Using Social Workers to Manage Inpatient Care Transitions: Evidence from a Randomized Experiment

Hospital readmissions produce $45 billion in spending in the Medicare and Medicaid programs. There is a growing recognition that social determinants of health are important drivers of preventable hospital readmissions, especially in vulnerable populations. Catholic Charities West Virginia (CCWVa) has partnered with three West Virginia hospitals to launch the Hospital Transition Program (HTP). Modeled after a successful care transition program in Chicago, the goal of the program is to provide support and training for continued care after a patient is discharged from the hospital. This continued care involves a CCWVa case manager meeting with eligible patients in the hospital, visiting them at their home after discharge, assessing needs, and coordinating services with local agencies to ensure that patients are in the best position to carry out their care plan for recovery. The Wilson Sheehan Lab for Economic Opportunities (LEO) at Notre Dame has partnered with CCWVa to design a randomized control trial to evaluate the impact of the HTP on hospital readmission rates and the costs of the readmissions. Both parties hypothesize that the HTP will reduce 30-, 60-, and 90-day readmission rates. The expected sample size is 4800 individuals with half of the sample being selected to receive services.