Journal of Gerontological Social Work, 58:437–444, 2015 ISSN: 0163-4372 print/1540-4048 online DOI: 10.1080/01634372.2015.1008167
Development of a Level 1 Geriatric Outpatient Social Work Screen in a Veterans Primary Care Clinic CAROLYN K. SMITH, LORI EMERY, and ANGELA WILLIAMS Veterans Healthcare Administration Tennessee Valley Healthcare System, Nashville, Tennessee, USA
JAMES S. POWERS Veterans Healthcare Administration Tennessee Valley Healthcare System and the Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA and Center for Quality in Aging, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Patient Aligned Care Teams (PACT) provide primary care to veterans. We describe our experience in a PACT (average age 66, 98% men, 8 medications, 16% yearly hospitalization rate) using a nurse-administered screen to identify patients in need of intervention by a Masters-level Social Worker. Our screening results—98% Positive predictive value (included social work concerns) and 73% negative predictive value (excluded social work concerns)—suggest that the nurse accurately identified patients. Another 15% of patients were identified by the social worker. Similar screens used in interprofessional clinics could help target patients in need of further social work care. KEYWORDS chronic illness, social work practice, quantitative
INTRODUCTION The Department of Veteran Affairs (VA) Geriatrics and Extended Care (GEC) vision statement empowers veterans to rise above the challenges of aging, disability, and serious illness. GEC’s mission is to honor veterans’ preferences This article not subject to US copyright law. Received 7 July 2014; revised 12 January 2015; accepted 12 January 2015. Address correspondence to James S. Powers, 7159 Vanderbilt Medical Center East, Nashville, TN 37232, USA. E-mail: [email protected] 437
438
C. K. Smith et al.
FIGURE 1 VA Geriatrics and Extended Care values (U.S. Department of Veterans Affairs, n.d.).
for health, independence, and well-being by advancing expertise, programs, and partnerships on behalf of veterans’ healthcare (Figure 1). As part of the strategic goals of the VA, the Patient Aligned Care Team (PACT) model was initiated in 2011 to provide a patient-centered medical home for all primary care enrollees (Rosland et al., 2013). Components of the PACT include a panel size of approximately 1,200 patients and a core teamlet consisting of a primary care provider, a registered nurse care manager, a licensed practical nurse (LPN), and a clerk. Working with the PACT as consultants are discipline-specific members, including a Masters-level social worker, a Doctor of Pharmacy, a dietitian, and a psychologist (Bowen & Schectman, 2013; Department of Veterans Affairs, 2014). PACT integrates and coordinates traditional outpatient care with community-based services. The PACT aims to provide patient-centered care while addressing the demand for VA primary care services. An increasing amount of care is provided between visits by teamlet members functioning in a collaborative interprofessional model. Frequent meetings or huddles with the team enable quality care to be provided and individual teamlet members supported to engage patients at the top of their scope of practice. Early evidence suggests that PACT may reduce return visits by up to 30% with increased patient convenience, which creates room for new patient visits (Rosland et al., 2013). The Geriatric Research, Education, and Clinical Centers (GRECC) are charged to help evaluate the alignment of medical resources. The GRECC
Development of Geriatric Outpatient Social Work Screen
439
has a long history of enhancing quality care while evaluating outcomes of new models of care for veterans. The Tennessee Valley Health System (TVHS) and GRECC has studied resource application in PACT. Screening for appropriate referrals to discipline-specific PACT teamlet members to efficiently utilize their skills, improve productivity, and appropriately allocate resources remains an important task for the evolution of PACT. Social work is critical in maintaining patient and caregiver stability while promoting patient-centered care. Development of assessment tools within clinic nurse protocols have been created for appropriate referrals to consulting PACT teamlet members. This quality management pilot study is designed to examine the process of utilizing a nurse-administered level 1 high-risk social work screen to identify patients potentially in need of intervention by a masters level Social Worker in a VA-Primary Care PACT population.
METHODS We utilized a brief screening tool consisting of five questions (Figure 2) previously piloted for social work screening of the frail and elderly VA
FIGURE 2 VA GEM Pact social work high risk screen—MSW. ADL = activities of daily living. IADL = instrumental activities of daily living.
