Three Partners staff have contributed a chapter to the new Encyclopedia of Social Work, the first continuously updated online collaboration between the National Association of Social Workers (NASW Press) and Oxford University Press (OUP). Partners CEO, June Simmons, Vice-President of Strategic Initiatives, Sandy Atkins, and Melissa Jones, Grants and Special Projects Director co-authored the chapter entitled: Care Transitions, Patient Health, and System Performance in the United States, along with Janice Lynch Schuster, who specializes in aging and end of life issues, and is a frequent contributor to the Washington Post.
The article explores the transitions in care that occur when a patient moves from an institutional setting, such as a hospital or nursing home, to home or community, often with the hope or expectation of improving health status. For some groups of vulnerable people, especially the very old and frail, such transitions often require specific, targeted coaching and supports that enable them to make the change successfully. Too often, as research indicates, these transitions are poorly executed and trigger a cycle of hospital readmissions and worsening health, even death. Lack of timely medical follow-up, transportation, inadequate nutrition, medication issues, low health literacy, and poverty can all too often present barriers to optimal health outcomes. By addressing social and environmental determinants of health and chronic disease self-management, social workers who make home visits and other proven timely interventions to assess and coach patients and their caregivers are demonstrating real results.
The article can be read here. Subscription to the publication is required.