Assessing the Impact of Social Work on Patient Outcomes and Health - - PowerPoint PPT Presentation
Assessing the Impact of Social Work on Patient Outcomes and Health Use Evidence from Rural Primary Care Teams in the Veterans Health Administration Portia Y. Cornell, PhD Providence VA Medical Center | Brown University
Portia Y. Cornell, PhD Providence VA Medical Center | Brown University Portia_Cornell@brown.edu @portiacornell
Enhancement Research Initiative (QUERI)
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ABSTRACT
Patient Aligned Care Team (PACT) focuses on health promotion, prevention and management of chronic
management of many conditions is dependent on the behavioral changes that patients are willing and able to make as well as environmental factors. The role of a social work case manager in the PACT is to assess and treat psychosocial and environmental factors that impact the patient’s ability to achieve maximum health and wellness. Social work case managers assess the patient’s psychological and emotional adjustment to illness within the context of medical diagnosis, prognosis, and treatment options. An assessment of environmental factors includes a review of the dynamics of the patient’s support system, functional status, vocational, economic, housing, spiritual, cultural and legal factors that influence their ability to adhere to medical recommendations and management
factors that contribute to the presenting concerns and develops interventions designed to promote lasting positive change to decrease stress, promote health and wellness and remove barriers to care. Psychosocial treatment options are reviewed with the patient, family and PACT team. A treatment plan based on the patient’s identified concerns and goals is established. Patients are given supportive assistance and referrals to appropriate resources to lessen the acuity of psychosocial stressors. This social work model describes the process for assessment, treatment, and interventions. The patient is assessed in 6 domains: access to care, economics, housing, psychological status, social support, and functional status. A level of acuity is assigned for each domain. Level 1 represents patients whose basic needs are met. Level 2 represents patients that have minor concerns in one
that have major concerns in one or more of the domains and Level 4 represents patients who have a crisis in one or more domains (i.e. have no income, no social support or are homeless). For each level, possible interventions are listed. The goal of the intervention(s) is to lessen acuity and move patients toward Level 1.
LEVEL 1
Patients generally have all their personal needs met. Access to care: Patients are entitled to care and have transportation. Economics: Patients have sufficient income for their needs. Housing: Patients have adequate housing for their needs. Psychological Status: Stable mood and behavior. Social Support: Patients have supportive relationships. Functional Status: Patients are functionally independent. LEVEL 1 INTERVENTIONS Answer questions regarding the business of health care to include the cost of health care in the VA and outside the VA (utilizing Medicare, Medicaid, private health insurance, and supplemental insurance policies). Refer to community dental programs if not eligible in the Veterans Health Administration. Answer questions regarding Veterans Benefits (health benefits, pensions/compensation, burial benefits, veterans homes, vocational rehabilitation, etc). Prepare Advance Directives Schedule/reschedule appointments, ensure that ordered equipment/services are received, and provide information and assistance with transportation arrangements. Provide supportive counseling to assist patient and family with their adjustment to a diagnosis or disability. Order respite care. Provide patient/family education about health promotion, disease prevention and management of self. Refer for competency exams (neuropsychological assessments, payee, guardianship, fiduciary, etc) consult with PCP.
LEVEL 2
Patients have a minor concern with access to care, economics, housing, psychological status, social support
Access to care: Patients may have questions or need assistance with the means test/eligibility for care or need assistance to arrange for transportation to the VA. They may need to have appointments rescheduled due to transportation problems. Economics: Patients have some income. They may need financial counseling to manage within their means. They may need assistance to either increase their income, or decrease their expenses. Housing: Patients have housing, but it isn’t entirely adequate for their needs. Psychological Status: Patients may have a minor mood or behavioral disturbance that occasionally interferes with daily functioning. Social Support: Patients have supportive relationships, but they aren’t receiving all the support or assistance that they need. Functional Status: They may need assistance with IADL’s LEVEL 2 INTERVENTIONS in addition to Level 1 Interventions Access to Care:
tests updated (to determine co-payment).
no-shows.
applications.
transportation programs.
assistance. Economics:
benefits.
