Complicated bereavement: a national survey of potential risk factors

We developed a Bereavement Risk Questionnaire to rate 19 possible factors for assessing complicated bereavement. A four-point scale was used (0 = no risk, 3 = significant risk). The questionnaire was mailed nationwide in the United States to 508 hospice bereavement coordinators, and 262 responded. Most rated the following as significant risks: perceived lack of caregiver social support (70 percent), caregiver history of drug/alcohol abuse (68 percent), caregiver poor coping skills (68 percent), caregiver history of mental illness (67 percent), and patient is a child (63 percent). Overall, 61 percent chose perceived lack of social support, and 47 percent chose poor coping skills, as one of the top three risk factors. There was no relationship between professional discipline and responses. We found a consensus among bereavement professionals regarding important indicators in assessing bereavement risk. We conclude that it is possible to assess bereavement risk in caregivers of seriously ill patients, prior to the death of the patient. This would allow palliative care teams to allocate resources and services to those at the greatest risk for complicated bereavement.     

Support workers in intermediate care

Despite the proliferation of support worker roles in the UK, little is known about their actual numbers, employment conditions or levels of training. Intermediate care services appear to be an important employer of support workers, but the diversity of intermediate care services makes the task of understanding support worker roles even more complex. This paper presents data from 33 services which were involved in an NHS Modernisation Agency's Changing Workforce Programme project, the Accelerated Development Programme for Support Workers in Intermediate Care in England. Within this project, the main employers of support workers were primary care trusts and/or social services. Participating intermediate care teams were involved in admission avoidance, assisted discharge and reablement, or combinations of these services, and the majority of care was provided in the patient's own home. The 33 services employed 794 support workers and 368 professionally qualified staff. The mean ratio of professionally qualified staff to support workers was 0.95 (range = 0-4.9, SD = 1.05). Support worker roles included multidisciplinary working, meeting rehabilitation needs, providing personal care and enablement. Team leaders included nurses, social workers, physiotherapists, professional managers, home carers and support workers. The most commonly reported sources of support worker training were National Vocational Qualifications and in-house training. In 80% of the services, at least half of the support workers had a qualification. Three models of supervision emerged across the services: the allocation of a mentor; team supervision; and formal and informal line management. These findings illustrate the diversity of employment of support workers in intermediate care. The variations in training, supervision and skill mix have implications for clinical governance and support worker regulation. The employment of support worker staff jointly across health and social care raises cross-boundary issues around employment contracts and pay.     

Addressing Social Determinants of Health for Dual-Use Veterans

An estimated 40% of Veterans are eligible for community care. Veterans who access care both outside of the Veterans Health Administration (VA) and at the VA are at risk for fragmented care and adverse outcomes. These dual-use Veterans often do not receive necessary follow-up care or linkage to resources addressing social determinants of health (SDOH) post–non-VA emergency department (ED) visits. We created a social worker–led advanced care coordination (ACC) program to reduce fragmented care, enhance care coordination, and provide longitudinal case management to address SDOH for dual users who access non-VA EDs. ACC collaborated with internal and external stakeholders (ie, clinicians and staff) to enhance care and address SDOH for dual users. The ACC social worker had regular contact with stakeholders through phone calls, emails, and in-services to enhance relationships and program buy-in. Stakeholders asked each patient if they were a Veteran and informed ACC of the Veteran’s non-VA ED visit. Postdischarge, the ACC social worker called the Veteran to complete a comprehensive assessment identifying SDOH needs. The ACC social worker provided case management via phone calls and home visits to the Veteran up to 90 days addressing SDOH needs and reconnected the Veterans to their primary care team through electronic closed-loop communication. We analyzed VA claim data postimplementation to compare intervention participants with nonparticipants. Using propensity score, Veterans were matched 3 to 1 on age, gender, comorbidities, and number of hospitalization and primary care physician (PCP) visits in the past year. Dual-use Veterans who accessed non-VA EDs in Denver, Colorado, and Omaha, Nebraska, metro areas. Veterans had to be eligible to receive care through the VA. When compared to a matched control group, Veterans who received the ACC intervention had significantly lower rates in readmission to the ED within 30 days of ED discharge (16.1% vs. 30.5%, P < 0.01). ACC connected Veterans to services addressing SDOH they may not have otherwise accessed due to lack of knowledge and resources. Using our program database to evaluate Veterans enrolled in ACC since April 2018, we found they were connected to: (1) VA PCP appointments (82%), (2) VA benefits including enrollment (33%), (3) home health care (21%), (4) financial assistance (ie, food benefits, rental and utility assistance, disability benefits, 18%), (5) homeless resources including housing vouchers and shelters (9%), (6) mental health treatment (9%) and transportation assistance (9%), and (7) substance use treatment (4%). Dual-use Veterans often fall through the cracks after receiving non-VA care. ACC addressed gaps in transitions by connecting Veterans to resources addressing SDOH needs and linking Veterans back to their VA primary care teams. Gaps in care will continue as Veterans increasingly access non-VA care. ACC bridged these gaps by enhancing relationships and communication between VA and non-VA providers. ACC addressed Veteran’s SDOH by connecting them to resources post–non-VA ED discharge. Programs similar to ACC should be implemented across health care systems to assist dual-use Veterans with SDOH needs and increase linkage to resources. The study was funded by QUERI.     

