Social Work in Health Care
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING Jules Schrager MSW, CSW , Marc Halman BSW , Diane Myers BSW , Rosemary Nichols BA & Lee Rosenblum BA To cite this article: Jules Schrager MSW, CSW , Marc Halman BSW , Diane Myers BSW , Rosemary Nichols BA & Lee Rosenblum BA (1978) IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING, Social Work in Health Care, 4:1, 65-79, DOI: 10.1300/J010v04n01_07 To link to this article: http://dx.doi.org/10.1300/J010v04n01_07
Published online: 12 Dec 2008.
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IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING
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Jules Schrager, MSW. CSW Marc Halman, BSW Diane Myers, BSW Rosemary Nichols. BA Lee Rosenblum, BA
ABSTRACT. This paper ezamines the proposition that "timing" (of refeml) is a crucial element in determining the effectiveness of the discharge planningprocess. A brief review of the relevant literature is followed by the description of a study undertaken to assess the impact that various impediments had upon discharge planning pmctice in two matched ward populations of a large, acute care university hospital. Along with timing, three other impediments were identified and their influence assessed; (a) noncompletion of tmnsfer forms required; (b) unavailability of an appropriate ke., needed level of care) bed in an approved facility; and (c) unanticipated change in the patient's medical condition. Some implications of the findings are examined and discussed, and directions for future study are identified Appended are facsimiles o f the instruments employed T h u s there remained 134 (out of 157) survivors of hospitalization who had physical or psychosocial handicap; 13% were disabled for physical reasons. . 51% b y conditions primarily attributable t o psychosocial factors, and 22% b y a combination of physical and psychosocial. . . (Duff&
.
Hollingshead, 1968)
Aside from the physical illness that brings a person into hospital care, he brings with him a repertoire of strategies, developed over a lifetime, that have made it possible for him to cope with various kinds and degrees of stress. He carries with him, too, a personal and social history made uniquely significant by the events that have occurred in his lifetime, the "cast of characters" associated with those events, and remembrances of their outcome, both positive and negative. Mr. Schrager is Chief. Social Work Services. and Associate Professor. School o f Social Work. University o f Michigan, Ann Arbor, Michigan 48106. Mr. Halman. Ms. Myers, Ms. Nichols, and Mr. Rosenblum are social workers in the Department'of Social Work. University of Michigan Medical Center. The group is indebted t o Anne Brantley Malcolm, Nancy Shulman. and Deirdre Warren for their early contributions to the project. Soda1WorkiaHaalthCare.VoL 4(11,Falll978 O1918 by The Haworth h a . AUrightsnuerved.
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There is little in the life of the average person that will have prepared him to cope with hospitalization. The successful management of earlier events involving separation and loss will, of course, modulate the effects. The availability of a vjable economic and psychological support system will have a great effect on the posthospital outcome for the patient. Nevertheless, hospitalization for treatment of an acute illness or injury constitutes a psychosocially hazardous event and places the patient "at-risk." This observation had been widely studied and reported(see,for example, Crane. 1975;Taco, 1958). The design of the process of induction of the patient into the hospital and his passage through and out of the institution reflects a set of tasks which, poorly managed, can severely influence the posthospital career of the patient-family. Commonly, social workers have no control over events antecedent to admission to the hospital, modest influence on the nature and course of the management of the medical care program, but considerable opportunity to shape the process of discharge back into the community. I t is to the last of these that this paper addresses itself, attempting to identify those elements of patient-care management that interfere with the successful movement of the patient into appropriate, after-hospital-care settings.
