Social Work Intervention Focused on Transitions "SWIFT"

Completed

Phase N/A Results N/A

Eligibility Criteria

Inclusion Criteria

- Age 65 or more
- English-speaking
- Community dwelling (own home, vs. assisted living facility/skilled care)
- Living within specified service net
- Cognitively intact (as measured by a score of 5 or more on the SPMSQ)
- Meeting at lease one or more of the following:
- Age 75 or more
- Taking 5 or more prescription medications
- Had at least one inpatient admission or emergency department visit in previous 6 months

Exclusion Criteria

- Age 64 or younger
- Non-English speaking
- Diagnosed with end-stage renal disease
- Hospice recipient
- Diagnosis of Alzheimer's disease or severe dementia
- Residing in assisted living or skilled care facility
- Homeless