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 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.     

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.     

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.     

Psychiatric nurse reports on the quality of psychiatric care in general hospitals

Although acute inpatient psychiatric care has changed dramatically over the past 2 decades, little is known about how these changes have affected the quality of care, psychiatric nurse staffing, or patient outcomes. The purpose of this report is to explore the quality of care, quality of the practice environment, and adverse events as assessed by psychiatric nurses in the general hospital setting. The study sample consisted of 456 registered nurses permanently assigned to psychiatric units, compared with a larger sample of 11,071 registered nurses who work permanently on medical, surgical, or medical-surgical units. Compared with nonpsychiatric nurses, psychiatric nurse characteristics reveal an older, more experienced workforce, with a higher proportion of male nurses. Nurses rated quality of patient care lower in the psychiatric specialty than in the medical-surgical specialty. Furthermore, psychiatric nurses reported significant concern about the readiness of patients for discharge and higher incidence of adverse events. They also experienced more verbal abuse, physical injuries, and complaints from patients and families. Collectively, the results from this study underscore the organizational problems and quality-of-care issues that cause psychiatric nurses in general hospital settings to evaluate their work environments negatively.     

Managing inpatient clinical nutrition services: a comprehensive program assures accountability and success

A major challenge facing clinical dietitians today is justifying inpatient clinical nutrition services. To meet this challenge, a comprehensive program for the delivery and management of clinical nutrition services was developed at Yale-New Haven Hospital. It is based on seven nutritional risk factors--age, diagnosis/treatment, diet, metabolic or mechanical problems, significant lab values, pertinent medications, and weight for height. These risk factors are used to categorize patients into one of seven classifications. In essence, this classification system is the screening tool used to provide the foundation for standards of practice and nutrition assessment and intervention. The inherent advantage of such a program is that it identifies patients at high nutritional risk, regardless of wide variations in patient population or diagnosis. It also provides standardized criteria for evaluating quality of care, patient acuity, and productivity and staffing. Clinical nutrition services can then be measured for both quality and quantity. Because protein-calorie malnutrition poses a serious threat to cost containment and quality patient care, this type of program can appeal to hospital administrators, physicians, and site visitors alike. It can serve as an adaptable model for the delivery and management of inpatient clinical nutrition services in a wide variety of health care facilities.     

Factors delaying discharge of psychiatric patients

The reliable identification of patients at high risk of experiencing delays in discharge is an important objective of social workers in psychiatric settings. This study discovered a number of factors associated with excessive hospital stays, marking an initial step in the development of a list of high-risk indicators to be used to achieve more timely and appropriate transitions for psychiatric patients no longer in need of inpatient care.     

Hospital overcrowding: an opportunity for case managers

Hospital overcrowding is primarily a shortage of inpatient beds, not a lack of emergency department capacity, as initially assumed. According to Asplin et al., many factors contribute to overcrowding, including inadequate or inflexible nurse-to-patient staffing ratios, isolation precautions, or delays in cleaning rooms after patient discharge; an overreliance on intensive care or telemetry beds; inefficient diagnostic and ancillary services on inpatient units; and delays in discharging hospitalized patients to postacute-care facilities. Hospital overcrowding presents a challenge for hospital employees and clients, often leading to frustration and dissatisfaction. Overcrowding also has a direct effect on patient care, including compromised patient safety, increased costs, increased length of stay, and increased mortality and morbidity rates. The emergency department is changed from a temporary holding area to an extended patient care unit, decreasing its ability to handle new admissions and to manage a mass casualty. Beds in the critical care units become filled with inappropriate patients if floor beds are not available, making placement of seriously ill patients difficult. Trauma patients may have to be diverted to other hospitals to receive the appropriate level of care. Patients who require specialty services may have to wait for extended periods to obtain a bed in a referral center.     

