Experiences and Perceptions of Hospital Social Workers Regarding Discharge Planning and Readmission
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The Centers for Medicare and Medicaid Services created the Hospital Readmission Reduction Program in 2010 to decrease the problem of hospital readmissions. This program reduces hospital reimbursements from Medicare or Medicaid when patients with specific diagnoses are readmitted within 30 days of discharge. This generic qualitative study explored hospital social workers’ experiences and perceptions of the impact of discharge planning on hospital readmission. Meleis’s transitions theory provided the conceptual framework for this study. Data were collected from semistructured interviews with 10 female medical social workers. Data analysis entailed categorizing and classifying the data into emerging themes to answer the research question. The themes were (a) lack of community resources, (b) hospital administrative challenges, (c) lack of family/social support, and (d) RN versus social worker issues/lack of role definition. Recommendations include standardizing health care social worker roles and providing more time for complex patients to ensure the implementation of all needed services before discharge. Implications for social change include improved discharge planning outcomes, increased support from administration, and consistent social worker role definition and tasks. Positive social change is possible at the policy level because findings showed that providing enough care for patients can reduce hospital readmissions.
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1. AAFP. (2022). Health care for all: A framework for moving to a primary care-based health care system in the United States. https://www.aafp.org/about/policies/all/health-care-for-all.html
2. Agency for Healthcare Research and Quality. (2018). 30-day readmission rates to U.S. hospitals. https://www.ahrq.gov/data/infographics/readmission-rates.html
3. Alper, E., O’Malley, T. A., & Greenwald, J. (2017). Hospital discharge and readmission.
UpToDate. http://www.uptodate.com/contents/hospital-discharge-and-readmission
4. Alrubaian, M., Al-Qurishi, M., Alamri, A., Al-Rakhami, M., Hassan, M. M., & Fortino,
5. G. (2018). Credibility in online social networks: A survey. IEEE Access, 7, 2828– 2855. https://doi.org/10.1109/ACCESS.2018.2886314
6. Alvarez, R., Ginsburg, J., Grabowski, J., Post, S., & Rosenberg, W. (2016). The social work role in reducing 30-day readmissions: The effectiveness of the bridge model of transitional care. Journal of Gerontological Social Work, 59(3), 222–227. https://doi.org/10.1080/01634372.2016.1195781
7. Amankwaa, L. (2016). Creating protocols for trustworthiness in qualitative research. Journal of Cultural Diversity, 23(3), 121–127.
8. Ambrose-Miller, W., & Ashcroft, R. (2016). Challenges faced by social workers as members of interprofessional collaborative health care teams. Health & Social Work, 41(2), 101–109. https://doi.org/10.1093/hsw/hlw006
9. Anney, V. N. (2014). Ensuring the quality of the findings of qualitative research: Looking at trustworthiness criteria. Journal of Emerging Trends in Educational Research and Policy Studies, 5(2), 272–281. https://tinyurl.com/3am5v24v
10. Ayabakan, S., Bardhan, I., & Zheng, Z. (2021). Triple aim and the hospital readmission reduction program. Health Services Research & Managerial Epidemiology, 8, Article 2333392821993704. https://doi.org/10.1177/2333392821993704
11. Babbie, E. (2017). The basics of social research. Cengage Learning.
12. Bailey, M. K., Weiss, A. J., Barrett, M. L., & Jiang, H. J. (2019). Characteristics of 30- day all-cause hospital readmissions, 2010–2016 (Statistical brief #248). Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb248-Hospital-Readmissions-2010-2016.jsp
13. Barnes, M. D., Hanson, C. L., Novilla, L. B., Magnusson, B. M., Crandall, A. C., & Bradford, G. (2020). Family-centered health promotion: Perspectives for engaging families and achieving better health outcomes. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, Article 0046958020923537. https://doi.org/10.1177/0046958020923537
14. Benoot, C., Enzlin, P., Peremans, L., & Bilsen, J. (2018). Addressing sexual issues in palliative care: A qualitative study on nurses’ attitudes, roles and experiences. Journal of Advanced Nursing, 74(7), 1583–1594. https://doi.org/10.1111/jan.13572
15. Birmingham, L. E., & Oglesby, W. H. (2018). Readmission rates in not-for-profit vs. proprietary hospitals before and after the Hospital Readmission Reduction Program implementation. BMC Health Services Research, 18(1), Article 31. https://doi.org/10.1186/s12913-018-2840-4
16. Boccuti, C., & Casillas, G. (2017, March). Aiming for fewer hospital U-turns: The Medicare Hospital Readmission Reduction Program [Issue brief]. http://files.kff.org/attachment/Issue-Brief-Fewer-Hospital-U-turns-The-Medicare-Hospital-Readmission-Reduction-Program
17. Boll, A. M., Ensey, M. R., Bennett, K. A., O’Leary, M. P., Wise-Swanson, B. M., Verrall, A. M., Vitiello, M. V., Cochrane, B. B., & Phelan, E. A. (2021). A feasibility study of primary care liaisons: Linking older adults to community resources. American Journal of Preventive Medicine, 61(6), e305–e312. https://doi.org/10.1016/j.amepre.2021.05.034
18. Braun, V., & Clarke, V. (2014). What can “thematic analysis” offer health and wellbeing researchers? International Journal of Qualitative Studies on Health and Wellbeing, 9(1), Article 26152. https://doi.org/10.3402/qhw.v9.26152
19. Browne, T. (2019). Social work roles and healthcare settings. In S. Gehlert, & T. Browne (Eds.), Handbook of health social work (pp. 21–37). John Wiley & Sons.
20. Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. H. (2020).
21. Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resource Health, 18. https://doi.org/10.1186/s12960-019-0411-3
22. Centers for Medicare and Medicaid Services. (2016). Readmissions Reduction Program. https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
23. Chernof, B. A. (2019). Integrating Medicare and Medicaid: Successes to date, lessons learned, and the road ahead. Milbank Quarterly, 97(1), 31–35. https://doi.org/10.1111/1468-0009.12371
24. Connell, C. M., Bory, C. T., Huang, C. Y., Genovese, M., Caron, C., & Tebes, J. K. (2019). Caseworker assessment of child risk and functioning and their relation to service use in the child welfare system. Children and Youth Services Review, 99, 81–86. https://doi.org/10.1016/j.childyouth.2019.01.027
25. Connelly, L. M. (2016). Trustworthiness in qualitative research. Medsurg Nursing, 25(6), 435–436. https://www.proquest.com/openview/44ffecf38cc6b67451f32f6f96a40c78/1?pq-origsite=gscholar&cbl=30764
26. Cope, D. G. (2014). Methods and meanings: Credibility and trustworthiness of qualitative research. Oncology Nursing Forum, 41(1), 89–91. https://doi.org/10.1188/14.ONF.89-91
27. Cowan, C., El-Hage, N., Green, J., Rice, L., Young, L., & Whiteside, M. (2020).
28. Investigating the readiness of hospital social workers to respond to domestic and family violence. Australian Social Work, 73(3), 357–367. https://doi.org/10.1080/0312407X.2019.1675735
29. Craig, S. L., & Muskat, B. (2013). Bouncers, brokers, and glue: The self-described roles of social workers in urban hospitals. Health & Social Work, 38(1), 7–16. https://doi.org/10.1093/hsw/hls064
30. Davies, S. (2005). Meleis’s theory of nursing transitions and relatives’ experiences of nursing home entry. Journal of Advanced Nursing, 52(6), 658–671. https://doi.org/10.1111/j.1365-2648.2005.03637.x
31. Daniel, B. K. (2019, June). What constitutes a good qualitative research study?
32. Fundamental dimensions and indicators of rigour in qualitative research: The TACT framework. In Proceedings of the European conference of research methods for business & management studies (pp. 101-108).
33. Ercia, A. (2021). The impact of the Affordable Care Act on patient coverage and access to care: Perspectives from FQHC administrators in Arizona, California, and Texas. BMC Health Services Research, 21(1), 1–9. https://doi.org/10.1186/s12913-021-06961-9
34. Findley, P. A. (2014). Social work practice in the chronic care model: Chronic illness and disability care. Journal of Social Work, 14(1), 83–95. https://doi.org/10.1177/1468017313475381
35. Finfeld-Connett, D. (2008). Qualitative convergence of three nursing concepts: Art of nursing, presence and caring. Journal of Advanced Nursing, 63(5), 527–534. https://doi.org/10.1111/j.1365-2648.2008.04622.x
36. Fonarow, G. C., Konstam, M. A., & Yancy, C. W. (2017). The hospital readmission reduction program is associated with fewer readmissions, more deaths: Time to reconsider. Journal of the American College of Cardiology, 70(15), 1931–1934. https://doi.org/10.1016/j.jacc.2017.08.046
37. Frankel, A. J., Gelman, S. R., & Pastor, D. K. (2018). Case management: An introduction to concepts and skills. Oxford University Press.
38. Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in qualitative research. The Qualitative Report, 20(9), 1408–1416. https://doi.org/10.46743/2160-3715/2015.2281
39. Hadi, M. A., & Closs, S. J. (2016). Ensuring rigor and trustworthiness of qualitative research in clinical pharmacy. International Journal of Clinical Pharmacy, 38(3), 641–646. https://doi.org/10.1007/s11096-015-0237-6
40. Hayajneh, A. A., Hweidi, I. M., & Abu Dieh, M. W. (2020). Nurses’ knowledge, perception and practice toward discharge planning in acute care settings: A systematic review. Nursing Open, 7(5), 1313–1320. https://doi.org/10.1002/nop2.547
41. Henke, R. M., Karaca, Z., Jackson, P., Marder, W. D., & Wong, H. S. (2017). Discharge Planning and Hospital Readmissions. Medical Care Research and Review, 74(3), 345–368. https://doi.org/10.1177/1077558716647652
42. Himmelstein, D. U., & Woolhandler, S. (2016). The current and projected taxpayer shares of US health costs. American Journal of Public Health, 106(3), 449–452. https://doi.org/10.2105/ajph.2015.302997
43. Hoffman, G. J., Tilson, S., & Yakusheva, O. (2020). The financial impact of an avoided readmission for teaching and safety-net hospitals under Medicare’s Hospital Readmission Reduction Program. Medical Care Research & Review, 77(4), 324–333. https://doi.org/10.1177/1077558718795733
44. Hussein, A. (2015). The use of triangulation in social sciences research: Can qualitative and quantitative methods be combined? Journal of Comparative Social Work, 4(1), 106–117. https://doi.org/10.31265/jcsw.v4i1.48
45. Ivic, R., Kurland, L., Vicente, V., Castrén, M., & Bohm, K. (2020). Serious conditions among patients with non-specific chief complaints in the pre-hospital setting: A retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28(1), 1–7. https://doi.org/10.1186/s13049-020-00767-0
46. Judd, R. G., & Sheffield, S. (2010). Hospital social work: Contemporary roles and professional activities. Social Work in Health Care, 49(9), 856–871. https://doi.org/10.1080/00981389.2010.499825
47. Kahlke, R. M. (2014). Generic qualitative approaches: Pitfalls and benefits of methodological mixology. International Journal of Qualitative Methods, 13(1), 37–52. https://doi.org/10.1177/160940691401300119
48. Kahlke, R. M. (2018). Reflection/commentary on a past article “Generic qualitative approaches: Pitfalls and benefits of methodological mixology.” International Journal of Qualitative Methods, 17(1), Article 1609406918788193. https://doi.org/10.1177/1609406918788193
49. Kennedy, D. M. (2016). Is it any clearer? Generic qualitative inquiry and the VSAIEEDC model of data analysis. The Qualitative Report, 21(8), 1369–1379. https://doi.org/10.46743/2160-3715/2016.2444
50. Klein, S. (2018). In focus: Preventing unnecessary hospital readmissions. The Commonwealth Fund. https://www.commonwealthfund.org/publications/newsletter-article/focus-
51. preventing-unnecessary-hospital-readmissions
52. Korstjens, I., & Moser, A. (2017). Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing, European Journal of General Practice, 24(1), 120–124. https://doi.org/10.1080/13814788.2017.1375092
53. Liao, H., & Hitchcock, J. (2018). Reported credibility techniques in higher education evaluation studies that use qualitative methods: A research synthesis. Evaluation and Program Planning, 68, 157–165. https://doi.org/10.1016/j.evalprogplan.2018.03.005
54. Liu, L. (2016). Using generic inductive approach in qualitative educational research: A case study analysis. Journal of Education and Learning, 5(2), 129–135. http://dx.doi.org/10.5539/jel.v5n2p129
55. Loskutova, N. Y., Tsai, A. G., Fisher, E. B., LaCruz, D. M., Cherrington, A. L., Harrington, T. M., Turner, T. J., & Pace, W. D. (2016). Patient navigators connecting patients to community resources to improve diabetes outcomes. The Journal of the American Board of Family Medicine, 29(1), 78–89. https://doi.org/10.3122/jabfm.2016.01.150048
56. Madgett, K. (2017). Julia Clifford Lathrop (1858–1932). In The embryo project encyclopedia. Arizona Board of Regents. http://hdl.handle.net/10776/11508
57. Mann, C. C., Golden, J. H., Cronk, N. J., Gale, J. K., Hogan, T., & Washington, K. T. (2016). Social workers as behavioral health consultants in the primary care clinic. Health & Social Work, 41(3), 196–200. http://doi.org/10.1093/hsw/hlw027
58. Massachusetts General Hospital. (2011). Social service. https://www.mghpcs.org/SocialService/History.asp
59. Mazloum, S. R., Heidari-Gorji, M. A., Bidgoli-Gholkhatmi, M., & Agayei, N. (2016). Effectiveness of discharge-planning on physical quality of life of patients with ischemic heart disease. International Journal of Applied & Basic Medical Research, 6(2), 129–133. https://doi.org/10.4103/2229-516X.179018
60. Meleis, A. I. (2010). Transitions theory: Middle-range and situation-specific theories in nursing research and practice. Springer.
