VAV LETTERS Author Clarifies Review
Reference
After the May issue of Health and Social Work went to press, I learned that I had made a serious omission in an article I authored that appeared in that issue. My article "Is Case Management Effective for People with Serious Mental Illness?" [vol. 17 (May 1992), pp. 138-150] reviewed recent outcome studies on case management. The results of those studies were inconsistent, which led me to conclude that although the hypothesis that case management is effective remains plausible, conclusive claims that its efficacy has been demonstrated empirically are premature. The omission in my review was of an important randomized experiment reported by Modrcin, Rapp, and Poertner (1988). The results of that study suggested that a developmental acquisition model of case management might be effective. Unfortunately, I did not become aware of that study in time to include it in my review. Had I been aware of that study in writing my review, it would not have changed in any dramatic way my basic conclusion about the inconsistency of findings among the studies and the need for more research before claiming conclusively that case management is effective. However, it would have changed the tone of my review, reducing its skepticism about the evidence supporting case management's efficacy. I hope that those who read my review will also read Modrcin et al.'s article to obtain a more comprehensive basis for considering the effectiveness of case management.
Modrcin, M., Rapp, C. A., & Poertner, J. (1988). The evaluation of case management services with the chronically mentally ill. Evaluation and Program Planning, 11, 307-314.
ALLEN RUBIN University of Texas at Austin 238
CCC Code: 0360-7283/92
Article Provides Excellent Perspective We found Cowles and Lefcowitz's article "Interdisciplinary Expectations of the Medical Social Worker in the Hospital Setting" [Health and Social Work, 17 (February 1992), pp. 57-65] an excellent perspective on how we as social workers are viewed by our nursing and physician colleagues. One application of these results is to rethink how we market ourselves in hospitals. We can transform the research terminology of the study into new ways of describing social work services to physicians, nurses, and patients. We can enhance the descriptions of social work services by indicating their effects on fiscal outcomes and quality improvement. For instance, "help patients examine possible solutions to their social-environmental problems" (Cowles & Lefcowitz, 1992, p. 59) could be termed "promoting continuity of care by connecting patients with chronic conditions to community based services which will reduce unnecessary hospital admissions" (Sharp, Coleman, Starling, Cline, & Rehm, 1991, p. 118). In addition, we must acknowledge the study findings that much of what we do overlaps with other professions. In our hospital, with an intensive nursing case management program, our role is no less essential but refined to serving the
$3.00 © 1992, National Association of Social Workers, Inc.
more dysfunctional families and providing family conferences to facilitate discharge and treatment planning in complex cases (Miller & Walsh, 1991). In this way we demonstrate the quality social work adds to medical services. We hope others will follow the foundation laid by this study with research that continues to clarify our changing tasks in a health care industry in constant flux. JOHN W. SHARP SUSAN ZETTLER Cleveland Clinic Foundation Cleveland
References
Cowles, L. A., & Lefcowitz, M. J. (1992). Interdisciplinary expectations of the medical social worker in the hospital setting. Health and Social Work, 17, 57 65. Miller, R. D., & Walsh, T. D. (1991). The role of a palliative care service family conference in the management of the patient with advanced cancer. Palliative Medicine, 5,34 39. Sharp, J. W., Coleman, E., Starling, N., Cline, J., & Rehm, S. (1991). Hospital utilization for AIDS: Are all hospital days necessary? Quality Review Bulletin, 17(4), 113 119. -
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Editorial's Viewpoint Is Strongly Supported I read with interest your recent editorial "Clinical Supervision: Key to Effective Social Work" [Health and Social Work, 17 (May 1992), pp. 83851 discusring the importance and efficacy of clinical supervision within a hospital-based practice, and I strongly support your viewpoint. Interestingly, just prior to the publication of the editorial, I had read an article by JamesRogers, Widrow, Schwankovsky, & Rasgon (1992) that reported that in a study of communitybased nephrology social workers, the percentage of time devoted to counseling patients decreased markedly as the number of years in practice increased. One conclusion was that the absence of professional validation may lead to an inability to retain a clinically oriented focus, LETTERS
thus contributing to worker burnout. Good supervision can provide that validation that is particularly essential if the medical social worker is to remain a dynamic member of the multidisciplinary team with an ability to provide an effective social work perspective to the decisionmaking process. In the May 1992 issue of Social Work, Kurland and Salmon wrote that the intractability of today's problems creates unusual stress for social workers and a perceived sense of hopelessness that can be mitigated by effective supervision that encourages practitioners to set realistic goals and to value small successes. Surely the development and maintenance of clinical practice skins related to the crisis intervention approach needed to work successfully with hospitalized patients, families, and significant others can be enhanced by skilled clinical supervision in which discharge planning and counseling are not polarized. Most departments of social work monitor patient delay days and I assume that a significant number of those delays are related to "difficult families." Families and patients are indeed "difficult," because they are having to make increasingly complex decisions within shorter and shorter time frames, often with fewer and fewer community resources at their disposal. Because these delay days can be readily understood by hospital administrators in terms of "real dollars," can we not justify the saving of some of these dollars by advocating for supervision geared to improving the worker's skills in complex crisis intervention, which helps patients and families move ahead at a faster pace in their decision-making process? Also, the core of successful crisis intervention is surely an extremely accurate differential diagnosis requiring the sophisticated skills of a knowledgeable medical social worker. I suggest that the development and maintenance of these assessment skills can be linked to a positive supervisor-supervisee relationship. In an informal poll in our own department last year, 10 out of 11 workers responded that supervision was essential and that the continued growth and advancement of clinical skills should be the primary goal of supervision. 239
Reference
After the May issue of Health and Social Work went to press, I learned that I had made a serious omission in an article I authored that appeared in that issue. My article "Is Case Management Effective for People with Serious Mental Illness?" [vol. 17 (May 1992), pp. 138-150] reviewed recent outcome studies on case management. The results of those studies were inconsistent, which led me to conclude that although the hypothesis that case management is effective remains plausible, conclusive claims that its efficacy has been demonstrated empirically are premature. The omission in my review was of an important randomized experiment reported by Modrcin, Rapp, and Poertner (1988). The results of that study suggested that a developmental acquisition model of case management might be effective. Unfortunately, I did not become aware of that study in time to include it in my review. Had I been aware of that study in writing my review, it would not have changed in any dramatic way my basic conclusion about the inconsistency of findings among the studies and the need for more research before claiming conclusively that case management is effective. However, it would have changed the tone of my review, reducing its skepticism about the evidence supporting case management's efficacy. I hope that those who read my review will also read Modrcin et al.'s article to obtain a more comprehensive basis for considering the effectiveness of case management.
