Care Coordination: Social Works Role

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Care CoordinationSocial Works Role

• Robyn Golden, LCSW
• Director of Older Adult Programs
• Rush University Medical Center
• Chicago, Illinois
• March 2009

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• The hospital of the future will be a health
  center, not just a medical centerthe hospital
  will offer valuable resources to the community on
  matters of health and well-being, and will be
  held increasingly accountable for the communitys
  health status.
• --Shi Singh, 2004

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Overview

• Discuss care coordination
• Care transitions and the challenges that
  accompany them
• Discuss the role of social work in improving
  transitions
• Discuss current social work care transition
  models
• Rush University Medical Centers Enhanced
  Discharge Planning Program

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Care Transitions

• Patients moving from one setting to another face
  particular care coordination challenges
• Abrupt transitions between settings
• Brief stays forcing quick decision-making while
  in pain, acutely ill, or experiencing difficulty
  concentrating
• Sudden self-management role with minimal
  preparation
• Poor communication between care providers
• Culture clash between institution-based medical
  model and community-based service model

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Financial Impact of Care Fragmentation

• Poor transitions can be dangerous and costly
• 19 of patients experience an adverse event
  within 3 weeks of hospital discharge1
• 18 of Medicare beneficiaries are readmitted in
  30 days2
• 15 billion total cost for Medicare in 2005
• According to CBO, 43 of Medicare costs can be
  attributed to 5 of Medicares most costly
  beneficiaries
• Each older adult readmission costs hospital an
  average of 7,4003

1 Forster, A.J., Murff, H.J., Peterson, J.F.,
Gandhi, T.K., and Bates, D.W. (2003). The
incidence and severity of adverse events
affecting patients after discharge from the
hospital. Annals of Internal Medicine,
138(3)161167. 2 Commonwealth Fund National
Scorecard on U.S. Health System Performance,
2008 Friedman, B., Basu, J. (2004). The rate
and cost of hospital readmissions for preventable
conditions. Medical Care Research and Review,
61(2), 225. 3 Friedman, B., Basu, J. (2004).
The rate and cost of hospital readmissions for
preventable conditions. Medical Care Research and
Review, 61(2), 225.
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Financial Impact of Care Fragmentation

• MedPac and AHRQ found that 75 of readmissions
  were preventable
• Medicare could save 12 billion annually
• 250 bed hospital will lose 2 million a year if
  rehospitalizations are not prevented
• Major reasons for preventable rehospitalizations
• Lack of coordination during transition between
  care settings
• Approximately 40-50 of hospital readmissions are
  linked to social problems and lack of community
  resources1

1 Proctor, E.K, Morrow-Howell, N., Li, H., and
Dore, P. (2000). Adequacy of home care and
hospital readmission for elderly congestive
heart failure patients. Health Social Work,
25(2).
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The Imperative

• Need for improved continuity and more accurate
  hand-offs between settings
• Need for improved dissemination of care
  information and education for patients
• Currently, patients go home without necessary
  information
• Patients and caregivers are physically and
  psychologically unprepared to manage care at home
• Need for better coordination to prevent serious
  consequences of poor care
• Need to meet current standards and initiatives
• The Joint Commission
• CMS
• National Quality Forum
• AMA-PCPI Transitions of Care measures

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Meeting the Imperative

• Social works potential and possibilities
• Masters prepared social workers with community,
  healthcare, and gerontology experience
• Advanced psychosocial assessment skills
• Able to perform sophisticated assessments and
  interventions
• Focusing on psychosocial factors that contribute
  to readmission and adverse events
• Through assessment, linkage to community
  resources, and effective partnerships
• Assessment and intervention focusing on patients,
  their caregivers, and their families

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Social Work Role

• Advantages of a social work model of care,
  according to Brown1
• Training in assessment of patients psychosocial
  needs and family dynamics
• Experience addressing patients financial needs
• Greater availability and reduced costs compared
  to nurse care coordinators makes social work
  models efficient and cost-effective
• Bridge health care and community based care
  model, not deficit model
• Successful social work transitional care models
  take a holistic view of the patient 1
• Social aspects
• Medical aspects
• Communications
• Behavioral aspects

1 Brown, R. (in print). The Promise and
challenges of improving care for Medicare
beneficiaries with chronic illnesses.
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Biopsychosocial Factors and Adverse Events

• Non-medical, or psychosocial factors, contribute
  to readmission and other adverse events1
• According to a study by Strunin, et al.
  Difficult life circumstances and gaps in ongoing
  care or support resulted in distress and behavior
  that exacerbated conditions2
• Lack of social and emotional support leads to
  difficultly prioritizing health maintenance

1 California HealthCare Foundation (2008).
Navigating care transitions in California Two
models for change. Issue brief. 2 Strunin, L.,
Stone, M., and Jack, B. (2007). Understanding
rehospitalization risk Can hospital discharge be
modified to reduce recurrent hospitalization?
Journal of Hospital Medicine, 2(5), 297-304.
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Social Workers and Biopsychosocial Factors

