THE QUALITY - CO$T CONNECTION

How to evaluate social service contributions

SWs an important link between providers, clients

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Social work services provide an important link between ambulatory and inpatient providers and health care clients. Social workers assist patients in finding available and appropriate resources, help with financial issues, arrange transportation for patients, and conduct many more enabling tasks.

Social workers assist in the assessment of patient needs and ensure that appropriate post-hospital services are provided. For the ambulatory care client, whether hospitalization has occurred or not, social workers can provide a link from one service to another. In addition to coordinating support services, social workers assist patients and their families in resolving personal or emotional problems that affect the patient's participation in clinical care. Equally important, they provide patients and families with a shoulder to lean on and encouragement to continue the care process until the treatment is concluded or the problem is resolved as effectively as possible.

Measures of the social worker's contribution to the case management process are linked to the job responsibilities. Listed below are common job tasks performed by social workers involved in hospital-based case management:

  • Conduct patient/family assessments to identify barriers that may impede recovery and/or patient's return to the community.
  • Help patients identify their concerns about their illness and recovery, consider solutions, and find necessary resources.
  • Investigate patient or family allegations of abuse and neglect, and intervene if necessary.
  • Plan for appropriate post-discharge supportive services and follow through to assure that services actually were provided and met patients' needs.

It is important that social workers collect and analyze data about the effectiveness of case management interventions so that opportunities for improvement can be identified.

Performance measures

Performance measures are generally easiest to determine for social work activities that have established and quantified goals. When no goals exist for an activity, the case management team should revisit the fundamental question of what it is that social workers are expected to achieve. Several examples of common goals for social work interventions are listed below:

  • patient/family are satisfied with social work services;
  • provider/community services' are satisfied with social work services;
  • timely response to referrals;
  • complete documentation of service plan and interventions;
  • case management goals, as established in patient-specific case management plans, are achieved;
  • unnecessary over-utilization of acute care services is minimized.

Patient and family satisfaction with social work services can be measured with a survey instrument. This survey can be mailed to patients after they leave the hospital or given to them on discharge. Shown in Figure 1 is an example of a questionnaire that is used to gather information about people's satisfaction with social work services. By periodically collecting data about patient and family perceptions of staff performance, the social work department can make constant improvements in its quality.

Include in the survey questions assessing the social worker's capacity to express sincere sympathy and empathy, the timeliness of their services, the clarity with which they communicate the service plan of care, and how well the plan meets the needs and wishes of the patient and their family. Similar types of survey instruments can be used to gather satisfaction information from physicians, post-hospital treatment providers, and community service agencies.

With today's short hospital lengths of stay, social workers must quickly evaluate patients' needs and make necessary post-hospital arrangements. Thus, identification of patients that may require social worker interventions should be done as soon as possible. A screening tool, such as the one completed by the hospital preadmission coordinator shown in Figure 2, can be a useful method for identifying patients who need a social work referral. When a preadmission screening process is in place, social workers can measure how quickly patients are seen after admission. Ideally, high-risk patients are seen the same day as admission or within 24 hours of referral.

The patient's medical record is a vital communication tool, and that's why it is essential that social workers adequately document patient assessments, service plans, and interventions. It is important that psychosocial issues be well documented so that the caregivers understand the environmental influences the patient is coping with while simultaneously undergoing medical care.

The thoroughness and conciseness of the social workers' documentation in the patient record is all-important, and no performance measurement system is complete without an analysis of documentation. However, the measure of quality should focus on aspects of patient care, not just the fact that charting did or did not occur. For example, the performance measure, "percent of medical records that contain an appropriate psychosocial assessment" places emphasis on documentation, not the patient.

By changing this measure to "percent of patients receiving appropriate psychosocial assessment," the importance of proper patient care is emphasized rather than the documentation.

Patient-specific case management plans should contain goals, and achievement of these goals is a common measure of performance. However, evaluating this aspect of social work services can be difficult when goal attainment is not expected to occur until after the patient leaves the facility. For example, it may be a week or more before the social worker can verify that a discharged patient actually is receiving the community services that have been arranged.

The fact that the social worker made the appropriate referral is important. However, the goal of obtaining community service support for a patient is not actually achieved until the services are being delivered as promised.

Gathering goal attainment information post-discharge will require some type of call-back system to verify that patients are receiving necessary services.

Social workers can help to reduce overutilization of acute care services. When social work assessments are completed on time and referrals initiated early in a patient's hospitalization, discharge is more likely to occur as soon as the patient is medically stable.

Measures of resource utilization problems that may be attributable to problems with social work services include:

  • number of patients with recognized psychosocial problems that were not resolved during their hospital stay and for whom no post-hospital support was arranged (these patients are at high-risk for readmission);
  • number of patients readmitted to the hospital within 30 days with suspected abuse/neglect who were not seen by social worker during their first hospital stay;
  • number of patients with a history of suicide or drug abuse not seen by social worker and/or not offered a referral to follow-up counseling clinic;
  • number of discharge delays due to late referrals/arrangements by social service staff.

Professional standards

The National Association of Social Work (NASW) has developed professional standards and clinical indicators for many aspects of social work and psychosocial services, including case management activities in acute care and psychiatric hospitals. These resources can be found on the NASW web site at: www.naswdc.org/credentials.

The NASW supports the establishment of systems and processes that enable social workers to evaluate the quality of case management services to patients, families, and other customers. Ideally, performance improvement of social work services is part of a coordinated effort of all disciplines within the case management department.