Characteristics of the clients in a geriatric intermediate care facility located in the suburbs of an urban area and factors related to the discharge destinations desired by family caregivers

Among the clients in a geriatric intermediate care facility located in the suburbs of Osaka and their family caregivers (72 subjects), the characteristics of the clients and their caregivers, and the discharge destination desired by their family caregivers were investigated, and the associated factors were evaluated. 1. Characteristics of the clients. The clients were elderly females with a low degree of independence, and dementia was observed in about 60% of them. The clients had a relatively large number of children, but many of them lived alone before admission. The rate of admission from hospitals was high (54%), and that of discharge to hospitals was also high (50%). Sixty-seven percent of the clients stayed for a long duration of over 6 months. 2. Conditions of the family caregivers. Most of the family caregivers were daughters or daughters-in-law, and considered themselves to be healthy. Sixty-three percent of the caregivers had jobs. However, most of the caregivers did not have sub-caregiver. 3. Factors related to the discharge destination desired by family caregivers. Not many family caregivers (19.4%) wanted them to go back to their homes after discharge, but their preferred discharge destinations were home (19.4%), hospitals (55.5%), and nursing homes (25.1%). The caregivers of single household clients often desired a nursing home as the discharge destination, and those of the clients from a 2- or 3-generation household often desired a hospital. The factors related to the discharge destination desired by client's family caregivers were that the client not show dementia, the job of the caregiver was a part-time job, there was a sub-caregiver, and the client had the experience of home public health nursing visits. This study showed, the percentage of the clients discharged from the geriatric intermediate care facility to their homes was low, and that of the family caregivers who desired their home as the discharge destination was also low. However, the results suggested that leading the discharge destination to the client's home is possible if social resources are provided such as the use of public health nursing services.     

Predicting elderly cardiac patients at risk for readmission.

Elder patients with cardiac disease are at high risk for physical deterioration during post hospital recovery and suffer frequent early readmission. It is important to identify such patients who frequently need help with discharge planning from social workers during their first admission. This study utilized computerized data on 628 patients, 238 of whom were readmissions. Question was raised as to what factors (functional, psychological, social and environmental), differentiated patients who were readmitted from those who were not. Using logistic regression, three variables: marital status, presence of coping difficulty and age of patients were identified as predictors of readmission within three months. Those who were married were less likely to be readmitted. Those with coping difficulties and older individuals were more likely to be readmitted. The accuracy of prediction, using these three factors, was 61 percent. Of those patients predicted as not being readmitted, sixty-nine percent were correctly predicted, while 39 percent were readmitted. Of patients predicted as readmissions, 49 percent were correctly predicted, while 51 percent were not. The major limitation of this study was that key physiological determinants of readmission were not collected. It is imperative that a valid screening device for predicting who is at risk for readmission should include physiological preconditions as well as functional and psychosocial data.     

Managing,making sense of and finding meaning in advanced illness: a qualitative exploration of the coping and wellbeing experiences of patients with lung cancer

Coping plays an essential role in maintaining the wellbeing of patients with cancer. A number of different coping responses and strategies have been identified in the literature. The value and relevance of meaning based coping theory has also been emphasised, including Antonovosky's Sense of Coherence (SoC) theory. Ten patients with advanced lung cancer were interviewed up to three times. A total of twenty in depth interviews were carried out, fully transcribed and data were analysed following a methodology of Interpretative Phenomenological Analysis. Three broad domains were identified to categorise the core life concerns of participants; making sense of and managing one's illness; maintaining daily life and relationships and confronting the future. Within these domains multiple coping themes are identified, which to varying degrees help to maintain patient wellbeing and quality of life. This article considers the relevance of SoC theory for understanding the coping experiences of patients with advanced cancer, and identifies resources and factors likely to support patient coping, with implications for health and social care services.     

Evidence that supports the value of social work in hospitals

The value of hospital social work is supported by one hospital's tracking system that monitored social work discharge services and compared outcome with non-social work discharges. The sample consisted of a total of 64,722 patients admitted to the "med-surg" hospital unit over a two and one-half year time period from 2002 to 2004. Of the total patients in the sample, 15.7% (n = 10,156) had social work involvement. Sixty percent of the social worker patients were age 70 or over compared with the mean age of the sample of 56.2 years. The mean length of stay for social work served patients was 11.4 days (sd = 13.9) compared to 4.3 days (sd = 6.3) non-social work patients, a difference that was significant (t =-68.3; p = .000). The authors attribute the longer lengths of stay to social workers' receiving older and more difficult-to-place patients. An evidence-based case is made for the cost-containment value of social workers in hospitals and for the creation of a tracking infrastructure to aid in monitoring the daily achievements of medical/surgical social workers.     