440
C. K. Smith et al.
Geriatric-PACT (Geri-PACT) clinic (Powers, Smith, & Carey, 2014). Briefly, a literature review was conducted to identify best practices for social work intervention in geriatric outpatients (Boult et al., 2009; Counsell, Callahan, Buttar, Clark, & Frank, 2006; Melis et al., 2009; Supiano et al., 2012). Our review indicated that patients who are medically complex, have cognitive impairments, mental health concerns, mobility deficits, activity of daily living insufficiencies, require a caregiver or are struggling financially often are in need of additional social supports (Boult et al., 2009; Counsell et al., 2006). The screen was designed to permit the PACT LPN to quickly identify patient or caregiver needs that might otherwise be overlooked, without an in-depth social work assessment. The primary care PACT LPN and social worker (MSW) collaborated so that the screening tool would not interrupt the normal clinic work flow. The PACT LPN routinely conducts VA clinical reminders upon each primary care check-in, which are pre-existing evidence-based screening tools. Each individual screen can assess for such things as housing issues, mental health, functionality, nutrition, abuse/neglect, etc. (Department of Veteran Affairs, 2014). If a clinical reminder screen is positive, a provider or specialist is alerted for follow up. The social work high-risk screen is an extension to these pre-established screening tools and utilizes some of the data already collected. Within the social work high-risk screening, questions were intentionally left broad to have the patient or caregiver identify any areas of concern without leading the participants to biased answers. For example, category two (Figure 2) intentionally does not specify what type of support the patient or family may need. This allows the patient/caregiver to identify any areas of concern whether this be emotional, psychological, financial, or other caregiver fatigue. Veterans at TVHS established with one primary care PACT were chosen to be screened for this pilot. The PACT had a full patient panel size of 956 patients. One hundred-six randomly selected consecutive patients were screened without bias for this pilot, comprising 11% of the PACT patient panel. The social work high-risk screen was performed by the clinic nurse, an LPN, on patients/caregivers presenting to a primary care PACT clinic visit at TVHS VA Hospital, Nashville Campus, between November 2013 and May 2014. The PACT social worker then conducted the same social work high-risk screen with the patient/caregiver during the same primary care visit. This was to determine a cohesive assessment between the expert social worker and general PACT LPN. This was a side-by-side comparison study of the LPN and social work responses using the same screening tool and accepting social work responses as the standard for comparison. A thorough psychosocial assessment was also completed by the social worker to further identify gaps in the screening tool for improvements and to determine if other referrals were appropriate, based on individual patient/family needs. This study was considered exempt as a quality improvement project by the TVHS Institution Review Board (IRB).
441
Development of Geriatric Outpatient Social Work Screen
RESULTS This specific but typical primary care PACT panel population consisted of 956 patients. Ninety-eight percent were men, mean age 66 years old (age range 25–96 years with 54% aged 65 and over) and took an average of eight medications. The panel included the following comorbidities: 61% hypertension, 36% diabetes, 22% depression, 6% congestive heart failure, and 2% dementia. There was a 16% yearly hospitalization rate, but were not any deaths in the previous 12 months (Table 1). Forty percent of the study patients did not require any social work review; however, there were 34% of patients with two or more indications for social work review. For the 60% of patients who required social work involvement, based on one indication in the screen, the following indicators were found: Category 1—patient with cognitive impairment, depression, end stage disease, mobility impairment, or caregiver needs (55%); Category 2—patient needs more support (16%); Category 3—patient struggling financially (16%); Category 4—everyday assistance needs (14%); Category 5—have other questions for the social worker (26%); with 34% of patients having a positive screen of two or more indications for social work assistance (Table 2). There was 74% sensitivity (ruling in social work concerns) and 98% specificity (ruling out social work concerns) for the LPN administered screen for at least one of the five TABLE 1 PACT Population N = 956 (98% male) Mean age 66 years (range 25–96), 54% > age 65 Medications mean 8 Comorbidities Hypertension Diabetes Depression Dementia Hospitalization past 12 months Deaths past 12 months
61% 36% 22% 2% 16% None
TABLE 2 Social Work Screen Results (N = 106) Patient with cognitive, mood, end stage disease, ADL, caregiver concerns Patient needs more support Patient struggling financially Patient needs assistance with everyday activities Patient/caregiver has questions for Social Worker
55% 16% 16% 14% 26%
Note. 40% patients had no need for social work assistance. 34% patients had 2 or more indications for social work assistance. Comparison of LPN screen to social work assessment revealed: sensitivity (74%), specificity (98%) for at least 1 category, with positive predictive value (98%) and negative predictive value (73%) for the LPN screen. Discordance between LPN screen and social worker assessment: 1 category (32%), 2 categories (47%), 3 categories (65%), 4 categories (74%), and 5 categories (100%) with range of differences for any individual category (9%–32%). ADL = activities of daily living.
