Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths

AHRQ Innovations Exchange | Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths

The program enhanced patients' and caregivers' knowledge and ability to manage at home, improved attendance at followup appointments, and reduced readmissions and deaths.