61. Meleis, A. I., Sawyer, L. M., Im, E. O., Messias, D. K. H., & Schumacher, K. (2000).
62. Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1), 12–28. https://doi.org/10.1097/00012272-200009000-00006
63. Melville, A., & Hincks, D. (2016). Conducting sensitive interviews: A review of reflections. Law and Method, 1(1), 1–26. https://doi.org/10.5553/rem/.000015
64. Miller, M. E. (2015, July 22). Hospital policy issues. MedPAC. https://tinyurl.com/57afrkut
65. Nasa, P., Jain, R., & Juneja, D. (2021). Delphi methodology in healthcare research: How to decide its appropriateness. World Journal of Methodology, 11(4), 116–129. https://doi.org/10.5662/wjm.v11.i4.116.
66. Ody, C., Msall, L., Dafny, L. S., Grabowski, D. C., & Cutler, D. M. (2019). Decreases in readmissions credited to Medicare’s program to reduce hospital readmissions have been overstated. Health Affairs, 38(1), 36–43. https://doi.org/10.1377/hlthaff.2018.05178
67. Ohta, B., Mola, A., Rosenfeld, P., & Ford, S. (2016). Early discharge planning and improved care transitions: Pre-admission assessment for readmission risk in an elective orthopedic and cardiovascular surgical population. International Journal of Integrated Care, 16(2), Article 10. https://doi.org/10.5334/ijic.2260
68. Pellett, C. (2016). Discharge planning: Best practice in transitions of care. British Journal of Community Nursing, 21(11), 542–548. https://doi.org/10.12968/bjcn.2016.21.11.542
69. Percy, W. H., Kostere, K., & Kostere, S. (2015). Generic qualitative research in psychology. The Qualitative Report, 20(2), 76–85. https://doi.org/10.46743/2160-3715/2015.2097
70. Prior, J., & Campbell, S. (2018). Patient and family involvement: A discussion of co-led redesign of healthcare services. Journal of Participatory Medicine, 10(1). https://doi.org/10.2196/jopm.8957. Ramos, M. (2015). The overwhelming moral and ethical reality of care management practice. New Definition, 29(2), 1–3. https://www.cfcm.com/wp-content/uploads/2018/03/Fall-2015.pdf
71. Rodakowski, J., Rocco, B., Ortiz, M., Folb, B., Schulz, R., Morton, C., Leathers, C., Hu, L., & James, E. (2017). Caregiver integration during discharge planning for older adults to reduce resource use: A metaanalysis. Journal of the American Geriatrics Society, 65(8), 1748–1755. https://doi.org/10.1111/jgs.14873.
72. Roshanghalb, A., Mazzali, C., & Lettieri, E. (2019). Multi-level models for heart failure patients’ 30-day mortality and readmission rates: The relation between patient and hospital factors in administrative data. BMC Health Services Research, 19(1), 1–12. https://doi.org/10.1186/s12913-019-4818-2
73. Rosner, D. (2019). Doing well or doing good: The ambivalent focus of hospital administration. In J. Golden (Ed.), The American general hospital: Communities and social contexts (pp. 157–169). Cornell University Press.
74. Rowlands, G., Shaw, A., Jaswal, S., Smith, S., & Harpham, T. (2017). Health literacy and the social determinants of health: A qualitative model from adult learners. Health Promotion International, 32(1), 130–138. https://doi.org/10.1093/heapro/dav093
75. Ruth, B. J., & Marshall, J. W. (2017). A history of social work in public health. American Journal of Public Health, 107(53), S236–S242. https://doi.org/10.2105/AJPH.2017.304005
76. Saunders, B., Kitzinger, J., & Kitzinger, C. (2015). Anonymizing interview data: Challenges and compromise in practice. Qualitative Research, 15(5), 616–632. https://doi.org/10.1177/1468794114550439
77. Schumacher, K. L., Jones, P. S., & Meleis, A. I. (1999). Helping elderly persons in transition: A framework for research and practice (School of Nursing Departmental Papers 10). http://repository.upenn.edu/cgi/viewcontent.cgi?article=1009&context=nrs
