Discharge planning and social work practice

Hospital social work and discharge planning for older people: challenges of working in a clinical setting

Across the world acute hospitals are under unprecedented pressures due to shrinking budgets and increasing demand, against this backdrop they are also experiencing record levels of activity in Accident & Emergency and delayed transfers of care. Reducing pressure on hospitals by avoiding unnecessary admissions and delayed discharges has risen up the global policy agenda. However, reviews of strategies and policies have rarely involved discussions about the role that hospital social workers play in achieving timely hospital discharge. Yet discharge planning has become a, if not the, central function of these professionals. This paper presents the results of a small-scale exploratory study of hospital social work in an acute hospital in Northern Ireland. The findings reveal that the work of hospital social workers is characterised by increased bureaucracy, an emphasis on targets and a decrease in the time afforded to forming relationships with older people. Hospital social workers highlight concerns that the emphasis on discharge planning and pressures associated with the austerity agenda limits their capacity to provide other more traditional roles such as advocacy and counselling. It is argued that hospital social work should not be narrowly defined as ‘simply’ co-ordinating discharge plans. The tension that arises between expediting hospital discharge and advocating for older people and their families is also discussed.

Examining professional competencies for emerging and novice social workers in health care

This participatory project identified competencies of social workers in health care, with a focus on entry to the field. Findings reflected discussion groups with n = 24 social workers in health care settings. Identified core competencies were: (a) a core base of knowledge specific to social work in health care, (b) understanding of the health care system and implications for practice, (c) a strong work ethic and confidence working with limited supervision, (d) interpersonal skills for multi-disciplinary teamwork, (e) understanding about complex role and power dynamics, (f) accountability for one's own work/practice and commitment to professional development, (g) reflectiveness on practice, and (h) an organizational commitment to capacity building.

Social workers, nurses, or both: Who is primarily responsible for hospital discharge planning with older adults?

This study examines the profession primarily responsible for discharge planning in all hospitals serving older adults in Minnesota. Quantitative analyses determined that the majority of hospitals in Minnesota serving older adults are small, rural hospitals with critical access designations, are private nonprofit, and are affiliated with a health care system. Social workers are primarily responsible for discharge planning in half of the hospitals, nurses in a quarter and either a nurse/social worker team or both nurse and social worker separately in the remaining quarter. Multinomial logistic regression determined that in critical access hospitals nurses are more likely than social workers to be the profession primarily responsible for discharge planning.

Screening by Social Workers in Medical Patients with Risk of Post-Acute Care Needs: A Stepped Wedge Cluster Randomized Trial / Evaluation eines Screenings durch Sozialarbeiter bei medizinischen Patienten mit einem Risiko für post-akuten Nachsorgebedarf: eine stepped wedge clusterrandomisierte Studie

Background

Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process.

Aim

To investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care.

Methods

Cluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences.

Results

A total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .11, 95%-CI -0.64 to 0.86).

Conclusion

Screening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planning.

Trends in Readmission Rates, Hospital Charges, and Mortality for Patients With Chronic Obstructive Pulmonary Disease (COPD) in Florida From 2009 to 2014

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a leading and costly cause of readmissions to the hospital, with one of the highest rates reported in Florida. From 2009 to 2014, strategies such as readmission reduction programs, as well as updated guidelines for COPD management, were instituted to reduce readmission rates for patients with COPD. Thus, the question has been raised whether COPD-related 30-day hospital readmission rates in Florida have decreased and whether COPD-related readmission costs during this period have changed. In addition, we examined trends in length of stay, hospital charges, and in-hospital mortality associated with COPD, as well as identified patient-level risk factors associated with 30-day readmissions.

METHODS

A retrospective analysis of adult patients (≥18 years of age) with COPD was conducted by using the Healthcare Cost and Utilization Project Florida State Inpatient Database, 2009 to 2014. Weighted least squares regression was used to assess trends in the COPD readmission rate on a yearly basis, as well as other outcomes of interest. A multivariable logistic regression was used to identify patient characteristics that were associated with 30-day COPD readmissions.

