The goal of this study was to determine the effectiveness of having an Independence Blue Cross (IBC) health plan social worker meet with patients who were members in IBC’s special needs program (SNP) prior to discharge during an acute hospital admission. SNP members have dual eligibility — i.e., they have both Medicare and Medicaid medical benefits. These patients have many non-medical factors that influence their use of services. These include poverty, lack of caregivers at home, difficult home environment, difficulty filling prescriptions (mail unsafe), transportation difficulties, and illiteracy.
The social worker’s role is to serve as a transition coach, as discussed in detail below. Such coaches aren’t direct caregivers and so can handle larger caseloads. The main objective was to increase enrollment in IBC’s case management program for this population. Some secondary objectives were to reduce hospital readmissions and emergency room (ER) visits. Other objectives included increasing primary care physician (PCP) and specialist visits and follow-up contact rates. This was a non-randomized study implemented at an urban academic hospital. A social worker was assigned to talk to the eligible patients with admissions from September 2007 to May 2008. The social worker made rounds at the hospital approximately two days per week, and interviewed half of all eligible patients. The social work intervention was designed to educate patients about the case management program available to them at IBC and about as other benefits, such as subsidized public transportation. In addition, the social worker focused on self-management skills, making sure the members scheduled follow-up appointments with their PCP, filled and adhered to prescriptions, and remained receptive to follow-up calls from social services. An information sheet with contact information and reminders was given to the member.