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C. K. Smith et al.
indicators, with 98% positive predictive value (accurately identifying social work concerns) and 73% negative predictive value (accurately excluding social work concerns) compared to the social work assessment. The social worker identified an additional 15% of patients for review. Discordance (lack of agreement between the LPN and social worker) was 32% for any one category, 47% for any two categories, 65% for any three categories, 74% for any four categories, and 100% for all five categories. Although differences for individual categories ranged between 9%–32%, the social worker documented more financial needs and eligibility for home and community based services than the LPN in her screening.
DISCUSSION Interprofessional care applied to primary care patients necessitates targeting of the population with the greatest potential for benefit. This has been done with pharmacy in a high-risk geriatric outpatient clinic and a nutrition screening in hospitalized patients. The nutrition screening tool was in two parts with level 1 screening by nurses at the time of admission followed by a detailed level 2 dietary assessment for individuals at high risk of nutrition related disorders (Powers, Edwards, & Carey, 2013). Use of the same level 1 social work screen by the clinic LPN in a frail elderly Geri-PACT clinic population (average age 80, average 10 medications, 13% yearly hospitalization rate, and 22% 12 month mortality) showed a high discordance between nurse and social work review with 79% positive predictive value (accurately excluding social work concerns) and 35% negative predictive value (poorly excluding social work concerns), suggesting that the instrument may have limited utility when used in a frail population where every patient may benefit from social work intervention (Powers et al., 2014). However, in a primary care general population PACT, utilizing the same screening process1 we note a much higher concordance between LPN and masters level social work screens, suggesting high screening utility to appropriately refer patients for more complete social work assessment in this more typical but still predominantly geriatric VA primary care population.
LIMITATION AND FUTURE DIRECTIONS Having the LPN screen for discipline-specific PACT consultation can be an effective strategy to efficiently identify primary care patients for referral. 1 This study builds on the cumulative experience with screening techniques based on the study of frail elderly, highlighting differences in the relative utility of screening instruments vis–a-vis different populations (Powers et al., 2013; Powers et al., 2014).
Development of Geriatric Outpatient Social Work Screen
443
Outpatient nursing personnel with LPN background would be expected to have comparable training and experience as our study nurse. An LPNadministered social work screen may be beneficial if used during a patients’ annual primary care appointment. In the VA, this screen was performed in addition to other established primary care clinical reminders that aid completion of the screen. In practices without clinical reminders, adoption of a level 1 high-risk social screen may take longer for the clinic nurse to administer. Although the tool accurately reflected the social worker’s experience in reviewing the high-risk patients, it may also have aided patients in considering social-work-related concerns, resulting in more findings and questions during the social work review. Within this tool, a patient or caregiver can answer on behalf of the patient. If there is a positive patient screen, it is assumed that caregiver issues also exist and can be addressed. However, only 26% of the discordance between the data sets could be attributable to patient requests for social work intervention not voiced to the nurse (Category 5). Future improvements to the screening tool might include specific closed-ended questions to common concerns, instead of such sterile questions used in our screen, such as “Are you paying bills on time?” “Do you have someone at home to help you?” “Do you need help with everyday activities like bathing, dressing, cooking, and cleaning?” If a positive screen is indicated, the Masters-level social worker can be consulted for further follow-up and complete a thorough biopsychosocial assessment. Category 1 can also be divided into multiple single questions, instead of aggregated, to provide more specific diagnostic information.
