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| Main Authors: | , , , , , , , , , |
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| Format: | Recurso digital |
| Language: | |
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Zenodo
2026
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| Subjects: | |
| Online Access: | https://doi.org/10.5281/zenodo.19075453 |
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Table of Contents:
- <p><strong><span>ABSTRACT</span></strong></p> <p><span>Hospital discharge is a vulnerable period, especially for adults with multimorbidity, limited social support, poverty, housing instability, or difficulty navigating follow-up care. This systematic review examined hospital-based social work interventions improvement of discharge planning and reduce hospital readmission in adult patients. A structured search of PubMed and PubMed Central was performed, and original adult studies with hospital-based transition interventions containing social work, psychosocial, case-management, navigation, or interprofessional discharge-planning elements were reviewed. Ten original studies were included in the results synthesis. The included studies showed clinically important findings. Interventions with strong post-discharge follow-up, psychosocial assessment, home contact, and linkage to community or primary care often improved follow-up processes and in several studies reduced readmission or later inpatient utilization. not all programs were effective, and some showed neutral results, especially when intervention intensity was low or implementation was difficult. Direct social work-led studies were limited, but broader transition models with clear social work or psychosocial components suggested that addressing social barriers is relevant to safer discharge. Hospital-based social work and socially oriented transitional care appear promising for improving discharge planning, but the effect on readmission is inconsistent in settings and populations. More trials focused specifically on social work-led models are still needed. </span></p> <p><strong><span>KEYWORDS</span></strong><span><br>Social work; discharge planning; hospital readmission; transitional care; care coordination</span></p>