Predicting patterns of social work staffing in hospital settings

One long-standing problem of social work departments in acute care hospitals has been their diverse patterns of staffing. The lack of a standard or guide has tended to diminish the utilization of social work services in hospital settings. Over a period of six years, the Society for Hospital Social Work Directors of the American Hospital Association developed and revised a guide for inpatient staffing. The guide is designed to assist hospital and social work administrators establish an inpatient line staffing plan which is based on the number of hospital beds, the number of patients to be served and the number of functions carried. The logic of the inquiry and the findings can serve as a base for future research in inpatient, ambulatory care and other settings which serve special populations.     

Psychiatric rehabilitation and community care: resettlement from a North Wales Hospital

The Health Services Research Unit, University College of North Wales, Bangor is evaluating the care provision and outcomes for a cohort of 63 long-stay psychiatric patients from the North Wales Hospital, Denbigh. Hospital closure is being phased in up to 1995 with reprovision of mental health services in the community. The paper reports on the care process in two specially designed community living schemes and assesses the outcomes for 34 patients from the cohort 12 months after discharge from hospital. The results show some positive outcomes with the majority resettled in well-resourced care settings. Levels of client dependency show significant improvement in these schemes, with increases in social activity, community skills and speech skills. The majority of clients have reacted well to changes in care provision and report a number of improvements in their quality of life. It is concluded that long-stay hospital clients need continuing high levels of support if care in community settings is to be successful.     

Professional Competencies and Training Needs of Professional Social Workers in Integrated Behavioral Health in Primary Care

The Affordable Care Act has led to a widespread movement to integrate behavioral health services into primary care settings. Integrated behavioral health (IBH) holds promise for treating mild to moderate psychiatric disorders in a manner that more fully addresses the biopsychosocial spectrum of needs of individuals and families in primary care, and for reducing disparities in accessing behavioral health care. For behavioral health practitioners, IBH requires a shift to a brief, outcome-driven, and team-based model of care. Despite the fact that social workers comprise the majority of behavioral health providers in IBH settings, little research has been done to assess the extent to which social workers are prepared for effective practice in fast-paced primary care. We conducted a survey of social workers (N = 84) in IBH settings to assess the following: (1) Key competency areas for social work practice in IBH settings and (2) Self-rated preparedness for effective practice in IBH settings. Online snowball sampling methods were used over a period of 1 month. Results indicate that social workers feel prepared for general practice in IBH settings, but would benefit from additional training in IBH-specific competency areas identified in the survey. Findings can help guide social work training to improve workforce preparedness for practice in IBH settings in the wake of health care reform.     

An evidence-based case for the value of social workers in efficient hospital discharge

A study was undertaken to make an evidence-based case for the value of social workers in efficient discharge of patients from acute care hospitals and to assist hospital managers in making informed staffing decisions. Hospital administrative databases from March 1 to November 30, 2008, were used for the analysis of inpatient discharges on days when social workers were on vacation compared with days fully staffed with social workers. Two performance measures, daily discharge rate and average length of stay, were evaluated. During the study period, 1825 patients were discharged from the General Internal Medicine inpatient service. Team discharge rates were significantly lower on social work vacation Fridays versus regular Fridays. In contrast, the average length of stay for patients discharged on social work vacation Fridays was significantly shorter than that for patients discharged on regular Fridays. It was concluded that daily discharge rate better quantified the role of social work in patient discharge. More generally, these results provide preliminary support for the need for adequate social work staffing in timely and efficient patient discharge.     

Community Care in Practice

SUMMARY

This paper examines the establishment of social work within primary health care settings in Great Britain, following the passage of the National Health Service and Community Care Act in 1990. Although the improvement of relationships between social workers and primary health care teams has been promoted for a number of years, the advent of formal policies for community care has made this a priority for both social services and health. This paper presents interim findings from the evaluation of three pilot projects in Nottinghamshire, Great Britain. These findings are analysed from three linked perspectives. The first is the extent to which structures and organisations have worked effectively together to promote the location of social workers within health care settings. The second is the impact of professional and cultural factors on the work of the social worker in these settings. The third is the effect of interpersonal relationships on the success of the project. The paper will conclude that there is significant learning from each of these perspectives which can be applied to the future location of social workers to primary health care.     

