Measure patients' progress with home SW paths
Measure patients' progress with home SW paths
By Elaine K. Williams, ACSW
President, Elaine K. Williams & Associates
Lathrup Village, MI
Social/emotional problems frequently impede management of illness, regardless of the patient's diagnosis. Clinical paths for home health care social workers will allow these problems to be addressed in a measurable, quantifiable way.
In writing Clinical Paths for Home Health Care Social Workers, I wrestled with several issues, not the least of which was the format for the paths themselves. (For more information on book, see editor's note, p. 107.) The paths were not written to address specific medical diagnoses, but instead to reflect the most common social/emotional problems referred for social work intervention in home health care. The paths address 11 social/emotional problems and include:
* change in family dynamics;
* change in mood/affect: depression;
* inadequate support system;
* knowledge deficits dementia/Alzheimer's;
* lack of need and appropriate resources to manage illness;
* nonadherence to treatment regime;
* social isolation;
* suicide/violence potential;
* unsafe environment;
* diminished coping skills;
* crisis situation endangering patient's medical, physical, mental, emotional health, and safety.
This approach prevents the repetition and redundancy that could occur if the social work paths were written by medical diagnosis.
The next complex issue was the care elements, which cue the skilled interventions to be used by the social worker. The care elements for the social work clinical paths closely follow the Medicare E Codes, which ensures only Medicare-prescribed skilled and reimbursable interventions will be used by the social worker. The care elements cue for:
* assessment of the primary social/emotional problem;
* assessment of other social/emotional problem(s);
* counseling for long-range planning and decision-making;
* community resources;
* short-term therapy;
* family counseling;
* crisis intervention;
* safety of home environment;
* interdisciplinary/coordination of services.
Each path has a prescribed set of goals and a prescribed set of outcomes, the latter of which if achieved ensure goal attainment. The paths require the selection of a primarily social/emotional problem and the prioritizing of other social/emotional problems. The paths prescribe certain skilled activities within each care element in a problem-solving fashion, but do not specifically prescribe everything the social worker might do on behalf of a patient.
For example, the path will cue the social worker for the delivery of short-term therapy. However, it is up to the social worker to determine the treatment modality of choice, based on their assessment of the problem(s). The path will cue the social worker to assess, link, and refer for needed community resources. It will not, however, tell the social worker which resources to link and refer the patient to in the community.
The reasons for this approach include:
1) It is impossible it know the variables that will influence a given patient situation;
2) It is impossible to know the combination of social/emotional problems a patient/caregiver system will present with;
3) The clinical paths cannot substitute for the professional skilled judgment of the social worker.
The paths provide a general route for the social worker to follow for each primary social/emotional problem identified; however, it is up to the social worker to use their professional judgment to determine the specifics within the context of the care element activities.
Paths get mixed review
Social work practitioners need to realize that the challenge in understanding the clinical path is simply developing a new appreciation of the social work process. The most common response by social workers who tested clinical paths in eight home health care sites across the country was a heightened sense of pride that the "body of knowledge required to perform home health care social work could be organized into a clinical path process." Social workers in all the test sites recognized that the paths simply reflect the skilled activities they already perform in their work with patients in their homes.
Social workers who have performed home health care for a while are not always comfortable with the prescriptive aspect the paths bring to their work. New home health care workers are relieved and excited to see the process organized and prescribed. Nurses overwhelmingly commented that they finally could understand what social workers do in home health care.
As the clinical paths become more and more familiar, social workers will become more comfortable with the path process and the shift in documentation from process to outcomes. We will also become more comfortable with the changes and challenges that will continue to confront us in the home care industry. Our increased comfort will be directly related to:
* our increased ability to define our role and service responsibilities, thus strengthening our place on the home care team;
* universalize home health care social work practice, thus diminishing variation in practice patterns;
* our ability to demonstrate that we can both define and measure social work outcomes in home health care.
[Editor's note: Elaine K. Williams Associates is a teaching and consulting firm that specializes in home health care and holistic healing techniques. The Clinical Paths for Home Health Care Social Workers will be published and available for purchase in September, 1996. Elaine K. Williams, ACSW can be contacted at (810) 557-6789, or write P.O. Box 1424, Southgate, MI, 48195.] *
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