Cost analysis of a hospital-at-home initiative using discrete event simulation

OBJECTIVES: To examine whether, from a National Health Service (NHS) and local authority social services' viewpoint, a hospital-at-home service was cost saving compared with conventional inpatient care. METHODS: The subjects of this part-retrospective and part-prospective cost analysis were 51 elderly medical and orthopaedic surgical patients assessed at Hillingdon Hospital, West London, as being suitable for hospital-at-home care. Thirty patients received hospital-at-home care, provided for up to 14 days, while 21 patients remained in hospital and received standard inpatient care. All direct costs to the NHS hospital, community health services' provider and social services' department during the initial episode of care and the three months after discharge were collected for each group of patients. Costs and clinical event data were entered in a discrete event simulation model which generated baseline results. Uncertainty surrounding the model's parameters was explored using sensitivity analysis. RESULTS: The baseline simulation performed with 1000 patients in each group showed the mean cost per patient for hospital-at-home care and three-month follow-up to be around three-fifths the mean cost per patient of inpatient care and follow-up. Most of the excess cost in the inpatient group was attributable to the initial period of hospitalisation. Under all assumptions used in the sensitivity analysis, the hospital-at-home service was less costly. CONCLUSIONS: For elderly patients assessed as needing no more than 14 days of hospital care, hospital-at-home care is cost saving to health and social care agencies when compared with conventional inpatient care.     

Hospital staffing adjustments under global budgeting

The U.S. Department of Veterans Affairs operates a hospital system that distributes a national global budget to 159 hospital units. Over recent years, cost containment and downward budgetary pressures have affected hospital performance and the quality of care delivered in unknown ways. This article examines hospital staffing levels as potential performance measures. We first develop a regression model to estimate the number and types of clinical staff required to meet current inpatient workloads at VA medical centers. We are able to improve on previous analyses by employing better data on physicians and by evaluating the behavior of hospitals in consecutive years. Our findings provide managers of hospital systems with promising new approaches for comparing hospital production processes and more information on the effects of global budgeting on individual hospital staffing within systems.     

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.     

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.     

A qualitative study of DRG coding practice in hospitals under the Thai Universal Coverage Scheme

Background  

In the Thai Universal Coverage health insurance scheme, hospital providers are paid for their inpatient care using Diagnosis Related Group-based retrospective payment, for which quality of the diagnosis and procedure codes is crucial. However, there has been limited understandings on which health care professions are involved and how the diagnosis and procedure coding is actually done within hospital settings. The objective of this study is to detail hospital coding structure and process, and to describe the roles of key hospital staff, and other related internal dynamics in Thai hospitals that affect quality of data submitted for inpatient care reimbursement.     

Community care in practice: social work in primary health care

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.     

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.     

Social workers as care coordinators: Leaders in ensuring effective,compassionate care

The concept of care coordination is at the forefront of national conversations in the context of health care reform. As pediatric social workers, we are interested in how care coordination benefits our patients, and which disciplines are providing coordination services. We have determined that significant overlap exists between the work social workers are already doing in inpatient and outpatient medical settings and the literature’s definition of care coordination activities. This article outlines our process of literature review and creation of a working definition of care coordination, and frames the concepts we believe remain central to the process of care coordination.     

A multidisciplinary audit of diabetes mellitus.

A multidisciplinary audit evaluating the quality of care of patients with a primary diagnosis of diabetes mellitus was performed at St. Mary's Hospital in Grand Rapids, Michigan. The audit served to evaluate the treatment and care of diabetic patients, in both the inpatient and ambulatory care settings, and also to identify interaction problems involving patient care among physicians, nurses, dieticians, and social workers. Analysis of the data indicated that each discipline rendered adequate patient care. As other published audits have also indicated, this multidisciplinary audit revealed that documentation of services is frequently lacking and that communication between the involved disciplines was less than desirable. The audit disclosed a need to educate the hospital staff (medical and nursing) as to the role and function of the Social Services Department. As a result of this audit, definite measures have been instituted in each participating department in an attempt to further upgrade the quality of medical care and improve interdepartmental communication and cooperation.     

The impact of DRGs on the cost and quality of health care in the United States.