Is Home Health Care a Substitute for Hospital Care?

A previous study used aggregate (region-level) data to investigate whether home health care serves as a substitute for inpatient hospital care and concluded that “there is no evidence that services provided at home replace hospital services.” However, that study was based on a cross-section of regions observed at a single point of time and did not control for unobserved regional heterogeneity. In this article, state-level employment data are used to reexamine whether home health care serves as a substitute for inpatient hospital care. This analysis is based on longitudinal (panel) data—observations on states in two time periods—which enable the reduction or elimination of biases that arise from use of cross-sectional data. This study finds that states that had higher home health care employment growth during the period 1998–2008 tended to have lower hospital employment growth, controlling for changes in population. Moreover, states that had higher home health care payroll growth tended to have lower hospital payroll growth. The estimates indicate that the reduction in hospital payroll associated with a $1,000 increase in home health payroll is not less than $1,542, and may be as high as $2,315. This study does not find a significant relationship between growth in utilization of home health care and growth in utilization of nursing and residential care facilities. An important reason why home health care may serve as a substitute for hospital care is that the availability of home health care may allow patients to be discharged from the hospital earlier. Hospital discharge data from the Healthcare Cost and Utilization Project are used to test the hypothesis that use of home health care reduces the length of hospital stays. Major Diagnostic Categories with larger increases in the fraction of patients discharged to home health care tended to have larger declines in mean length of stay (LOS). Between 1998 and 2008, mean LOS declined by 4.1%, from 4.78 to 4.59 days. The estimates are consistent with the hypothesis that this was entirely due to the increase in the fraction of hospital patients discharged to home health care, from 6.4% in 1998 to 9.9% in 2008. The estimated reduction in 2008 hospital costs resulting from the rise in the fraction of hospital patients discharged to home health care may have been 36% larger than the increase in the payroll of the home health care industry.     

Hospital staffing, organization, and quality of care: cross-national findings.

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey. SETTING: Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. STUDY PARTICIPANTS: 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.     

How many beds? Capacity implications of hospital care demand projections in the Irish hospital system, 2015‐2030

Existing Irish hospital bed capacity is low by international standards while Ireland also reports the highest inpatient bed occupancy rate across OECD countries. Moreover, strong projected population growth and ageing is expected to increase demand for hospital care substantially by 2030. Reform proposals have suggested that increased investment and access to nonacute care may mitigate some increased demand for hospital care over the next number of years, and it is in this context that the Irish government has committed to increase the supply of public hospital beds by 2600 by 2027. Incorporating assumptions on the rebalancing of care to nonhospital settings, this paper analyses the capacity implications of projected demand for hospital care in Ireland to 2030. This analysis employs the HIPPOCRATES macrosimulation projection model of health care demand and expenditure developed in the ESRI to project public and private hospital bed capacity requirements in Ireland to 2030. We examine 6 alternative projection scenarios that vary assumptions related to population growth and ageing, healthy ageing, unmet demand, hospital occupancy, hospital length of stay, and avoidable hospitalisations. We project an increased need for between 4000 and 6300 beds across public and private hospitals (an increase of between 26.1% and 41.1%), of which 3200 to 5600 will be required in public hospitals. These findings suggest that government plans to increase public hospital capacity over the 10 years to 2027 by 2600 may not be sufficient to meet demand requirements to 2030, even when models of care changes are accounted for.     