Security.
property taxes.
assistance programs.
Housing:
maintenance.
infestations. Psychological Status:
to ask for and accept assistance.
Social Support:
Functional Status:
ability.
LEVEL 3
Patients have a major concern with access to care, economics, housing, psychological status, social support
Access to care: Patients may have limited or cost prohibited transportation to the VA. They may need to have many appointments scheduled for the same day, or schedule overnight accommodations due to transportation problems. Economics: Patients have too-little income to support basic human needs. Their expenses exceed their
increase their income, or decrease their expenses. Housing: Patients have housing that is inadequate for their needs. Psychological Status: Patients may have a major mood or behavioral disturbance that interferes with daily functioning. Social Support: Caregiver is overwhelmed and stressed by patient care needs. Patients have strained relationships and do not receive adequate assistance. Functional Status: Patients may be at risk for falls or other injuries. Patients may need assistance with ADL’S/ IADL’S. LEVEL 3 INTERVENTIONS In addition to Level 1 and 2 Interventions Access to Care:
no health insurance, apply for Medicaid.
access care, coordinate appointments on the same date.
exist for transportation. Economics:
food stamps.
prevent eviction.
aid.
Housing:
to make home handicapped accessible.
Psychological Status:
substance abuse treatment program or day program. Social Support:
relationships with family/friends.
Functional Status:
functional ability/ improve safety.
IADL’s.
homes.
LEVEL 4
Patients have a crisis with access to care, economics, housing, psychological status, social support or functional status. Access to care: Patients may be unable to afford or find transportation. Economics: Patients have no income. Patients need immediate assistance to either find work or receive benefits. Housing: Patients have no home. Psychological Status: Patient needs inpatient psychiatric admission. Social Support: Patient lacks social supports. Functional Status: Patient is functionally dependent. LEVEL 4 INTERVENTIONS In addition to Level 1, 2, and 3 Interventions Access to Care:
Economics: (as listed previously in level 2 & 3, but with increased emphasis and advocacy).
Housing:
Psychological Status:
functioning and safety. Social Support:
relationships with family/friends. Functional Status:
ability and safety.
Levels of Case Management Case management will be determined by clinical assessment and acuity scoring as well as the severity and urgency of the presenting problem(s). Veterans with an acuity level of 2, 3, or 4 will receive case management
Patient generally has all personal needs met with low psychosocial aculty rating. Generally one to two contacts required.
Patient has minor concerns with access to care, economics, housing, psychological status, social support or functional status. Monthly-quarterly contact as clinically indicated to ensure sufficient support to meet case management goals.
Patient has major concerns with access to care, economics, housing, psychological status, social support or functional status. Weekly-monthly contact as clinically indicated to ensure sufficient support to meet case management goals.
Patient has a crisis with access to care, economics, housing, psychological status, social support or functional status. Daily-weekly contact as clinically indicated to meet case management goals.