Modrcin, M., Rapp, C. A., & Poertner, J. (1988). The evaluation of case management services with the chronically mentally ill. Evaluation and Program Planning, 11, 307-314.
ALLEN RUBIN University of Texas at Austin 238
CCC Code: 0360-7283/92
Article Provides Excellent Perspective We found Cowles and Lefcowitz's article "Interdisciplinary Expectations of the Medical Social Worker in the Hospital Setting" [Health and Social Work, 17 (February 1992), pp. 57-65] an excellent perspective on how we as social workers are viewed by our nursing and physician colleagues. One application of these results is to rethink how we market ourselves in hospitals. We can transform the research terminology of the study into new ways of describing social work services to physicians, nurses, and patients. We can enhance the descriptions of social work services by indicating their effects on fiscal outcomes and quality improvement. For instance, "help patients examine possible solutions to their social-environmental problems" (Cowles & Lefcowitz, 1992, p. 59) could be termed "promoting continuity of care by connecting patients with chronic conditions to community based services which will reduce unnecessary hospital admissions" (Sharp, Coleman, Starling, Cline, & Rehm, 1991, p. 118). In addition, we must acknowledge the study findings that much of what we do overlaps with other professions. In our hospital, with an intensive nursing case management program, our role is no less essential but refined to serving the
$3.00 © 1992, National Association of Social Workers, Inc.
more dysfunctional families and providing family conferences to facilitate discharge and treatment planning in complex cases (Miller & Walsh, 1991). In this way we demonstrate the quality social work adds to medical services. We hope others will follow the foundation laid by this study with research that continues to clarify our changing tasks in a health care industry in constant flux. JOHN W. SHARP SUSAN ZETTLER Cleveland Clinic Foundation Cleveland
References
Cowles, L. A., & Lefcowitz, M. J. (1992). Interdisciplinary expectations of the medical social worker in the hospital setting. Health and Social Work, 17, 57 65. Miller, R. D., & Walsh, T. D. (1991). The role of a palliative care service family conference in the management of the patient with advanced cancer. Palliative Medicine, 5,34 39. Sharp, J. W., Coleman, E., Starling, N., Cline, J., & Rehm, S. (1991). Hospital utilization for AIDS: Are all hospital days necessary? Quality Review Bulletin, 17(4), 113 119. -
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-
Editorial's Viewpoint Is Strongly Supported I read with interest your recent editorial "Clinical Supervision: Key to Effective Social Work" [Health and Social Work, 17 (May 1992), pp. 83851 discusring the importance and efficacy of clinical supervision within a hospital-based practice, and I strongly support your viewpoint. Interestingly, just prior to the publication of the editorial, I had read an article by JamesRogers, Widrow, Schwankovsky, & Rasgon (1992) that reported that in a study of communitybased nephrology social workers, the percentage of time devoted to counseling patients decreased markedly as the number of years in practice increased. One conclusion was that the absence of professional validation may lead to an inability to retain a clinically oriented focus, LETTERS
thus contributing to worker burnout. Good supervision can provide that validation that is particularly essential if the medical social worker is to remain a dynamic member of the multidisciplinary team with an ability to provide an effective social work perspective to the decisionmaking process. In the May 1992 issue of Social Work, Kurland and Salmon wrote that the intractability of today's problems creates unusual stress for social workers and a perceived sense of hopelessness that can be mitigated by effective supervision that encourages practitioners to set realistic goals and to value small successes. Surely the development and maintenance of clinical practice skins related to the crisis intervention approach needed to work successfully with hospitalized patients, families, and significant others can be enhanced by skilled clinical supervision in which discharge planning and counseling are not polarized. Most departments of social work monitor patient delay days and I assume that a significant number of those delays are related to "difficult families." Families and patients are indeed "difficult," because they are having to make increasingly complex decisions within shorter and shorter time frames, often with fewer and fewer community resources at their disposal. Because these delay days can be readily understood by hospital administrators in terms of "real dollars," can we not justify the saving of some of these dollars by advocating for supervision geared to improving the worker's skills in complex crisis intervention, which helps patients and families move ahead at a faster pace in their decision-making process? Also, the core of successful crisis intervention is surely an extremely accurate differential diagnosis requiring the sophisticated skills of a knowledgeable medical social worker. I suggest that the development and maintenance of these assessment skills can be linked to a positive supervisor-supervisee relationship. In an informal poll in our own department last year, 10 out of 11 workers responded that supervision was essential and that the continued growth and advancement of clinical skills should be the primary goal of supervision. 239
