Social Work and Transitions of Care: Observations from an Intervention for Older Adults

Abstract

Making the transition from hospital to home can be challenging for many older adults. This article presents practice perspectives on these transitions, based on a social work intervention for older adults discharged from an acute care setting to home. An analysis of interviews with clinical social workers who managed 356 cases (n = 3) and a review of their clinical notes (n = 581) were used to identify salient themes relevant to care transitions. Concepts developed and discussed identify the role of surprises after discharge, an expanded view of the client system, and relationship building as instrumental in carrying out effective care transitions.

Keywords:

• transitions of care
• discharge planning
• medical social work
• qualitative analysis

Acknowledgments

This project was supported by the department of Older Adult Programs at Rush University Medical Center as an extension of the Enhanced Discharge Planning Program. Thank you to Jung-Hwa Ha at the University of Chicago for reviewing this article.