Emergency care. Identification of psychosocial problems

Psychosocial problems are common among emergency department visitors, and can remain undetected if not focused upon. In the present study the magnitude of these problems was analysed by a social worker through telephone interviews 3-5 days after patients emergency department visit. This survey revealed not only those patients recognized by the regular staff as in need of help because of social problems (5%) but also an additional 33% of patients whose problems went undetected. Fifteen percent of the visitors found contact with a social worker to be helpful and six percent requested such help. A follow-up investigation five months after the visit revealed that assistance had been given to 83% of those patients.     

A Scoping Review of Food Insecurity and Related Factors among Cancer Survivors

Despite growing awareness of the financial burden that a cancer diagnosis places on a household, there is limited understanding of the risk for food insecurity among this population. The current study reviewed literature focusing on the relationship between food insecurity, cancer, and related factors among cancer survivors and their caregivers. In total, 49 articles (across 45 studies) were reviewed and spanned topic areas: patient navigation/social worker role, caregiver role, psychosocial impacts, and food insecurity/financial toxicity. Patient navigation yielded positive impacts including perceptions of better quality of care and improved health related quality of life. Caregivers served multiple roles: managing medications, emotional support, and medical advocacy. Subsequently, caregivers experience financial burden with loss of employment and work productivity. Negative psychosocial impacts experienced by cancer survivors included: cognitive impairment, financial constraints, and lack of coping skills. Financial strain experienced by cancer survivors was reported to influence ratings of physical/mental health and symptom burden. These results highlight that fields of food insecurity, obesity, and cancer control have typically grappled with these issues in isolation and have not robustly studied these factors in conjunction. There is an urgent need for well-designed studies with appropriate methods to establish key determinants of food insecurity among cancer survivors with multidisciplinary collaborators.     

A description of inappropriate hospital stays in selected in-patient services: a study of cases receiving social work services.

The number of discharges (63,303) from a university-affiliated medical center in Israel were reviewed. Eight percent of cases in three departments rcceivcd social work services. Patients experiencing inappropriate hospital stay (discharge delay) and who received social work services were characterized and compared with social work clients not experiencing delay. Discharge delay patients differed from other social work clients on key sociodemographic variables. Patients admitted because of "injury" were significantly more likely to experience delay than patients admitted because of "illness." "Waiting for community/institutional resources" was the most common reason for delay and discharge to an institutional setting increased the likelihood of delayed discharge. High risk factors were department-specific and should be studied in context. Results suggested the limited but positive impact of hospital-community collaborative strategies in reducing the incidence of delay over time.     

Listening to the rural health workers in Papua New Guinea - the social factors that influence their motivation to work

Despite rural health services being situated and integrated within communities in which people work and live, the complex interaction of the social environment on health worker motivation and performance in Low Middle Income Countries has been neglected in research. In this article we investigate how social factors impact on health worker motivation and performance in rural health services in Papua New Guinea (PNG). Face-to-face in-depth interviews were conducted with 33 health workers from three provinces (Central, Madang, and Milne Bay) in PNG between August and November 2009. They included health extension officers, community health workers and nursing officers, some of whom were in charge of the health centres. The health centres were a selection across church based, government and private enterprise health facilities. Qualitative analysis identified the key social factors impacting on health worker motivation and performance to be the local community context, gender roles and family related issues, safety and security and health beliefs and attitudes of patients and community members. Our study identified the importance of strong supportive communities on health worker motivation. These findings have implications for developing sustainable strategies for motivation and performance enhancement of rural health workers in resource poor settings.     

The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers

OBJECTIVES: We assessed the effectiveness of a community health worker intervention focused on reducing exposure to indoor asthma triggers. METHODS: We conducted a randomized controlled trial with 1-year follow-up among 274 low-income households containing a child aged 4-12 years who had asthma. Community health workers provided in-home environmental assessments, education, support for behavior change, and resources. Participants were assigned to either a high-intensity group receiving 7 visits and a full set of resources or a low-intensity group receiving a single visit and limited resources. RESULTS: The high-intensity group improved significantly more than the low-intensity group in its pediatric asthma caregiver quality-of-life score (P=.005) and asthma-related urgent health services use (P=.026). Asthma symptom days declined more in the high-intensity group, although the across-group difference did not reach statistical significance (P=.138). Participant actions to reduce triggers generally increased in the high-intensity group. The projected 4-year net savings per participant among the high-intensity group relative to the low-intensity group were 189-721 dollars. CONCLUSIONS: Community health workers reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score. Improvement was greater with a higher-intensity intervention.     