The impact of organizational change on social work staffing in a hospital setting: a national,longitudinal study of social work in hospitals

Market forces continue to shape the health care environment, producing radical changes within the hospital. These changes are affecting social work structure, staffing, and processes within the hospital setting, particularly in the area of social work staffing. This paper examines the changes impacting hospital settings over three fiscal years. A primary question is whether or not social work staffing is being negatively impacted by these hospital changes, and what factors predict the downsizing of social work staff.     

Program Redesign Based on the Model of Human Occupation: Inpatient Services for People Experiencing Acute Mental Illness in the UK

This paper discusses the current context of the UK mental health service system and the resulting need for program change within acute-care inpatient hospitals. The primary focus is to illustrate through practice example what can be done to support the delivery of client treatment packages by using the concepts described by the Model of Human Occupation (MOHO). The paper concentrates on explaining how MOHO has helped to guide program redesign and develop an Occupational Therapy Care Pathway to support occupation-focused services. The example given is of a hospital service in Gloucestershire, England, which provides inpatient care for people experiencing acute mental illness.     

Communicating With Pediatricians: Developing Social Work Practice in Primary Care

While social work models of interdisciplinary collaboration suggest that communication is important, the research literature on social worker–physician collaboration infrequently considers work with pediatricians or practice outside the hospital setting. A cross-sectional survey was sent to a stratified random sample of social workers to assess their communication satisfaction with pediatricians. The study found that social workers in health settings were more satisfied than those in mental health settings. The implications of this finding for the development of colocated, collaborative care models are discussed.     

Assessing care‐giving demands,resources and costs of family/friend caregivers for persons with mental health disorders: A scoping review

As mental health (MH) care has shifted from institutional settings to the community, families and friends are responsible for providing the majority of the care at home. The substantial literature on the adverse effects experienced by caregivers has focused mainly on psychological morbidity. Less attention has been paid to how caregivers for persons with MH disorders interact with larger social systems and the impacts of factors such as financial strain, lost time from leisure activities, and the availability of health and social services. We conducted a scoping review of MH and other caregiver questionnaires published between 1990 and 2016 to determine whether they addressed four key domains: caregiver work demands, resource needs, resource utilisation and costs. A range of health and social care databases were searched, including MEDLINE and Health and Psychosocial Instruments. After screening for relevance and quality, our search identified 14 instruments addressing elements related to one or more of our domains. Because these instruments covered only a small portion of our domains, we conducted a second targeted search of the general care‐giving literature and consulted with experts, identifying an additional 18 instruments. A total of 32 questionnaires were reviewed, 14 specific to care‐giving for mental health problems and 18 for other health conditions. Our search identified instruments or items within instruments that assess constructs in each of our domains, but no one instrument covered them completely. Additionally, some constructs were evaluated in detail and others only addressed by single items. While these instruments are helpful for moving measurement beyond the psychological impacts of care‐giving, our results serve only as an initial guide. Additional methodological work is needed to more comprehensively measure the impact of care‐giving for individuals with MH disorders and to contribute to the development of more meaningful and effective policies and programmes.     

The Challenges of Health Care Reform for Hospital Social Work in the United States

This article examines the potential impact of the Patient Protection and Affordable Care Act (ACA) of 2010 on the practice of hospital social work in the United States and its implications for social work education and training. It briefly traces the history of hospital social work, outlines some contemporary issues in the health care field, particularly those that create persistent health disparities, summarizes the major provisions of the Act that have implications for social work practice, and discusses how social workers in hospital settings might respond effectively to the changes produced by the legislation.     