FINDINGS

Overall, 268,084 adults were identified as having COPD. Between 2009 and 2014, more than half of patients aged 65-84 years, most were white, 55% were female, and 73% had Medicare. The unadjusted rate for COPD-related 30-day readmissions did not change (8.04% to 7.85%; P = 0.434). However, the mean total charge for 30-day COPD-related readmissions was significantly higher in 2014 ($40,611) compared with that in 2009 ($36,714) (P = 0.011). The overall unadjusted in-hospital mortality of COPD-related hospitalizations significantly decreased from 1.83% in 2009 to 1.34% in 2014 (P < 0.001). In a multivariable logistic regression model, patients with COPD were 2% less likely to be readmitted to the hospital for each additional year (odds ratio [OR], 0.98 [95% confidence interval (CI), 0.97-0.99]). Factors associated with significantly higher odds of COPD-related readmission were: older age (45 ≤ age ≤ 64 years; OR, 1.91 [95% CI, 1.70-2.14]), being male (OR, 1.14 [95% CI, 1.10-1.17]), and being a Medicaid beneficiary (OR, 1.28 [95% CI, 1.21-1.35]).

IMPLICATIONS

Although the adjusted odds of COPD readmissions slightly decreased, as did the length of stay and all-cause in-patient mortality, the financial burden increased substantially. Future strategies to further reduce readmissions of patients with COPD and curb financial burden in Florida are needed.

Resisting Throughput Pressures: Physicians' and Patients' Strategies to Manage Hospital Discharge

In recent years, quickly discharging patients has become a collective goal at hospitals, as excessive medical workups and extended hospital stays have been associated with unnecessary healthcare spending. Physicians, however, frequently encounter numerous barriers when trying to discharge patients. Presenting ethnographic and interview data collected from September 2010 to September 2013, this paper examines one of the most difficult discharge cases physicians encounter on the internal medicine service at a U.S. teaching hospital: resistant patients-patients and families who refuse to leave the hospital. As physicians try to discharge resistant patients, they are met with conflicting financial and professional incentives. Drawing from the sociological literature on professions, managerialism, and consumerism, I analyze the strategies physicians develop to manage these difficult discharge cases.

Experiences and Views of the Discharge Planning Process Among Swedish District Nurses and Home Care Organizers

Discharge planning is an important care process, but deficits in planning are common. The aim of this study was to explore district nurses’ (DNs) and home care organizers’ (HCOs) experiences and views of the workflow during the discharge planning process (DPP). Demands, workload, time, collaboration, and engagement, together with knowledge and professional confidence, are factors that influence workflow and outcome of the DPP for DNs and HCOs. Strengths and obstacles at the organization, group, and individual levels affect the workflow during the discharge planning. Knowledge of these strengths and obstacles should help care providers in their practice as well as help management and politicians become more aware of prerequisites needed to achieve a safe and efficient workflow for securing the patient’s discharge.

Thinking big, supporting families and enabling coping: the value of social work in patient and family centered health care

Patient and family-centered care has become a focus in health services. Social work has a rich history of providing responsive patient care. This study identified the contribution and value of social work to PFCC from the key stakeholder perspectives of health social workers (n = 65). Utilizing interpretive description, four themes emerged: (1) Thinking big and holistically, (2) Intervening with families, (3) Enabling patient and family coping, and (4) Maximizing hospital and community resources. Barriers included a lack of power, professional isolation and role creep. Implications for research and practice are provided.

The value of the presence of social work in emergency departments

The value of the presence of social work in emergency rooms is supported by directly examining the hospitalization rates of patients seen by social workers. It utilizes a 3-year-long data set of social work self-reports on medical emergency room outcomes at a large, teaching hospital in the New York Metropolitan area with a sample size of 3370. The study findings suggest that social workers in this acute care hospital's emergency room often are referred the most complex cases. The data on this site indicate that the majority of social work dispositions were to home (54%) or a nursing facility (8.4%). Only 16% of the patients seen by social work were admitted to the hospital. These findings support the cost-effective nature of social work in the emergency room setting and the importance of finding alternatives to hospital admissions. The results of a logistic regression suggest that the criteria used by social workers to assess patients are based on sound psychosocial factors. Patients who were assessed as having "Environmental" (p = .00) or "Relationship" problems (p = .00) were much less likely to be admitted. Conversely, patients with "Care/ADL" problems (p = .00) and behavior problems (p = .00) had a heightened chance of being admitted. Being African American has less effect but was still relevant.

Hospital social work: contemporary roles and professional activities

Since its inception in the 1900s, hospital social work has been impacted by the ever changing hospital environment. The institution of Diagnostic Related Groups (DRGs), the era of reengineering, and the constant struggle toward health care reform make it necessary to evaluate and substantiate the value and efficacy of social workers in hospital settings. This study identifies current roles and activities carried out by social workers in acute hospital settings from across the nation in the aftermath of reengineering. Findings suggest the primary role of respondents in this study to be discharge planning with little to no involvement in practice research or income-generating activities.