Social workers respond to the AIDS epidemic in an acute care hospital

Acquired immune deficiency syndrome (AIDS) has had dramatic effects on hospital staff, particularly social workers. However, little documentation exists of how hospitals and their social work departments have responded to the myriad needs of people with human immunodeficiency virus-related conditions. Patterns of social work service delivery to 152 persons with AIDS at St. Luke's-Roosevelt Hospital Center in New York City were reviewed. Gaps were identified; in particular, social workers provided services to only 40 percent of the identified persons with AIDS. The need for staff education and training, dedicated resources for services to persons with AIDS, and increased out-of-hospital services are discussed.     

Mothers of IVF twins: the mediating role of employment and social coping resources in maternal stress

Twin pregnancies and births resulting from assisted reproductive technologies have been associated with adverse perinatal outcomes and maternal health complications leading to psychologically complex parenting. In the current study the authors assess the prevalence of clinical levels of maternal stress among mothers of twins resulting from in vitro fertilization and examine the association of social coping resources with three maternal stress sub-scales. During the years 2003-2005, 88 primiparous Israeli mothers of in vitro fertilization-conceived twins provided socio-demographic data during their third trimester of pregnancy, and at 6 months after birth provided data on delivery and medical condition of infants, coping resources (social support and marital quality), and a maternal stress scale. Forty-one percent of the mothers reached a clinically significant level of maternal stress. Social support and maternal employment were the most significant variables associated with experience of the stress in the early stages of adaptation to mothering in vitro fertilization twins. Primiparous mothers of in vitro fertilization twins are vulnerable to maternal stress in early stages of adaptation to the maternal role, some of whom reach clinical levels that may require professional interventions. Unemployed mothers with low social support were the most susceptible to the deleterious effects of in vitro fertilization treatment.     

Mothers of IVF Twins: The Mediating Role of Employment and Social Coping Resources in Maternal Stress

Twin pregnancies and births resulting from assisted reproductive technologies have been associated with adverse perinatal outcomes and maternal health complications leading to psychologically complex parenting. In the current study the authors assess the prevalence of clinical levels of maternal stress among mothers of twins resulting from in vitro fertilization and examine the association of social coping resources with three maternal stress sub-scales. During the years 2003–2005, 88 primiparous Israeli mothers of in vitro fertilization-conceived twins provided socio-demographic data during their third trimester of pregnancy, and at 6 months after birth provided data on delivery and medical condition of infants, coping resources (social support and marital quality), and a maternal stress scale. Forty-one percent of the mothers reached a clinically significant level of maternal stress. Social support and maternal employment were the most significant variables associated with experience of the stress in the early stages of adaptation to mothering in vitro fertilization twins. Primiparous mothers of in vitro fertilization twins are vulnerable to maternal stress in early stages of adaptation to the maternal role, some of whom reach clinical levels that may require professional interventions. Unemployed mothers with low social support were the most susceptible to the deleterious effects of in vitro fertilization treatment.     

Hospice Care: What Services Do Patients and Their Families Receive?

OBJECTIVE: To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered. DATA SOURCE: Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey. STUDY DESIGN: Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support. DATA COLLECTION: Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review. PRINCIPLE FINDINGS: In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio=1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low. CONCLUSIONS: Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families.     

Utilization of health social work services by older immigrants and veterans in Israel

The authors examined factors related to utilization of health social work services among older immigrants from the former Soviet Union and veteran residents of Israel, using Andersen's behavioral model. A sample of 476 patients age 55 and older was interviewed. The immigrants and veterans had similar backgrounds, but immigrants had fewer resources and higher need. Veteran Israelis were twice as likely to have been in contact with a hospital social worker. Factors related to seeing a social worker were male gender, social network size (no network or large network), activity limitations, and sick days. The main barriers to contacting a social worker stemmed from information problems. The findings have implications for providing services in areas with large numbers of immigrants.     

Evaluating social work discharge planning services for elderly people: access, complexity, and outcome.

The discharge planning role of hospital social workers has become increasingly important in services to elderly people. This article examines three issues: (1) the extent to which elderly people most in need receive social work services, (2) the extent to which the discharge planning performed is a professional task, and (3) the effectiveness of discharge planning for those who return to their homes after hospitalization. The study focused on 1,100 elderly patients from five Baltimore hospitals. Data were gathered from their social workers, from the patients themselves (by phone after discharge), and from medical records. Results show that only a minority of elderly patients who return to the community after hospitalization receive social work services while in the hospital but that those who do are likely to have posthospital needs. In most cases, the discharge planning uses professional skills, but 28 percent of cases are fairly routine. Finally, social work services were effective in reducing the level of unmet needs in the areas of nursing, medication, and physical therapy.