Social Services Post-discharge and Their Association With Readmission in a 2016 Swedish Geriatric Cohort

Abstract

Objectives: To describe the social services received by a 2016 Swedish cohort after discharge from inpatient geriatric care and to analyze the association between level of social services post-discharge and 30-day readmission.

Design: Observational, closed-cohort study.

Setting and participants: All patients admitted to 1 of 3 regionally operated inpatient geriatric care settings in Region Stockholm, Sweden, in 2016 (n = 7453).

Methods: Individual-level data from medical records and population registries were linked using unique personal identification numbers. Descriptive statistics were reported for 4 levels of municipal social services post-discharge: long-term care, 1 to 50 home help hours per month, >50 home help hours per month, and no home help. Multinomial logistic regression was performed to analyze the association between level of social services post-discharge and 3 outcomes within 30 days: readmission, death without readmission, or neither readmission nor death.

Results: Results show that almost 11% of patients were discharged to long-term care and 54% received municipal home help services. Individuals with no municipal home help or with 1 to 50 hours per month were more likely to be readmitted within 30 days compared with those in long-term care. Living with more than 50 hours of help was not associated with an increased likelihood of 30-day readmission.

Conclusions and implications: Patients who received inpatient geriatric care are significant users of municipal social services post-discharge. Living in long-term care or with extensive home help appears to be a protective factor in preventing readmission compared with more limited or no home help services. Care transitions for this frail patient group require careful social care planning. Supporting individuals discharged with fewer social service hours may help reduce readmissions.

Keywords: Social care; care transitions; older adults; rehospitalization.