Social Work in the Hospital Setting: Interventions
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Trivia About Social Work in th Thus, social work—driven interventions—social workers facilitating access to multidisciplinary care and interventions—may potentially reduce readmission rates and medical service use, as well as facilitate linkage to community-based social services to increase the quality of transitional care. Yet little is known about the social work role in improving care transitions.
We present a case study of a social work—driven care transitions intervention. This case study provides insight into how a social worker can potentially improve the transition experience and health outcomes for at-risk older adults. A single-case, case study methodology was used to investigate the social work role in providing care transition support for an at-risk older adult. Case studies provide an opportunity for in-depth investigation of a phenomenon to develop a greater understanding within a real-world context Yin, Case studies also represent the preliminary stage of research, spark interest, and suggest possibilities for deeper and more detailed investigation of novel concepts in the future Rowley, This case provides insights into the specific social work tasks that may support older adults transitioning from hospital to home.
The case was selected from a larger study of a social work intervention.
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Participants were recruited from a large, non-profit, urban community hospital in Los Angeles County. Eligibility criteria included adults aged 65 years or more, currently hospitalized, cognitively intact five or more correct on Short Portable Mental Status Questionnaire , English-speaking, residing within a study-designated geographical area, and identified as at high risk for readmission. High risk was determined by meeting at least one of the following criteria: Patients were screened and consented at bedside.
In addition, they received the following assessments: The intervention also employed problem-solving therapy PST Nezu, to assist the patient with prioritizing needs and identifying possible solutions.
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The social worker worked with the patient to identify problems or issues and to develop a plan to address them. Those assigned to the SWIFT group received an in-home assessment at least one visit conducted within hours of discharge and a maximum of two visits to address unresolved issues identified during the first home visit, as determined by the social worker and telephone follow-up up to a maximum of four phone contacts. Social worker chart notes, baseline documents taken in-hospital by a clinical research assistant, and all assessments completed over the phone and during home visits were sources of data for this study.
Patient demographics and other characteristics including age, gender, marital status, and presence of advance directive were collected from patient surveys conducted at bedside.
INTRODUCTION
Current medications were entered into the Medications Management Improvement System database Partners in Care Foundation, and electronically screened for errors and potential problems using the home health criteria developed by a panel of experts Meredith et al. Any problems were reported to the primary care physician and discussed with the patient. Numeric rating scale 0—10 , where zero indicates no pain and 10 corresponds to the worst pain imaginable.
Self-reported health service use was measured at six months following study enrollment. These self-reports were confirmed via electronic medical rewards at the clinical study site. S was a year-old widowed Latina woman with a second-grade education level. She resided with her granddaughter, who was her primary caregiver, and had both Medicare and Medicaid health care insurance. At the time of her index hospitalization, she was taking seven prescription medications for six health conditions and had been admitted for nausea and gastrointestinal bleeding via the hospital emergency department.
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Her chronic conditions included hypertension, asthma, arthritis, anemia, diabetes, and heart disease. The patient reported minimal depression with a score of 3 on the PHQ-9 Depression Scale, and reported moderate physical limitations in lifting and carrying groceries and climbing stairs. The patient ambulated with a cane, had no fear of falling, and had transportation to medical appointments from her granddaughter. As part of the intervention, the social worker conducted a medication reconciliation using the HomeMeds medication software program.
She found the medication regimen was clear of duplication, interactions, and medications contraindicated for older adults. The social worker also conducted a home safety check resulting in recommendation for installation of grab bars in her bathroom. Using a problem-solving approach, Mrs.
S, her granddaughter caregiver , and the social worker worked together to identify ways to better manage her pain. S established goals including getting a heating pad to ease discomfort and making a follow-up appointment with her primary care physician to obtain improved pain management interventions.
Due to the extreme pain experienced by Mrs. S, the social worker made a second home visit four days later. During this visit, the social worker discovered that Mrs. S had not scheduled her follow-up physician appointment and continued to experience sustained high levels of pain. S from obtaining a refill. With the help of the social worker, Mrs. S set goals to immediately schedule a physician visit, request that her physician provide improved pain management, and coordinate with her physical therapist to get a hospital bed for increased comfort at home.
The social worker conducted a follow-up by phone four days after her second home visit with Mrs. The patient reported that she had made and attended an appointment with her primary care physician; however, the visit had focused on her anemia diagnosis, and her pain issues were not discussed or addressed. As a result, Mrs. S continued to experience high levels of pain and only had a few pain pills remaining. The patient agreed to call the physician after the holiday to request Tylenol Acetominophen mg , a pain medication that had previously proven effective in alleviating her pain, or another alternative prescription medication to control her pain.
Twelve days following hospital discharge and three days following the previous telephone call, the social worker conducted a second follow-up telephone call fourth contact overall. S reported that she had received a prescription for Tylenol to treat her pain. However, her pain level remained high at 7 on a scale from 0 no pain to 10 worst pain possible. The social worker subsequently contacted Mrs. Three days later, the social worker conducted a third follow-up call and discovered that Mrs.
S felt continued high levels of pain, but had scheduled an appointment with a new physician.
A Role for Social Workers in Improving Care Setting Transitions: A Case Study
The social worker placed her on the wait list to ensure ongoing access to needed social services and case management. On the 26th day after her discharge from the hospital, Mrs. S received her fourth and final telephone contact from the SWIFT social worker a summary of all contacts can be seen in Table 1. The social worker learned that the family successfully advocated with the original primary care physician to obtain stronger pain medications.
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Additionally, the hospital bed was delivered, and Mrs. S stated she was feeling more comfortable at home. S also reported increased socialization, significant reduction in pain, and subsequent ability to resume basic functions and simple errands, such as grocery shopping. Significantly, the patient was not readmitted to either the emergency department or the hospital in the six months following her hospital discharge. Our case study highlights potential patient needs during transition from hospital to home and the role of a social worker in improving care and maximizing health outcomes.
The social worker focused on traditional transition issues, such as ensuring follow-up with primary care physician and performing medication reconciliation, and also worked with Mrs. S to identify and address other health-related needs, such as improved pain management and increased access to supportive services.
Social Work in the Hospital Setting: Interventions
The social worker provided important coaching that enabled Mrs. This coaching was perhaps one of the most essential aspects of this case study: Interventions like SWIFT that encourage person-centered self-advocacy, self-management, and problem solving Coleman et al. In particular, studies have suggested that pain may worsen executive functions that lead to decreased compliance in older adults Karp et al. With coaching and an emphasis on social solutions to positively impact physical conditions, Mrs.
The patient also received referrals to community-based resources, such as a Medicaid-waiver program. This study provides a detailed case study of a patient enrolled in a social work-driven intervention to improve transition from hospital to home. The National Association for Social Workers Herman, identifies key social work values and practice standards that bring strength to their role in transitional care for older adults.
These include their focus on person-centered care, the ecological framework that includes assessment of personal and environmental factors, and their practice approach that includes collaboration with informal and formal caregivers and providers. Additionally, social workers often have more experience in geriatrics and community-based practice and may better address social-service issues e. Social workers are knowledgeable in successfully utilizing mechanisms to overcome disciplinary boundaries, such as the electronic medication system used in this study Fabbre et al.
They are also trained to relieve caregiver burden, to help patients cope with changes in health status, and to connect patients with services ordered at discharge, which is oftentimes a challenge Altfeld et al. Rush University developed and tested another social work driven transition intervention.
The Bridge Model Altfeld et al. Your request to send this item has been completed. Citations are based on reference standards. However, formatting rules can vary widely between applications and fields of interest or study.
A Role for Social Workers in Improving Care Setting Transitions: A Case Study
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