To evaluate resource allocation and efficiency of ancillary service delivery in aggregate cost and 3 month follow up in regards to hospital readmission, living environment, and utilization of social services.
This is a randomized study which will compare the current Standard of Care in hospital to EARLY assessment and referrals with respect to social work services, rehabilitation, psychiatry, and nursing. In this study, the control group will receive the hospital support services provided under current system of delivery and allocation. The intervention group will not receive any new or different services not already provided to all patients at New York Presbyterian Hospital. The difference between the 2 groups will be the uniformity of screening to identify the needs of the patient in the respective area of social services, rehabilitation, psychiatric assistance, and nursing care, and the timeliness by which the referrals for support services will be placed.
Potential interventions: (In both control and experimental group)
1. Social work: Discharge planning (homecare, visiting nursing services, skilled nursing facility placement).
2. Rehabilitation: Physical Therapy (improve ADLs-activities of daily living).
3. Psychiatry: Diagnosis and Assistance in management of Depression.
4. Nursing: Prevention of in hospital falls and decubitus ulcer formation.