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Enabling Factors Individual level
competing for attention Interpersonal level
Organizational level
Community level
community organizations and providers Use of health services Health Outcomes Social work Case management
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Social workers in primary care
Not shown: Hawaii and American Samoa
Age, mean (SD) 62.53 Homeless 3.7% Gender: Male 91.9% Current Smoker 2.4% Race: White 81.5% Hypertension 45.9% Race: Black 7.0% Congestive Heart Failure 3.7% Race: Other 11.6% Diabetes Mellitus 19.8% Location: Rural 10.4% Dementia 2.2% Service-connected disability 2.2% Elixhauser, mean (SD) 1.94 Psychiatric Dx 27.5% Hospitalizations (Prev 30d) 0.76% Substance Abuse 6.8% Hospitalizations (Prev. 12m) 5.44%
Binary (Any in month) Pct Continuous (per 1000 Veteran- months) mean (SE) Any social work encounter 1.02% # of social work encounters 0.01361 (0.16) Any personal care services (PCS) 0.34% PCS days 0.08015 (1.82) Home based primary care (HBPC) 0.10% HBPC days 0.00396 (0.16) Hospice/Palliative Care 0.03% H/PC days 0.00314 (0.38) Hospitalization 0.11% Hospital days 0.07142 (1.20) ACSC† hospitalization 0.11% ACSC Hospital days 0.01067 (0.49) ED Visit 0.33% ED Visits 0.05463 (0.50) Nursing home (NH) admission 0.46% NH days 0.19546 (3.24) Died 0.39% †ACSC=ambulatory care sensitive condition
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First month
Exclude first 2 months as training period
Group Any social work Number of social work encounters Full Cohort (N=8,283,044) 0.00488*** 0.00794*** Rural (N=864,441) 0.00260* 0.00424** High-risk group† (N=378,434) 0.00169** 0.00278** Hosp prev. 30 days (N=62,856) 0.0289*** 0.0523*** Dementia (N=181,402) 0.0191*** 0.0355***
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any social work Pct change Number of social work encounters Pct change Full Cohort (N=8,283,044) 0.00488*** 85% 0.00794*** 108% Rural (N=864,441) 0.00260* 14% 0.00424** 22% High-risk group† (N=378,434) 0.00169** 25% 0.00278** 33% Hosp prev. 30 days (N=62,856) 0.0289*** 54% 0.0523*** 79% Dementia (N=181,402) 0.0191*** 41% 0.0355*** 52%
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any PCS Pct change Number PCS days Pct change Full Cohort (N=8,283,044) 0.000227
Rural (N=864,441) 0.000395 0.0123 High-risk group† (N=378,434)
Hosp prev. 30 days (N=62,856) 0.00298 0.00354 Dementia (N=181,402) 0.00680** 19% 0.114 15%
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any HBPC Pct change Number HBPC visits Pct change Full Cohort (N=8,283,044)
Rural (N=864,441) 8.10e-05 0.000395 High-risk group† (N=378,434) 7.58e-05
Hosp prev. 30 days (N=62,856) 0.00327** 27% 0.0183* 28% Dementia (N=181,402) 0.00229 0.00547
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any hospice/ palliative Pct change Days hospice/ palliative Pct change Full Cohort (N=8,283,044) .0008.62** 33% 0.000478 Rural (N=864,441) 0.000192* 11% 0.00305 High-risk group† (N=378,434) 0.000207 0.000668 Hosp prev. 30 days (N=62,856) 0.00412*** 53% 0.0371* 77% Dementia (N=181,402) 0.000573 0.00761
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any IP hospital admission Pct change Days inpatient hospital stay Pct change Full Cohort (N=8,283,044)
0.00342* Rural (N=864,441)
0.00213 High-risk group† (N=378,434)
0.00766 Hosp prev. 30 days (N=62,856)
0.150* Dementia (N=181,402) 0.000306
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any ACSC hospital admission Pct change Days ACSC hospital stay Pct change Full Cohort (N=8,283,044)
Rural (N=864,441) 3.33e-05 0.00132 High-risk group† (N=378,434)
Hosp prev. 30 days (N=62,856) 0.000797 0.00315 Dementia (N=181,402)
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any ED visit Number ED visits Full Cohort (N=8,283,044) 0.000504 0.00210 Rural (N=864,441)
High-risk group† (N=378,434) 0.00190 0.00135 Hosp prev. 30 days (N=62,856)
0.0104 Dementia (N=181,402) 0.00228 0.00988
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95
Group Any NH stay NH days Full Cohort (N=8,283,044)
Rural (N=864,441)
High-risk group† (N=378,434)
Hosp prev. 30 days (N=62,856)
Dementia (N=181,402) 0.000420
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95 ‡Any stay in a community nursing home, state Veterans’ home, or VA community living center
Group Mortality Full Cohort (N=8,283,044)
Rural (N=864,441) 0.000053 High-risk group† (N=378,434)
Hosp prev. 30 days (N=62,856)
Dementia (N=181,402)
*p<0.10, **p<0.05, ***p<0.001 †Veterans with Care Assessment Needs Score (CANS)>95