Hospital length of stay: social work services as an important factor

In earlier studies it was found that the severity of patients' psychosocial problems was a significant predictor of length of stay (LOS). This current study compared predictors of LOS for samples of patients referred to social services in three large urban hospitals in June-October 2002 (n = 176) and 2006 (n = 147), and examined changes in patient characteristics and the nature of social work practice. A significant relationship between psychosocial severity and LOS was again found, confirming the important role that social services can potentially play in controlling hospital costs. Some significant changes were also found in the pattern of social work practice; this was generally in the direction of more community consultation and collaboration, suggesting a greater emphasis on multidisciplinary teamwork.

Key factors impeding discharge planning in hospital social work: an exploratory study

Despite its long historical tradition in Northern Ireland, there is a dearth of research studies on the role of hospital social work and the professional challenges involved at the health and social care interface. This is the first small-scale exploratory study in Northern Ireland that sought to identify the key factors that hospital social workers perceive as impeding their practice in the discharge planning process. A 15-item postal questionnaire was developed and distributed to 30 hospital social workers from four hospital social work departments in a city in Northern Ireland. The study group comprised social workers based in a range of hospital directorates who had differing levels of hospital social work experience. Data generated from the questionnaires suggested that deficits in community resources impacted most negatively on social workers' practice in discharge planning. The length of time respondents had been in their current post was also shown to influence their responses to the perceived impediments in their discharge planning role. The implications of the study and recommendations are discussed in relation to in-service training, social work practice and continuing education in Northern Ireland.

Deprofessionalization or postprofessionalization? Reflections on the state of social work as a profession

Recent literature considering the state of the social work profession has primarily focused on concerns about deprofessionalization. This article provides an overview of the literature on professionalization and professional decline in order to situate the social work profession within a broader context. The article then describes the emergence of a new role for social workers in Canada that crosses the boundaries between clinical, managerial, and legal aspects of client care in the area of mental health forensics. It is argued that the future of social work's professionalization project around the world may not be as bleak as has been portrayed in the literature.

A systematic approach for providing concrete services and discharge planning based on using information handouts

While information handouts are commonly used in healthcare education, this paper is about social workers systematically developing and using them to provide timely, efficient, and ultimately better patient care for concrete services and discharge planning. How to identify topics and suggestions for composing user-friendly handouts are discussed. Many clinical uses for handouts are considered including: engaging, assessing, and empowering patients, groups, and families. Related uses are considered such as educating the treatment team and students. How handouts can be a crucial bridge to developing a comprehensive, focused social resource database is considered. Follow-up survey results with an inner city VA social work staff (N= 41) confirm that social work discharge planners and non-discharge planners find systematically developed handouts valuable for providing efficient, better patient care.

Collaborative models of patient care:new opportunities for hospital social workers

Hospitals are increasingly recognizing the importance of moving away from the traditional medical model of care to more collaborative models that integrate patients and families into the planning and delivery of healthcare. A few existing studies suggest that collaborative models of care result in higher levels of consumer satisfaction, treatment compliance, effective team performance, and increased care coordination (Gance-Cleveland, 2005; DiMatteo et al., 2002; Reid Ponte et al., 2004; Institute for Family-Centered Care, 2004). Key values underpinning social work practice make medical social workers well-positioned to play leadership roles as hospitals make the shift to more patient-centered care. Specific strategies are presented for medical social workers to use in advocating for change in the way health services are planned and delivered within hospital settings.

Discharge planning, nursing home placement, and the Internet

BACKGROUND

Effective discharge planning and well-coordinated case management related to nursing home (NH) placement are key services in acute-care hospitals.

OBJECTIVES

(1) identify the individuals and important factors involved in the discharge planning process; (2) describe the types/sources of information used by discharge planners to recommend specific nursing homes for patients and families; and (3) determine which methods are used to evaluate the quality of US nursing homes (NHs).

METHODS

Descriptive study, with a convenience sample of 41 discharge planners and case managers from California acute-care hospitals.

RESULTS

This study found that patients, families, friends, and physicians are all involved in the discharge planning process along with discharge planners and/or case managers. Discharge planners/case managers were generally concerned about NH bed availability, geographic location, and financial considerations. Although the discharge planners and case managers were able to articulate important indicators of quality in NHs, such information was not routinely considered during discharge planning activities.

CONCLUSIONS

Discharge planners and case managers need to play a more central role in the decision-making process related to the selection of a NH, especially because decisions are time-limited and can benefit from a well-planned discharge planning program that uses a variety of data on quality and costs. The widespread use of Internet-based information sources can be expanded to aid this process.