REFERENCES Boult, C., Green, A.F., Boult, L.B., Pacala, J.T., Snyder, C., & Leff, B. (2009). Successful models of comprehensive care for older adults with chronic conditions: Evidence for the institute of medicine’s “retooling for an aging America” report. Journal of the American Geriatrics Society, 57(12), 2328–2337. Bowen, J. L., & Schectman, G. (2013). VA academic PACT: A blueprint for primary care redesign in academic practice settings. VA Offices of Primary Care and Academic Affiliations Academic PACTWork Group, Department of Veterans Affairs. Retrieved from http://www.va.gov/oaa/docs/va_academic_ PACT_blueprint.pdf Counsell, S. R., Callahan, C. M., Buttar, A. B., Clark, D. O., & Frank, K. I. (2006). Geriatric resources for assessment and care of elders (GRACE): A new model of primary care for low-income seniors. Journal of the American Geriatrics Society, 54(7), 1136–1141. Department of Veterans Affairs, Veterans Health Administration. (2014). Patient Aligned Care Team (PACT) handbook. Washington, DC: Author. Retrieved from http://www.va.gov/vhapublications/publications.cpm?pub=2
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C. K. Smith et al.
Melis, R. J., Van Eijken M. I. J., Van Achtergerg, T., Teerenstra, S., Vernooij-Dassen, M. F. J., Van De Lisdonk, E. H., & Olde Rikkert, M. G. M. (2009). The effect on caregiver burden of a problem-based home visiting programme for frail older people. Age and Ageing, 38, 542–547. Powers, J. S., Edwards, L., & Carey, A. (2013). Development of a level 1 geriatric outpatient pharmacy screen. Journal of the American Geriatrics Society, 61(4), 654–655. Powers, J. S., Smith, C. K., & Carey, A. (2014). Development of a level 1 geriatric outpatient social work screen. Journal of the American Geriatrics Society, 62(5), 988–989. Rosland, A.-M., Nelson, K., Sun, H., Dolan, E. D., Maynard, C., Bryson, C., . . . Schectman, G. (2013). The patient centered medical home in the Veterans Health Administration. American Journal of Managed Care, 19(7), e263–e272. Supiano, M. A., Alessi, C., Chernoff, R., Goldberg, A., Morley, J. E., Schmader, K. E., & Shay, K. (2012). Department of veterans affairs geriatric research, education and clinical centers: Translating aging research into clinical geriatrics. Journal of the American Geriatrics Society, 60, 1347–1356. U.S. Department of Veterans Affairs. (n.d.). About the Office of Geriatrics and Extended Care Services. Retrieved from http://www.va.gov/GERIATRICS/ About_Us.asp
Copyright of Journal of Gerontological Social Work is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Development of a Level 1 Geriatric Outpatient Social Work Screen in a Veterans Primary Care Clinic CAROLYN K. SMITH, LORI EMERY, and ANGELA WILLIAMS Veterans Healthcare Administration Tennessee Valley Healthcare System, Nashville, Tennessee, USA
JAMES S. POWERS Veterans Healthcare Administration Tennessee Valley Healthcare System and the Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA and Center for Quality in Aging, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
Patient Aligned Care Teams (PACT) provide primary care to veterans. We describe our experience in a PACT (average age 66, 98% men, 8 medications, 16% yearly hospitalization rate) using a nurse-administered screen to identify patients in need of intervention by a Masters-level Social Worker. Our screening results—98% Positive predictive value (included social work concerns) and 73% negative predictive value (excluded social work concerns)—suggest that the nurse accurately identified patients. Another 15% of patients were identified by the social worker. Similar screens used in interprofessional clinics could help target patients in need of further social work care. KEYWORDS chronic illness, social work practice, quantitative
INTRODUCTION The Department of Veteran Affairs (VA) Geriatrics and Extended Care (GEC) vision statement empowers veterans to rise above the challenges of aging, disability, and serious illness. GEC’s mission is to honor veterans’ preferences This article not subject to US copyright law. Received 7 July 2014; revised 12 January 2015; accepted 12 January 2015. Address correspondence to James S. Powers, 7159 Vanderbilt Medical Center East, Nashville, TN 37232, USA. E-mail: [email protected] 437
438
C. K. Smith et al.
FIGURE 1 VA Geriatrics and Extended Care values (U.S. Department of Veterans Affairs, n.d.).