The prospective Payment System (PPS) represents a fundamental change in the way the United States government reimburses hospitals for medical services covered under Medicare, a federal health care insurance program for the elderly and disabled. PPS replaced the retrospective cost-based system of payment for Medicare services with a prospective payment system. Under PPS, a predetermined specific rate for each discharge dictates payment according to the diagnosis related group (DRG) in which the discharge is classified. The PPS was intended to create financial incentives that encourage hospitals to restrain the use of resources while providing high-quality inpatient care. Both objectives appear to have been met under PPS. Hospital utilization has declined, average length of stay has fallen, and the locus of care has shifted from the inpatient setting to less costly outpatient settings. The growth in inpatient hospital benefits has slowed and the impending insolvency of the Medicare trust fund has been forestalled. Studies have found no deterioration in the quality of care rendered to Medicare beneficiaries. Neither the mortality rate nor the rate of re-admission (presumably related to premature discharge) increased under PPS. Indeed, PPS appears to have enhanced the quality of inpatient care by discouraging unnecessary and potentially harmful procedures, and by encouraging the concentration of complex procedures in facilities in which the high frequency of these procedures promotes efficiency. Incentive-based reimbursement also appears to have contributed to the growth in alternative delivery systems, such as HMOs and PPOs, which contain costs by maintaining a high volume of a limited range of services. The success of the PPS/DRG system in controlling costs and promoting quality in this country suggests its application in other countries, either as a method of reimbursement or as a product line management tool.     

How many social workers are needed in primary care? A patient-based needs assessment example

This study measured levels of self-reported social need in a sample of 684 veterans seen in four primary care clinics of a large Veterans Affairs health care system, using the Social Needs Checklist, and calculated levels of social work staffing to meet these needs. Data were obtained on the presence and severity of 15 areas of social needs, housing status, patient requests for social work services, and current access to other providers for social services. Data were also obtained from primary care social workers who estimated the average time needed to provide basic social work services. Nearly two-thirds of the sample had problems related to finances and personal stress. Three in four patients reported multiple needs. One-third requested social work services. Social work staffing needed for highest acuity patients was estimated to be 61 percent higher than actual staffing available. The study presents a method of estimating staffing levels based on social needs reported by patients.     

Peer counseling in health care: a collaboration of social work and voluntarism

Professional-volunteer collaboration is a growing trend in social work practice in health care. The social work profession can benefit from partnerships with volunteers to extend, enhance, and maximize the scope and quality of patient care. This article examines a program of social work collaboration with volunteers, trained as peer counselors, in a hospital setting. A model is described which provides long-term social support to chronically and terminally ill patients and their families during hospitalization and after discharge. Implications for replication in other settings are discussed.     

The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel comprehensive integrated program

The Cleveland Clinic is a large multispecialty group practice. The need for a palliative care program was identified and the program started in 1987. A key concept has been that the existing structure of hospice care as defined by Medicare is insufficient to address the needs of patients with incurable disease. The field of palliative medicine implies physician expertise in several key areas: (1) communication; (2) decision-making; (3) management of complications; (4) symptom control; (5) care of the dying; and (6) psychosocial care. The development of the program (the first in the United States) since 1987 has put in place the following major services, listed consecutively: (1) hospital consultation service; (2) outpatient clinics; (3) acute care inpatient service; (4) hospice and home care service; (5) acute-care palliative medicine inpatient unit; and (6) hospice inpatient facility. Program development has meant that a new program has been introduced approximately every 18 months since the start of the program. This has considerable implications for staffing, the management of change, and competition for scarce resources within a contracting health care budget. The staffing of the program has focused on developing specialized attending physicians using a multidisciplinary approach dedicated to enhancing the role of nursing in the field. The major budgeted areas are (1) the acute-care palliative medicine unit, and (2) the hospice and home care service. Specific commitment has been made to research and education because of the desire to develop an intellectual basis for the practice of palliative medicine. This requires structured activities in both areas with a systematic approach to research and education. The complexity of developing a service should not be underestimated. There has been consistent support for the program by senior leadership within the Cleveland Clinic Foundation, including the cancer center. The major lessons learned during program development have been: (1) to focus on quality of patient care; (2) to commit to academic endeavor in research and education; (3) to secure institutional commitment to program development; (4) to establish a positive, proactive, businesslike approach; (5) to defend budget and personnel, albeit within a difficult time in health care; and (6) to commit to success, i.e., never promise anything on which you do not deliver. The future development of post-acute-care services serving predominantly the chronically ill elderly population suggest an expanded administrative and conceptual role for the future development of palliative medicine to help serve the needs of the aging population in the United States.