Care Coordination: Social Work s Role

1. Care Coordination:Social Work’s Role Robyn Golden, LCSW Director of Older Adult Programs Rush University Medical Center Chicago, Illinois March 2009

2. “The hospital of the future will be a health center, not just a medical center…the hospital will offer valuable resources to the community on matters of health and well-being, and will be held increasingly accountable for the community’s health status.” --Shi & Singh, 2004

3. 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 Center’s Enhanced Discharge Planning Program

4. 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

5. 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 Medicare’s most costly beneficiaries Each older adult readmission costs hospital an average of $7,4003 Financial Impact of Care Fragmentation

6. 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 Financial Impact of Care Fragmentation

7. 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

8. Meeting the Imperative Social work’s potential and possibilities Master’s 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 Social workers have been practicing in medical settings (hospitals, outpt clinics like dialysis, hospice, SNF) for a long time. Interdisciplinary team members providing the psychosocial expertise that compliments good medical care. Advocates for patients and families in linking them to health and community based services. Knowledge of community based services, care coordination and navigating complex systems has been ingrained in our profession since its start Social workers have been practicing in medical settings (hospitals, outpt clinics like dialysis, hospice, SNF) for a long time. Interdisciplinary team members providing the psychosocial expertise that compliments good medical care. Advocates for patients and families in linking them to health and community based services. Knowledge of community based services, care coordination and navigating complex systems has been ingrained in our profession since its start

9. 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

10. 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 conditions…”2 Lack of social and emotional support leads to difficultly prioritizing health maintenance

11. 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 A systems framework and person in environment approach is part of our theoretical practice (therefore a natural fit). Patients/families sometimes view social workers as less threatening Sandy McFolling’s comment: Patients “want to be a good patient” for doctors or nurses More honest about their circumstances with social workersA systems framework and person in environment approach is part of our theoretical practice (therefore a natural fit). Patients/families sometimes view social workers as less threatening Sandy McFolling’s comment: Patients “want to be a good patient” for doctors or nurses More honest about their circumstances with social workers

12. 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

13. 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

14. Rush Enhanced Discharge Planning Program (EDPP) Joint collaboration between Rush University Medical Center’s 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

15. Rush EDPP: Process

17. 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 More than one call necessary: unmet needs were identified that needed followup.  Problems occurred either due to an inadequate plan or due to unanticipated problems in service delivery or needs that were not known (to pt, to caregiver, to case manager?) prior to dcMore than one call necessary: unmet needs were identified that needed followup.  Problems occurred either due to an inadequate plan or due to unanticipated problems in service delivery or needs that were not known (to pt, to caregiver, to case manager?) prior to dc

18. 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

19. 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%)

20. 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 intervention’s impact

21. 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

22. Thanks to… Our funders and supporters: Community Memorial Foundation sanofi aventis New York Academy of Medicine

23. 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