Social work-based transitional care intervention for super utilizers of medical care: a retrospective analysis of the bridge model for super utilizers

Soc Work Health Care. 2019 Jan;58(1):126-141. doi: 10.1080/00981389.2018.1547345. Epub 2018 Nov 14.


The present study was a retrospective evaluation of a social worker-led transitional care intervention that addresses the medical and social needs of inpatient super utilizers with ≥5 inpatient admissions in a 12-month period. Bivariate analyses revealed significant reductions in the total number of hospital admissions, 30-day readmission rates, number of emergency department visits, average hospital charges per episode, and total hospital charges per person after the intervention. This social work intervention may be of interest to providers and payers, particularly regarding addressing the psychosocial needs of complex patients who account for most of health care costs.

Keywords: Care coordination; social workers; super utilizers; transitional care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Comorbidity
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Hospital Charges / statistics & numerical data
  • Humans
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Patient Readmission / statistics & numerical data
  • Retrospective Studies
  • Sex Factors
  • Social Work / organization & administration*
  • Socioeconomic Factors
  • Transitional Care / organization & administration*