Efficiency of a care coordination model: A randomized study with stroke patients

Objectives: This study investigated the efficiency of a social work care coordination model for stroke patients. Care coordination addresses patient care and treatment resources across the health care system to reduce risk, improve clinical outcomes, and maximize efficiency. Method: A randomly assigned, pre-post experimental design measured medical utilization of 28 patients postrehabilitation hospitalization. The experimental group received individual assessment, problem solving around barriers to services, advocacy, crisis counseling, educational reinforcement to patients and caregivers, brief psychological counseling, and referral. Hospitalization, emergency room, and physician utilization measures were collected 3 months prior to inpatient rehabilitation and compared to utilization during the study. Results: Repeated measures ANOVA showed significant changes for the intervention group in medical utilization. Recipients' care-seeking behavior appeared to change toward more appropriate use of outpatient physicians rather than the emergency room. Conclusions: Care coordination provided by social workers significantly improved stroke patients' medical utilization with significant cost savings.