BRIEF REVIEW OF SOME RELEVANT LITERATURE Continuity of care has become a prime issue in health care. There has been an increasing awareness that the total patient must be considered in planning medical treatment. The focus of this paper is on discharge planning, defined by the American Hospital Association (1974) as "the term given to the centralized, coordinated program developed by a health care institution to insure that each patient has a planned program for needed continuing care andlor follow-up." For the medical facility, discharge planning means "cost-effective use of resources to provide a continuum of care for individual patients based on their needs." (AmericanHospital Association, 1974).The hoped-for result of the planned discharge is that the patient will leave when medically ready and advised medical treatment will be carried out in the community, thereby reducing the cost of the hospital stay and avoiding possible rehospitalization and unnecessary clinic visits. For the hospital, this should result in greater efficiency in the use of beds and equipment; for the patient, a well-designed program meetine individual medical. social..and economic needs. There are several i m p o r k t elements that contribute to successful discharge planning. First, the physician, as the patient's primary planL 8
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Jules Schrager, etaL
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ner, must be sensitive to his patient's total needs. Second, he should consult and collaborate with other health care professionals in developing and carrying through the plan for aftercare. Third, since collaborative work takes time, the physician must be alert to early indicators of patients' need for help in developing a discharge plan and facilitating its implementation. Most authors addressing the issue of discharge planning agree that early assessment, covering the psychosocial and economic situation as well as health history, is the most important step toward identifying patients who would require posthospitalization assistance. "Both the patient and relatives need support and skilled guidance at such a time, not only in locating and arranging for concrete aftercare services such as.nursing, physical therapy, health aide, homemaker, equipment rentals, etc.. but in the area of relationship counseling as well; old feelings and family problems are often brought to the surface at such times, and new feelings about health and living changes do influence and can adversely affect the health outcome unless skilled and timely intervention prevails" (Simpson, 1969). The timing of referral as crucial to success in discharge planning has been explored by several hospital task forces (Greater Detroit Area Health Care, 1977).Discussing this issue, the University of Minnesota's task group on discharge planning suggests that it should begin at time of admission, be strengthened by observations of the total patient and family needs, and be an ongoing part of the patient's health care treatment plan and goals. Another author exploring this issue described one of thebften seenproblem situations in discharge planning, the late referral: "To often the ~hvsiciancomments that he did not know until the last minute that the i n k y would be unwilling or unable to take care of the patient and needs an alternate plan" (Phillips, Note 1, pp. 23-26). Eleanor Clark (1969) disucsses the special situation of the elderly. as she describes the success of the Transfer Office instituted at Massachusetts General Hospital. In increasing communication and understanding b e tween the hospital and community facilities and awareness of the needs of the elderly, she states that "better understanding of the issues by hospital staff has cut down needless pressure and misunderstanding," resulting in more timely referrals. She goes on to state that "despite the 99 percent occupancy of nursing homes in the state, the average delay between the time patients are medically ready for transfer and the day of transfer was reduced approximately five days during 1967." A study showing the result of earlier discharge through earlier assessment is described by Berkman and Rehr (1972,pp. 257-263)in which a group of patients referred in the normal fashion were compared to a group of patients randomly selected at admission for an assessment of "need for service.'' A pertinent finding is that "those
'
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SOCIAL WORK IN HEALTH CARE
patients in the experiment who were helped by social worker from time of admission had stays that were 10 days shorter on the average, than those patients in the traditional referral system, who were referred late in their hospitalization." They suggest that "social workers may have had decided effect on shortening lengths of stay" and that "it is possible that patients whose hospitalizations might have extended beyond the need for acute medical care because of complex posthospital-planning needs may have had shorter stays because social workers intervened early." They conclude that "social work intervention in the predischarge period may come too late to enable the worker to offer the full range of sound, comprehensive services needed by the patient and his family." Other sources have revealed an increased awareness of the need for early referrals to facilitate timely discharge and successful planning (Cucuzzo, 1976; Furbank, 1976). Establishing a nurisng referral system whereby nursing staff are responsible for admission assessment and appropriate referral suggests one way of changing hospital policy in order to assure more effective discharge planning. Gonnersman (1968)suggests a planned discharge coordinator who makes regular rounds a t the nursing station for identification of patients requiring discharge planning. A Transfer Office, which communicates discharge planning concerns between the hospital and the community, is described by Clark (1969).and the use of an extensive patient assessment questionnaire is submitted by Ryder, Elkin, and Doten (1971). HYPOTHESIS I t is our hypothesis that timing of referral for social work assistance is a major influence upon the course of discharge planning. We theorize that early referral to social work leads to a greater incidence of success in discharge planning. Discharge planning, in our view, is the process of conceptualizing and initiating a plan whereby a patient is transferred from the acute care hospital to an extended care facility, to home, or an alternative living arrangement. The discharge plan is contingent upon the patient's being able to receive whatever medical or nonmedical assistance is deemed necessary. From the hospital's standpoint, all discharge plans are a success when the patient has left the hospital. However, one might judge how successful the discharge plan was by the expeditiousness with which the process was completed without any negative sequelae.
