testing the efficacy of SWIFT: Social Work Intervention Focused on Transitions among at-risk older adults following hospital discharge to home. This study is drawn from several observations. First, transitions between care settings create elevated risk for poor outcomes and for readmission among older adults leaving the hospital for home largely due to fragmented care and poor communication. Next, while few studies exist that test methods to improve transitions, those available are largely medically focused, using a nurse or advanced practice nurse in their approach. Although evidence exists to support the effectiveness of these models, few have been replicated and none have been integrated into standard health care practice. This may be attributed to several factors including the availability of the needed staff, the lack of existing structures to support these roles, and the costs of implementing these interventions. Finally, a social work driven intervention may provide a replicable mechanism for bridging medical care, addressing psychosocial needs as well as medical needs, and improving linkages with community services while reducing care duplication. This study aimed to test a structured social work transition intervention model to reduce rates of hospital readmission and medical service use while improving patient satisfaction with the care transition process. A randomized pilot study was used to test a social work transitions model designed to improve care provided to frail older adults being discharged from the hospital to return to the community. Eligible patients consenting to participate (n=181) were randomly assigned to either the social work transitions model intervention or usual care. This project was conducted at Huntington Hospital, a 525-bed, nonprofit, community hospital located in Pasadena, California. In an average year, Huntington Hospital has approximately 10,000 older adults discharged from their facility, 44% of who are 80 years old or older. Those randomized to the intervention arm received up to six sessions from the social worker, at least one provided in the home. The social work intervention was designed to overcome common problems following hospital discharge including medication review, discussion and planning around discharge instruction, assistance in scheduling follow up appointments, assessments of psychosocial and other support service needs and provision of linkages to address those needs. Outcomes were measured three and six months following arrival at home, with an interim measure of satisfaction at 10 days following arrival at home, with measures including patient level of depression, pain, physical functioning, self-efficacy with disease management, and medical service use.

Condition or disease Intervention/treatment Phase
Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention Heart Disease Diabetes Hypertension Cancer Depression Asthma Chronic Heart Failure Chronic Obstructive Pulmonary Disease Stroke Other: SWIFT home intervention Not Applicable

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 181 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary Purpose: Health Services Research
Official Title: Social Work Intervention Focused on Transitions Among At-Risk Older Adults
Study Start Date : February 2011
Actual Primary Completion Date : October 2013
Actual Study Completion Date : October 2013

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
No Intervention: Usual Care
Experimental: Intervention Other: SWIFT home intervention
1 in-home assessment performed by study social worker, another in-home visit performed if needed. Up to 4 telephone contacts performed by study social worker. A maximum of 6 contacts

Primary Outcome Measures :
  1. 30-day Hospital Readmission [ Time Frame: 30-days post hospitalization ]
    The outcome measure is the number of readmissions experienced by participants in the Usual Care and Intervention groups within 30-days of their index discharge.

Secondary Outcome Measures :
  1. 30-day Readmission Among Intervention Participants [ Time Frame: 30-days ]
    The outcome measure is the rate of 30-day readmissions among Intervention group participants that declined to receive the in-home social work intervention versus those Intervention group participants that received the in-home social work intervention.

Information from the National Library of Medicine

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Ages Eligible for Study:   65 Years and older   (Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes

Inclusion Criteria:

  • Age 65 or more
  • English-speaking
  • Community dwelling (own home, vs. assisted living facility/skilled care)
  • Living within specified service net
  • Cognitively intact (as measured by a score of 5 or more on the SPMSQ)
  • Meeting at lease one or more of the following:
  • Age 75 or more
  • Taking 5 or more prescription medications
  • Had at least one inpatient admission or emergency department visit in previous 6 months

Exclusion Criteria:

  • Age 64 or younger
  • Non-English speaking
  • Diagnosed with end-stage renal disease
  • Hospice recipient
  • Diagnosis of Alzheimer's disease or severe dementia
  • Residing in assisted living or skilled care facility
  • Homeless

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02232126

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United States, California
University of Southern California
Los Angeles, California, United States, 90089
Huntington Hospital
Pasadena, California, United States, 91105
Sponsors and Collaborators
University of Southern California
Huntington Hospital
National Institute on Aging (NIA)
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Responsible Party: Susan Enguidanos, Associate Professor of Gerontology, University of Southern California Identifier: NCT02232126    
Other Study ID Numbers: UP-10-00372
5R21AG034557-02 ( U.S. NIH Grant/Contract )
First Posted: September 5, 2014    Key Record Dates
Results First Posted: February 10, 2017
Last Update Posted: February 10, 2017
Last Verified: December 2016
Keywords provided by Susan Enguidanos, University of Southern California:
Hospital readmissions
Randomized controlled trial
Older adults
Care transitions
Social work
Additional relevant MeSH terms:
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Lung Diseases, Obstructive
Pulmonary Disease, Chronic Obstructive
Heart Diseases
Cardiovascular Diseases
Lung Diseases
Respiratory Tract Diseases