Photo: Corbis

What the new Rush program does, says Anthony Perry, a geriatrician at Rush, is look beyond medical treatments to see what the patients will need once they have left the hospital’s care. “We only see a piece of that patient, and we sometimes don’t know what all the issues are” when the patient returns home, he says.

Perry says social workers are best equipped to make the follow-up calls, especially to older patients, because they are familiar with the community services and can cut through bureaucratic thickets.

Readmission rates cut by half

Rush doesn’t yet have complete results on whether its program is reducing hospital readmissions. Other studies, however, have shown this kind of out-of-hospital help can cut readmissions by about half. At a University of Pennsylvania hospital, where nurses made home visits and arranged follow-up visits and community services, just 28 percent of patients were back in the hospital within 26 weeks. In the control group, 56 percent had to be readmitted.

This fall, Rush will offer the same sort of assistance before people even leave the hospital. Doctors and social workers will spend more time with the patients and their families or caregivers, going over their medications and discharge instructions and contacting their personal doctors to provide medical updates and arrange appointments. All this attention to the patient is part of a pilot program that involves Rush and 29 other hospitals across the country. It’s called Project BOOST—Better Outcomes for Older adults through Safe Transitions—and is sponsored by the Society of Hospital Medicine.

Fixing a fragmented system

Rooney, the Rush social worker, says better care doesn’t require a lot more people or money. What’s needed are better, more effective ways to use the people, programs and money already there.

That’s a sentiment that patients like 84-year-old Elizabeth Schickel can understand. Eye problems had forced her to give up driving. After her surgery in April, Schickel wasn’t sure how she would get back to Rush for her follow-up appointment. A Rush social worker told her about free rides available from the city. “That was really helpful,” Schickel says. “You don’t know those things unless someone calls you and tells you.”

Donald Musil, who has been in a wheelchair since a fall last year, didn’t need the help of a Rush social worker—but his wife did. Susan Musil says she was emotionally drained from caring for her 73-year-old husband. She worried that her stress could affect his health. When she asked the rehabilitation center treating her husband to help her find counseling, the staff gave her the only number it had—for a crisis hotline. A Rush social worker, however, found a counseling agency that specialized in therapy for caregivers and even checked back with Musil after her first appointment.

“When she called,” Musil says, “it was just a breath of fresh air.”

As for Katherine Ellis, she, too, had a fresh start thanks to the Rush program: She hasn’t been back in a hospital since she left Rush almost seven months ago.

Phuong Ly is a freelance writer based in Chicago.

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