Delayed discharge from mental health hospitals: results of an English postal survey

This paper reports findings from a postal survey conducted by the UK's NHS Confederation to explore the rate and cause of delayed hospital discharges in mental health inpatient services. With delayed discharges the subject of considerable UK government activity in general hospital settings, there has been debate about extending recent financial penalties to mental health, fining social services departments for delayed discharges (a system known as reimbursement). Against this background, the NHS Confederation sent a postal survey to all 83 English mental health trusts and Primary Care Trusts with responsibility for providing mental health services. This asked respondents about delayed discharges from mental health inpatient beds in terms of number of delays, duration of delay, specialty and cause. Responses were then analysed quantitatively (in terms of number and extent of delays) and qualitatively (attitudes to reimbursement and other policies that might help resolve the issue). Overall, the survey reveals high levels of delayed discharges (with from 4% to 16% of beds affected and some 25 to 2,366 bed days lost depending on specialty). The causes of delayed discharge are varied, with a range of factors interacting. Although opinion was divided on the benefits of extending reimbursement, closer analysis revealed greater agreement than may at first be apparent. In particular, those favouring extension tended not to be 'pro-reimbursement' per se, but rather desperate to tackle delayed discharges and prepared to consider any policy that might help. This is an important addition to the current literature and debate, as it suggests that those seemingly in favour of reimbursement may actually be more motivated by a desire to try anything that might reduce delays rather than by commitment to this particular policy.     

The mental health residential care study: the "hidden costs" of provision

Reforms to the organization and funding of health and social care in the UK have placed new responsibilities on social and health care purchasers to undertake assessment of the accommodation and care needs of people with mental health problems who are living in the community. This responsibility is hampered by a lack of reliable or complete data on the range of services and costs associated with residential care, in particular the non-accommodation or costs which are hidden in the sense that they are often unaccounted for by individual agencies, such as the use of hospital, community and peripatetic services falling outside residential facilities core functions or budgets. Employing service use and cost data from a wider study of residential care, non-accommodation costs were calculated for a number of residential settings (both in and outside London). As a proportion of total costs of care, these ranged from below 10% in hospital settings to between 13% and 39% in community-based staffed hostels. These figures represent estimates of the cost “add-ons” required for this element of care where only accommodation costs are known. Multiple regression analyses were also undertaken to examine the possible influence of resident, facility and area characteristics on hidden costs. Resident characteristics alone explained only a small amount of the inter-resident variation in hidden costs. The inclusion of care environment, sector and locality enhanced the predictive power of the models. The relevance and interpretation of these findings are discussed.     

Shared Decision Making in Health Care Settings: A Role for Social Work

Shared decision making (SDM) is a process integral to social work practice, one where the provider/professional and the consumer/patient discuss treatment alternatives based on patient values and life circumstances and make a shared decision about whether and how to proceed with treatment. Evidence-based medicine suggests that for many health conditions, having the choice of several effective treatment options is not uncommon. In these cases treatment should be based on what is best for the individual, since many factors influence an individual's treatment preference, including the psychological, social, cultural, and spiritual history she/he brings to the medical encounter; a history that has long been ignored in somatic health care. This article develops the argument that medical social workers possess the professional knowledge and skill base to provide decisional coaching, and implementing SDM in primary care settings. Of particular importance are the values that guide professional social work practice, including client self-determination, which is the basis of SDM, and the ability to maintain neutrality.     

Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015

Policy Points

• US policymakers considering proposals to expand public health care (such as “Medicare for all”) as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well‐funded universal health care systems are already in place.
• In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity.
• Based on England''s experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups.

ContextExpanding access to health care is once again high on the US political agenda, as is concern about those who are being “left behind.” But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education‐level‐defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use.MethodsNovel linkage of data from six waves (2004‐2015) of the English Longitudinal Study of Ageing (ELSA) with participants’ hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004‐2005 to 2008‐2009 and 2010‐2011 to 2014‐2015 to examine whether potential education‐related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010.FindingsFor the study period, our sample of ELSA respondents in the low‐education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high‐education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11‐0.47). Additional outpatient health care use in the high‐education group was driven by follow‐up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high‐education group made 0.48 (95% CI, 0.21‐0.74) more annual outpatient visits than those in the low‐education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high‐education group made 0.04 (95% CI, −0.075 to 0.001) fewer annual ED visits than the low‐education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period.ConclusionsAfter controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less ED care than peers in the low‐education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.     