78. Schumacher, K. L., & Meleis, A. L. (1994). Transitions: A central concept in nursing.
79. Image: The Journal of Nursing Scholarship, 26(2), 119–127. https://doi.org/10.1111/j.1547-5069.1994.tb00929.x
80. Seo, V., Baggett, T. P., Thorndike, A. N., Hull, P., Hsu, J., Newhouse, J. P., & Fung, V. (2019). Access to care among Medicaid and uninsured patients in community health centers after the Affordable Care Act. BMC Health Services Research, 19(1), Article 291. https://doi.org/10.1186/s12913-019-4124-z
81. Shepperd, S., Lannin, N. A., Clemson, L. M., McCluskey, A., Cameron, I. D., & Barras,
82. S. L. (2013). Discharge planning from hospital to home. Cochrane Database of Systematic Reviews, 31(1), Article CD000313. https://doi.org/10.1002/14651858.CD000313.pub4
83. Shuster, C., Hurlburt, A., Tam, P., & Staples, J. (2018). Unplanned hospital readmissions in British Columbia. British Columbia Medical Journal, 60(5), 263–267. https://doi.org/10.14288/1.0412183
84. Smith, L. M., Keiser, M., Turkelson, C., Yorke, A. M., Sachs, B., & Berg, K. (2018). Simulated interprofessional education discharge planning meeting to improve skills necessary for effective interprofessional practice. Professional Case Management, 23(2), 75–83. https://doi.org/10.1097/NCM.0000000000000250
85. Stokes, J., Panagioti, M., Alam, R., Checkland, K., Cheraghi-Sohi, S., & Bower, P. (2015). Effectiveness of case management for at risk patients in primary care: A systematic review and meta-analysis. PLoS One, 10(7), e0132340. https://doi.org/10.1371/journal.pone.0132340
86. Sullivan, W. P., Kondrat, D. C., & Floyd, D. (2015). The pleasures and pain of mental health case management. Social Work in Mental Health, 13(4), 349–364. https://doi.org/10.1080/15332985.2014.955942
87. Sutton, J., & Austin, Z. (2015). Qualitative research: Data collection, analysis, and management. The Canadian Journal of Hospital Pharmacy, 68(3), 226–231. https://doi.org/10.4212/cjhp.v68i3.1456
88. Udo, C., Forsman, H., Jensfelt, M., & Flink, M. (2019). Research use and evidence-based practice among Swedish medical social workers: A qualitative study. Clinical Social Work Journal, 47(3), 258–265. https://doi.org/10.1007/s10615-018-0653-x
89. Wadhera, R. K., Yeh, R. W., & Joynt Maddox, K. E. (2019). The Hospital Readmissions Reduction Program: Time for a reboot. The New England Journal of Medicine, 380(24), 2289–2291. https://doi.org/10.1056/NEJMp1901225
90. Wicks, D. (2017). The coding manual for qualitative researchers (3rd ed.). Qualitative Research in Organizations and Management: An International Journal, 12(2), 169–170. https://doi.org/10.1108/QROM-08-2016-1408
91. Wilkinson, A., Whitehead, L., & Ritchie, L. (2014). Factors influencing the ability to self-manage diabetes for adults living with Type 1 or 2 diabetes. International Journal of Nursing Studies, 51, 111–122. http://doi.org/10.1016/j.ijnurstu.2013.01.006
92. Wilson, L. (2019). MA patients’ readmission rates higher than traditional Medicare.Healthcare Dive.
93. Wong, E. L., Yam, C. H., Cheung, A. W., Leung, M. C., Chan, F. W., Wong, F. Y., & Yeoh, E.-K. (2011). Barriers to effective discharge planning: A qualitative study investigating the perspectives of frontline healthcare professionals. BMC Health Services Research, 11(1), 1–10. https://doi.org/10.1186/1472-6963-11-242
94. Yam, C. H., Wong, E. L., Cheung, A. W., Chan, F. W., Wong, F. Y., & Yeoh, E. K. (2012). Framework and components for effective discharge planning system: A Delphi methodology. BMC Health Services Research, 12, Article 396. https://doi.org/10.1186/1472-6963-12-396
95. Zuckerman, R. B., Joynt Maddox Karen, E., Sheingold, S. H., Chen, L. M., & Epstein, A.
96. M. (2017). Effect of a hospital-wide measure on the Readmissions Reduction Program. The New England Journal of Medicine, 377(16), 1551–1558. https://doi.org/10.1056/NEJMsa1701791
97. Zurlo, A., & Zuliani, G. (2018). Management of care transition and hospital discharge.
98. Aging Clinical and Experimental Research, 30(3), 263–270. https://doi.org/10.1007/s40520-017-0885-6
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