Admissions social worker improves LOS, referrals

Multiple benefits result from program

A Missouri hospice has discovered that it is cost-effective, efficient, and it improves length of stay (LOS) and referrals to have a social worker serve as an admissions coordinator.

Option Care-Missouri River Hospice of Columbia, MO, decided to implement a program in which a social worker would serve as admissions coordinator as a nursing shortage affected the Midwest, says Denise Swenson, MSW, LCSW, admissions coordinator.

"Our hospice's director looked at ways we could utilize different roles so that we could maximize the use of nurses in direct patient care," Swenson says. "When nurses were doing admissions it would take two visits and sometimes three visits before the families were comfortable accepting hospice services."

This was inefficient and left hospice patients with less time in which to benefit from the holistic approach to hospice services, she notes.

Since the hospice began to use a social worker in the role of admissions coordinator, the benefits have been multiple:

1. It saves money. The social worker's salary is on average $5 per hour less than hospice nurses, so the hospice has experienced a cost savings, Swenson says.

"Last year, I did 600 introductions to hospice, so it was about $3,000 less last year to send me to do the introductions than it would be to send a nurse," Swenson says.

Another $2,800 was saved in the admissions process. Of the 600 people who heard the hospice introduction, 560 were admitted, and the admission process takes another hour, which again saves money when the social worker is the one doing the admission, Swenson adds.

2. It saves time. "It also saves time," Swenson says. "When nurses were conducting the introduction and admissions, and then if they had to do a nursing assessment too, it would take them about three hours."

When an MSW does the introduction and admissions, it will take 1½ to two hours, depending on the family's questions, she says.

The nursing assessment still will need to be done when patients are admitted, she notes.

But in cases where the family does not accept hospice services, the nurse's time is not used needlessly, Swenson says.

3. Staffing efficiency and productivity are improved. Prior to the change, when nurses would do admissions, it would interrupt their day and they couldn't schedule their visits efficiently, Swenson says.

"Now, the RNs can focus on direct patient care, which is the greatest utilization of their time," she says. "Nurses know where they will be visiting patients and can more efficiently manage mileage and drive time."

Also, nurses can schedule chart documentation days, Swenson says.

"When someone is dedicated in the role of hospice admissions, it frees everyone else to schedule their day more efficiently," she says.

Swenson's own time is scheduled to be efficient for both the hospice and patients. Since there are very few referrals on Fridays and many families would like her to visit during the evening hours, she typically works four 10-hour days, Monday through Thursday.

"This schedule accommodates families very nicely, because if they want to see me at 7 p.m., that's not a problem," Swenson says.

4. LOS and overall admissions are up. The hospice's LOS has improved since switching to having a social worker serve as admissions coordinator. In 2001, the agency's median LOS was 16.5 days, Swenson says.

In 2005, the median LOS was 22 days, she adds.

The change in LOS occurred almost immediately as the LOS rose to 21 days by the end of 2002, Swenson says.

Increasing it still further has proven more challenging because the hospice's admissions also have increased, which includes many admissions in which patients receive hospice care for seven days or less, Swenson notes.

5. There are psychosocial benefits. "Also, there have been real and significant benefits to utilizing the MSW over nurse from the psychosocial aspects," Swenson says.

While nurses are trained to focus on the physical aspects of patient care, the social worker looks at both the patient and everyone in the patient's life, she says.

"A great amount of what hospice offers is intended to support the caregiver and family, as well," Swenson notes. "So when the social worker goes out on an admission visit, the social worker is looking at what everyone needs in this experience."

This is why patients who are visited by the social worker at introduction are more likely to accept hospice services sooner than they did when nurses were making the first visit, Swenson explains.

Also, the social worker at admissions will help the family focus on volunteer and other hospice services, showing patients what the hospice can do to help them, she adds.

In one situation, Swenson met with a family in which both the patient and caregiver were elderly and had health problems.

"The initial plan was for the wife, who was the patient, to go home from the hospital and be cared for by her husband," Swenson says. "But her husband didn't know how he was going to take care of her because he couldn't take care of himself, and other family members were not volunteering to provide services in their home or to take Mom and Dad home with them."

So Swenson spent time talking with the family about a feasible and safe plan, and with her assistance, the family decided that the best step would be to place the wife in a nursing home, where she would receive her end-of-life care.

"Sometimes the most loving thing to do is to allow the patient to have health care professionals available 24 hours around the clock to do all the nursing and health care things that families aren't trained to do," Swenson says.

"So it really does help from a psychosocial and emotional perspective to have that social worker in there from the very beginning, supporting the family as well as the patient," Swenson says.

6. Patient referrals have increased. "Because we have someone dedicated in the role of hospice admissions, we are able to respond to every hospice referral within 12 hours," Swenson says. "And every hospice introduction is conducted within 24 hours, unless the family specifically requests that we wait until other family members are available."

Each admission is consistent. Swenson uses an outline at each admission, saying the same thing each time.

"I also do an initial assessment of what equipment needs they might have, and I notify the team when the patient has psychosocial or spiritual needs or when the patient is out of medicine," she explains. "So when the nurse goes out to do the nursing assessment, she already has an idea of what she's walking into."

Physicians are very pleased with the prompt response to their referrals, Swenson says.

In 2003, there were 370 hospice introductions with 350 admissions, compared with 600 introductions and 560 admissions in 2005, Swenson says.

"I don't know how much of that increase is attributable to the social worker in the role, but the physicians we work with strongly support our model of delivery of services," Swenson says.

Also, the nursing assessments have been made more efficient because each of the hospice's offices has a clinical coordinator with an RN degree who conducts the nursing assessment, following the admissions coordinator's visit, Swenson says.

7.The admissions coordinator also can serve as community liaison. "We have designated as part of the responsibilities of this role that I do all of the community education programs and speak at clubs, organizations, agencies, and nursing homes," Swenson says. "I also speak at national health care and long-term care conferences about hospice services."