Hospitals in pursuit of excellence

Strength Improves Care

Aesop?s fable "The Bundle of Sticks" teaches a lesson in working together: "Union gives strength." Care coordination at hospitals is also a tale of strength in teamwork. At Rush University Medical Center, Chicago, social workers from the medical center?s Older Adult Programs have teamed with the Case Management Department to provide telephonic post-discharge follow-up to patients age 65 or older. With the Enhanced Discharge Planning Program, Rush social workers phone an older adult deemed at risk after inpatient hospitalization and, using a biopsychosocial framework, assess how the patient is recovering and adhering to the treatment plan. Trained in care coordination and knowledgeable about community resources, social workers help Rush deliver patient-centered care that meets the patients? medical and social needs and improves health outcomes. In addition, EDPP potentially prevents hospital readmissions?particularly significant as almost 20 percent of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, and each older adult readmission is estimated to cost hospitals an average of $7,400.