for health, independence, and well-being by advancing expertise, programs, and partnerships on behalf of veterans’ healthcare (Figure 1). As part of the strategic goals of the VA, the Patient Aligned Care Team (PACT) model was initiated in 2011 to provide a patient-centered medical home for all primary care enrollees (Rosland et al., 2013). Components of the PACT include a panel size of approximately 1,200 patients and a core teamlet consisting of a primary care provider, a registered nurse care manager, a licensed practical nurse (LPN), and a clerk. Working with the PACT as consultants are discipline-specific members, including a Masters-level social worker, a Doctor of Pharmacy, a dietitian, and a psychologist (Bowen & Schectman, 2013; Department of Veterans Affairs, 2014). PACT integrates and coordinates traditional outpatient care with community-based services. The PACT aims to provide patient-centered care while addressing the demand for VA primary care services. An increasing amount of care is provided between visits by teamlet members functioning in a collaborative interprofessional model. Frequent meetings or huddles with the team enable quality care to be provided and individual teamlet members supported to engage patients at the top of their scope of practice. Early evidence suggests that PACT may reduce return visits by up to 30% with increased patient convenience, which creates room for new patient visits (Rosland et al., 2013). The Geriatric Research, Education, and Clinical Centers (GRECC) are charged to help evaluate the alignment of medical resources. The GRECC
Development of Geriatric Outpatient Social Work Screen
439
has a long history of enhancing quality care while evaluating outcomes of new models of care for veterans. The Tennessee Valley Health System (TVHS) and GRECC has studied resource application in PACT. Screening for appropriate referrals to discipline-specific PACT teamlet members to efficiently utilize their skills, improve productivity, and appropriately allocate resources remains an important task for the evolution of PACT. Social work is critical in maintaining patient and caregiver stability while promoting patient-centered care. Development of assessment tools within clinic nurse protocols have been created for appropriate referrals to consulting PACT teamlet members. This quality management pilot study is designed to examine the process of utilizing a nurse-administered level 1 high-risk social work screen to identify patients potentially in need of intervention by a masters level Social Worker in a VA-Primary Care PACT population.
METHODS We utilized a brief screening tool consisting of five questions (Figure 2) previously piloted for social work screening of the frail and elderly VA
FIGURE 2 VA GEM Pact social work high risk screen—MSW. ADL = activities of daily living. IADL = instrumental activities of daily living.
440
C. K. Smith et al.
Geriatric-PACT (Geri-PACT) clinic (Powers, Smith, & Carey, 2014). Briefly, a literature review was conducted to identify best practices for social work intervention in geriatric outpatients (Boult et al., 2009; Counsell, Callahan, Buttar, Clark, & Frank, 2006; Melis et al., 2009; Supiano et al., 2012). Our review indicated that patients who are medically complex, have cognitive impairments, mental health concerns, mobility deficits, activity of daily living insufficiencies, require a caregiver or are struggling financially often are in need of additional social supports (Boult et al., 2009; Counsell et al., 2006). The screen was designed to permit the PACT LPN to quickly identify patient or caregiver needs that might otherwise be overlooked, without an in-depth social work assessment. The primary care PACT LPN and social worker (MSW) collaborated so that the screening tool would not interrupt the normal clinic work flow. The PACT LPN routinely conducts VA clinical reminders upon each primary care check-in, which are pre-existing evidence-based screening tools. Each individual screen can assess for such things as housing issues, mental health, functionality, nutrition, abuse/neglect, etc. (Department of Veteran Affairs, 2014). If a clinical reminder screen is positive, a provider or specialist is alerted for follow up. The social work high-risk screen is an extension to these pre-established screening tools and utilizes some of the data already collected. Within the social work high-risk screening, questions were intentionally left broad to have the patient or caregiver identify any areas of concern without leading the participants to biased answers. For example, category two (Figure 2) intentionally does not specify what type of support the patient or family may need. This allows the patient/caregiver to identify any areas of concern whether this be emotional, psychological, financial, or other caregiver fatigue. Veterans at TVHS established with one primary care PACT were chosen to be screened for this pilot. The PACT had a full patient panel size of 956 patients. One hundred-six randomly selected consecutive patients were screened without bias for this pilot, comprising 11% of the PACT patient panel. The social work high-risk screen was performed by the clinic nurse, an LPN, on patients/caregivers presenting to a primary care PACT clinic visit at TVHS VA Hospital, Nashville Campus, between November 2013 and May 2014. The PACT social worker then conducted the same social work high-risk screen with the patient/caregiver during the same primary care visit. This was to determine a cohesive assessment between the expert social worker and general PACT LPN. This was a side-by-side comparison study of the LPN and social work responses using the same screening tool and accepting social work responses as the standard for comparison. A thorough psychosocial assessment was also completed by the social worker to further identify gaps in the screening tool for improvements and to determine if other referrals were appropriate, based on individual patient/family needs. This study was considered exempt as a quality improvement project by the TVHS Institution Review Board (IRB).
