[Social intervention at discharge. Cooperation between a hospital department, general practice and the social sector]

The object of this investigation is to illustrate the effect of intensive social assistance at and after discharge from hospital and, if possible, to present some practical proposals. The investigation was controlled: 100 patients domiciled in two communities in the catchment region of the hospital participated in the investigation. The patients were aged 25-75 years and they were discharged from a neuromedical inpatient department. These were subdivided at random into an intervention and a control group. The investigation comprises interviews with the patients, questionnaires to the general practitioners and the social and health authorities. Intervention was undertaken for five months in one of the groups in cooperation with the general practitioner. Although the intervention revealed that there were numerous unsolved problems and that patients with poor ability were left to themselves to a great extent, the intervention did not result in any measurable difference in patient satisfaction as compared with the control group. No readmissions occurred on account of social reasons in the intervention group. A series of planned forms of assistance did not function on discharge. The fact that patients are discharged earlier in the course of the condition than previously is considered to be the cause of a number of the unsolved problems. At the conclusion of the investigation, there were more numerous unsolved problems in the control group than in the intervention group and the need for advice and support, not only for the patients but also for the relatives, which was considerable after discharge, was documented. This need has not fulfilled and proposals are discussed.