Inpatient and outpatient health care demand in Cairo,Egypt

This paper uses the results of a household survey conducted in Cairo, Egypt in 1992 to examine the factors that influence the demand for inpatient and outpatient health services. Multi-stage discrete choice models of the demand for health care, which identify the importance of individual, household, and facility level variables on each treatment decision, are estimated separately for outpatients and inpatients. Consumers are assumed to decide whether to seek any treatment and then choose between three categories of providers: a large public hospital (Embaba Hospital), all other public providers, and private/charitable providers. The results confirm that more affluent consumers prefer the higher cost, higher quality private and charitable hospitals. Age, sex, education, and insurance are also found to strongly impact the use of medical services. The results are suggestive but do not conclusively show that inpatient care is less price responsive than outpatient care. Price responsiveness of inpatient and outpatient demand are imprecisely estimated because price is highly correlated with quality, and the available data on facility quality do not permit us to adequately control for quality variations across facilities.     

Does older adults’ use of social care influence their healthcare utilisation? A systematic review of international evidence

Improving our understanding of the complex relationship between health and social care utilisation is vital as populations age. This systematic review aimed to synthesise evidence on the relationship between older adults’ use of social care and their healthcare utilisation. Ten databases were searched for international literature on social care (exposure), healthcare use (outcome) and older adults (population). Searches were carried out in October 2016, and updated May 2018. Studies were eligible if they were published after 2000 in a high income country, examined the relationship between use of social care and healthcare utilisation by older adults (aged ≥60 years), and controlled for an indicator of need. Study quality and bias were rated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross‐Sectional Studies. Study data were extracted and a narrative synthesis was conducted. Data were not suitable for quantitative synthesis. Thirteen studies were identified from 12,065 citations. Overall, the quality and volume of evidence was low. There was limited evidence to suggest that longer lengths of stay in care homes were associated with a lower risk of inpatient admissions. Residents of care homes with onsite nursing had fewer than expected admissions to hospital, compared to people in care homes without nursing, and adjusting for need. Evidence for other healthcare use outcomes was even more limited and heterogeneous, with notable gaps in primary care. We conclude that older adults’ use of care homes may moderate inpatient admissions. In particular, the presence of registered nurses in care homes may reduce the need to transfer residents to hospital. However, further evidence is needed to add weight to this conclusion. Future research should build on this evidence and address gaps regarding the influence of community based social care on older adults’ healthcare use. A greater focus on primary care outcomes is imperative.     

Quantifying posthospital care transitions in older patients

BACKGROUND: Older patients frequently receive care in multiple settings. However, there has been a paucity of studies that quantify the number of care transitions or that attempt to explain utilization patterns over a given time period. Furthermore, no studies have examined transitions based on method of payment. OBJECTIVE: The objective of this study was to examine the number of different posthospital interinstitutional transfers (including hospital, inpatient rehabilitation facilities [IRF], and skilled nursing facilities [SNF]) by method of payment (managed Care [MC] or fee-for-service [FFS]). DESIGN: Prospective cohort followed for 12 months. Method: A total of 1055 older patients were identified on transfer from an acute hospital to either an SNF or IRF. Utilization and mortality was tracked over 12 months through analysis of administrative data, chart review, nursing assessments, and patient interviews. RESULTS: After 3 months, 65.3% of MC patients and 75.6% of FFS patients experienced between two and three transfers and an additional 13.8% of MC patients and 14.6% of FFS patients experienced between four and six transfers. Over the next 9 months, the frequency of patient transfers uniformly declined in both payment groups. CONCLUSION: This study demonstrates that interinstitutional transfers are common in older patients. The majority of these transfers occurred within the first 3 months after hospital discharge for both payment groups. Understanding the frequency and patterns of posthospital care transitions is an important step toward designing innovative approaches to improve the quality of care transitions and ensuring patient safety across settings.