441
Development of Geriatric Outpatient Social Work Screen
RESULTS This specific but typical primary care PACT panel population consisted of 956 patients. Ninety-eight percent were men, mean age 66 years old (age range 25–96 years with 54% aged 65 and over) and took an average of eight medications. The panel included the following comorbidities: 61% hypertension, 36% diabetes, 22% depression, 6% congestive heart failure, and 2% dementia. There was a 16% yearly hospitalization rate, but were not any deaths in the previous 12 months (Table 1). Forty percent of the study patients did not require any social work review; however, there were 34% of patients with two or more indications for social work review. For the 60% of patients who required social work involvement, based on one indication in the screen, the following indicators were found: Category 1—patient with cognitive impairment, depression, end stage disease, mobility impairment, or caregiver needs (55%); Category 2—patient needs more support (16%); Category 3—patient struggling financially (16%); Category 4—everyday assistance needs (14%); Category 5—have other questions for the social worker (26%); with 34% of patients having a positive screen of two or more indications for social work assistance (Table 2). There was 74% sensitivity (ruling in social work concerns) and 98% specificity (ruling out social work concerns) for the LPN administered screen for at least one of the five TABLE 1 PACT Population N = 956 (98% male) Mean age 66 years (range 25–96), 54% > age 65 Medications mean 8 Comorbidities Hypertension Diabetes Depression Dementia Hospitalization past 12 months Deaths past 12 months
61% 36% 22% 2% 16% None
TABLE 2 Social Work Screen Results (N = 106) Patient with cognitive, mood, end stage disease, ADL, caregiver concerns Patient needs more support Patient struggling financially Patient needs assistance with everyday activities Patient/caregiver has questions for Social Worker
55% 16% 16% 14% 26%
Note. 40% patients had no need for social work assistance. 34% patients had 2 or more indications for social work assistance. Comparison of LPN screen to social work assessment revealed: sensitivity (74%), specificity (98%) for at least 1 category, with positive predictive value (98%) and negative predictive value (73%) for the LPN screen. Discordance between LPN screen and social worker assessment: 1 category (32%), 2 categories (47%), 3 categories (65%), 4 categories (74%), and 5 categories (100%) with range of differences for any individual category (9%–32%). ADL = activities of daily living.
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C. K. Smith et al.
indicators, with 98% positive predictive value (accurately identifying social work concerns) and 73% negative predictive value (accurately excluding social work concerns) compared to the social work assessment. The social worker identified an additional 15% of patients for review. Discordance (lack of agreement between the LPN and social worker) was 32% for any one category, 47% for any two categories, 65% for any three categories, 74% for any four categories, and 100% for all five categories. Although differences for individual categories ranged between 9%–32%, the social worker documented more financial needs and eligibility for home and community based services than the LPN in her screening.
DISCUSSION Interprofessional care applied to primary care patients necessitates targeting of the population with the greatest potential for benefit. This has been done with pharmacy in a high-risk geriatric outpatient clinic and a nutrition screening in hospitalized patients. The nutrition screening tool was in two parts with level 1 screening by nurses at the time of admission followed by a detailed level 2 dietary assessment for individuals at high risk of nutrition related disorders (Powers, Edwards, & Carey, 2013). Use of the same level 1 social work screen by the clinic LPN in a frail elderly Geri-PACT clinic population (average age 80, average 10 medications, 13% yearly hospitalization rate, and 22% 12 month mortality) showed a high discordance between nurse and social work review with 79% positive predictive value (accurately excluding social work concerns) and 35% negative predictive value (poorly excluding social work concerns), suggesting that the instrument may have limited utility when used in a frail population where every patient may benefit from social work intervention (Powers et al., 2014). However, in a primary care general population PACT, utilizing the same screening process1 we note a much higher concordance between LPN and masters level social work screens, suggesting high screening utility to appropriately refer patients for more complete social work assessment in this more typical but still predominantly geriatric VA primary care population.