• Social work utilization of the person in
  environment framework for assessment can address
  biopsychosocial factors contributing to
  transition issues
• Target emotional and practical issues
  contributing to adverse events in a culturally
  competent manner
• Empower patients and families to take an active
  role in care
• Target systemic issues related to complex
  healthcare and social service delivery systems

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Social Workers and Community Resources

• The California HealthCare Foundation reports that
  community resources are necessary to address the
  non-medical issues that threaten a safe
  discharge1
• Social workers have knowledge of community
  resource options that can supplement the
  discharge plan
• Social workers are aware of program eligibility
  criteria
• Hand-off between medical culture and community
  social service culture
• Social workers create a bridge between medical
  institutions and community agencies

1 California HealthCare Foundation (2008).
Navigating care transitions in California Two
models for change. Issue brief.
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Current Social Work Models

• Community-based programs
• Southwest Suburban Center on Aging, La Grange, IL
• Sheltering Arms, Houston, TX
• Hospital-based programs
• Piedmont Hospital, Atlanta, GA
• SCAN Health Plan, Los Angeles,CA
• Rush University Medical Center, Chicago, IL

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Rush Enhanced Discharge Planning Program (EDPP)

• Joint collaboration between Rush University
  Medical Centers Older Adult Programs and
  Utilization Management Department
• Initiated March 2007
• Piloted on 4 units
• Provides telephonic post-discharge follow-up and
  short term social work care coordination to two
  populations
• At-risk older adults identified by referral
• Patients new to anticoagulation therapy

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Rush EDPP Process
At-risk seniors are identified through electronic
referral
Electronic referral sent to EDPP
EDPP SW responds to CM that referral was received
and accepted
EDPP SW initiates post-discharge phone contact
within 48-72 hours of discharge
EDPP SW documents intervention outcomes
Intervention outcome is reported to originating
CM for review
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Rush EDPP Systems Framework
Healthcare Services Policies
EDPP Social Worker
The Client
Rush EDPP Short-term Care Coordination
Bio/psycho/social characteristics Environmental
factors
Personal characteristics Professional background
Helping roles Practice frameworks Practice
principles
Healthcare problem or change
Aging Network Services Policies
Adapted from Sheafer, B.W., Harejsi, C.R., and
Horejsi, G.A. (2000). Techniques and Guidelines
for Social Work Practice. Fifth ed. New Jersey
Allyn and Bacon.
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Rush EDPP Preliminary Findings

• Total referrals since March 2007 1186 referrals
• Total phone calls completed since March 2007
  4152 calls
• Patients requiring more than one call 62
• Average calls per person 3.5 calls
• Maximum 41 calls
• Average duration of intervention 4.6 days
• Maximum 82 days
• Future contact with EDPP Social Worker
• Recontacted EDPP Social Worker 4
• Mean time until recontact 20 days

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Preliminary Findings

• Most common referral reasons
• Follow up needed on referred services (77.82)
• Ex Delay in start of services, home health
  orders incomplete
• Adjustment to a new illness or treatment (27.99)
• Caregivers requiring emotional support (20.15)
• Issues regarding increased dependency on others
  (18.97)
• Only 38 of program participants
• Received needed community services as planned
• Followed through on discharge recommendations
• Coped well with care demands

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Anticoagulation Summary

• Total anticoagulation referrals since
• May 1, 2008 51 referrals
• EDPP interventions documented 44
• Issues present with anticoagulation patients
• Missed appointments (40)
• Medication issues (28)
• Assistance with follow-up appointments (20)
• Unable to contact patient (16)
• Assistance with scheduling transportation (16)
• Home health services set-up (12)

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EDPP Research Study

• Prospective randomized control group study will
  begin in April 2009
• Patients referred based on presence of specified
  medical and psychosocial risk criteria
• Commonalities and outcomes will be measured
• Issues requiring the most assistance
  post-discharge
• Systemic problems producing breakdowns or gaps in
  service
• Ability of EDPP intervention to prevent adverse
  events post-discharge
• Impact of EDPP on preventable readmissions
• Implement a patient satisfaction survey created
  to better capture the interventions impact

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Next Steps

• The Bridge
• A social work transition model serving older
  adults from selected Chicago suburbs
• A partnership with Southwest Suburban Center on
  Aging
• Develop discharge standards of care for Rush
  patients
• Expand partnerships with health and
  community-based agencies in improve service
  delivery
• Create a model for broad implementation

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Thanks to

• Our funders and supporters
• Community Memorial Foundation
• sanofi aventis
• New York Academy of Medicine

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Conclusion

• Nothing will change unless or until those who
  control resources have the wisdom to venture off
  the beaten path of exclusive reliance on
  biomedicines as the only approach to health
  care.
• --George Engel, 1977