LIMITATION AND FUTURE DIRECTIONS Having the LPN screen for discipline-specific PACT consultation can be an effective strategy to efficiently identify primary care patients for referral. 1 This study builds on the cumulative experience with screening techniques based on the study of frail elderly, highlighting differences in the relative utility of screening instruments vis–a-vis different populations (Powers et al., 2013; Powers et al., 2014).
Development of Geriatric Outpatient Social Work Screen
443
Outpatient nursing personnel with LPN background would be expected to have comparable training and experience as our study nurse. An LPNadministered social work screen may be beneficial if used during a patients’ annual primary care appointment. In the VA, this screen was performed in addition to other established primary care clinical reminders that aid completion of the screen. In practices without clinical reminders, adoption of a level 1 high-risk social screen may take longer for the clinic nurse to administer. Although the tool accurately reflected the social worker’s experience in reviewing the high-risk patients, it may also have aided patients in considering social-work-related concerns, resulting in more findings and questions during the social work review. Within this tool, a patient or caregiver can answer on behalf of the patient. If there is a positive patient screen, it is assumed that caregiver issues also exist and can be addressed. However, only 26% of the discordance between the data sets could be attributable to patient requests for social work intervention not voiced to the nurse (Category 5). Future improvements to the screening tool might include specific closed-ended questions to common concerns, instead of such sterile questions used in our screen, such as “Are you paying bills on time?” “Do you have someone at home to help you?” “Do you need help with everyday activities like bathing, dressing, cooking, and cleaning?” If a positive screen is indicated, the Masters-level social worker can be consulted for further follow-up and complete a thorough biopsychosocial assessment. Category 1 can also be divided into multiple single questions, instead of aggregated, to provide more specific diagnostic information.
REFERENCES Boult, C., Green, A.F., Boult, L.B., Pacala, J.T., Snyder, C., & Leff, B. (2009). Successful models of comprehensive care for older adults with chronic conditions: Evidence for the institute of medicine’s “retooling for an aging America” report. Journal of the American Geriatrics Society, 57(12), 2328–2337. Bowen, J. L., & Schectman, G. (2013). VA academic PACT: A blueprint for primary care redesign in academic practice settings. VA Offices of Primary Care and Academic Affiliations Academic PACTWork Group, Department of Veterans Affairs. Retrieved from http://www.va.gov/oaa/docs/va_academic_ PACT_blueprint.pdf Counsell, S. R., Callahan, C. M., Buttar, A. B., Clark, D. O., & Frank, K. I. (2006). Geriatric resources for assessment and care of elders (GRACE): A new model of primary care for low-income seniors. Journal of the American Geriatrics Society, 54(7), 1136–1141. Department of Veterans Affairs, Veterans Health Administration. (2014). Patient Aligned Care Team (PACT) handbook. Washington, DC: Author. Retrieved from http://www.va.gov/vhapublications/publications.cpm?pub=2
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C. K. Smith et al.
Melis, R. J., Van Eijken M. I. J., Van Achtergerg, T., Teerenstra, S., Vernooij-Dassen, M. F. J., Van De Lisdonk, E. H., & Olde Rikkert, M. G. M. (2009). The effect on caregiver burden of a problem-based home visiting programme for frail older people. Age and Ageing, 38, 542–547. Powers, J. S., Edwards, L., & Carey, A. (2013). Development of a level 1 geriatric outpatient pharmacy screen. Journal of the American Geriatrics Society, 61(4), 654–655. Powers, J. S., Smith, C. K., & Carey, A. (2014). Development of a level 1 geriatric outpatient social work screen. Journal of the American Geriatrics Society, 62(5), 988–989. Rosland, A.-M., Nelson, K., Sun, H., Dolan, E. D., Maynard, C., Bryson, C., . . . Schectman, G. (2013). The patient centered medical home in the Veterans Health Administration. American Journal of Managed Care, 19(7), e263–e272. Supiano, M. A., Alessi, C., Chernoff, R., Goldberg, A., Morley, J. E., Schmader, K. E., & Shay, K. (2012). Department of veterans affairs geriatric research, education and clinical centers: Translating aging research into clinical geriatrics. Journal of the American Geriatrics Society, 60, 1347–1356. U.S. Department of Veterans Affairs. (n.d.). About the Office of Geriatrics and Extended Care Services. Retrieved from http://www.va.gov/GERIATRICS/ About_Us.asp
Copyright of Journal of Gerontological Social Work is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