Jules Schrager, etaL
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METHOD Subjects This study was conducted a t the University of Michigan Medical Center, which is an acute care referral facility sewing patients from all parts of Michigan and surrounding areas. The patients on the Internal Medicine Unit were chosen as the population for this study for two reasons: (a) the patients on this unit tend to require more discharge planning services involving social work intervention than other units available to this study; (b) this unit is geographically divided into two sections (6 East and 6 West), lendingitself to the controYexperimentaldesignof this study. Patients are admitted to either 6 East or 6 West on a rotating basis; for example, the first four patients go to 6 East, the second four go to 6 West, and so on. There are no demonstrable differences between the types of patients by diagnosis, level of care, or medical staffing on the two areas. Six East has a capacity of 47 patients and was designated as the control population. Six West has a capacity of 46 patients and became the experimental population. Only those patients who were referred to the Department of Social Work for discharge planning were used as subjects. There was a total of 29 cases in this study, 16 from the control population and 13 from the experimental group. They ranged in age from 51 to 85 years, except for one subject who was under 30. Fifteen of the subjects were males and 14 were females. Fifteen subjects (over half) were married, 6 were widowed. 6 were divorced, and 2 were single. Of the 29 cases, 24 were Caucasian and 5 were Negro patients. Other information was gathered on each case, including whom the patients resided with prior to admittance to the hospital, primary diagnosis, and level of functioning as assessed prior to discharge. Process On the experimental side, interns, resident physicians, and nurses from 6 West were briefed on the study's objective and methodology and were asked to participate by referring within 2 days after admission to the hospital those patients who might need discharge planning assistance. The referral system on these units included both formal and inforfial contact with interns, residents, and nurses by the social workers on the unit. Formal requests were written on referral sheets, and the appropriate social worker was notified. Informal requests might be initiated during daily Kardex rounds (where the medical staff discuss the patient's plan for care and treatment) or more casual meetings with doctors, nurses, occupational therapists, physical therapists, and other disciplines. Occasionally, families of patients would initiate social work involvement prior to a referral from a medical staff member. Sometimes, too, the social worker on the unit might identify the needful patient and seek sanction from the physician for initiating social work contact. To assist the interns (who made the majority of referrals) with making an early referral, a questionnaire was placed on the front of the patient's chart by the desk clerk at the time of admission. This questionnaire (see Appendix A) outlined four criteria for assessing the need of social work in-
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70
tenrention. Three questions were asked concerning where the patient came from prior to admission, what posthospital plans the patient might have already formulated, and whether the doctor saw a need for social work intervention. These questionnaires were taken off the chart by the social worker a day or 2 after admission. The interns then followed the usual procedure for referring a patient to a social worker on a written referral sheet. On the control side, 6 East, the medical staff were simply to continue to follow the referral system as in the past. The social worker responded to all referrals for discharge planning and documented the procedure for each case on the data collection sheet (see Appendix B).These data collection sheets were then collated by the members of the research study group. These contained demographic, social, and medical information, the process of discharge planning, and significant dates such as date of admission, referral to social worker, and anticipated discharge date.
RESULTS Two groups of data generated by this study will be examined here: (a) the effects of time of referral t o social work on discharge planning; and (b)the areas in which impediments occurred in the discharge planning process. We found that referrals t o social work tended to come earlier in the patients' stay on the experimental unit than on the control unit (see Table 1).The average number of days into th.e hospital stay a t the time of referral was 12.06 on the control unit, compared to 8.76 days for the experimental unit. There was a considerable degree of variation b e tween individual cases within the study, with the earliest referrals coming on the 2nd day of stay and the latest coming on the 52nd. Due t o the wide variability and the small sample size, the difference between the control and experimental groups (for time to referral) was not found to be statistically significant.
I. TLms Pastors Refer
~ i s c h e r g eE x p e c t e d Number of S o c .
Difference
Jules Schrager, eta1 TABLE 1 (coat'd) 11.
Impedimencs 1.
Impedimant occurred bemeen d a t e of r e f e r r a l t o s o c i a l work end dace
worker made r e q u e s t t o h c i l i t y . Control A.
T r a n s f e r form not completed
8.
Family r e s i s t a n c e r e q u i r i n g
C.
Change i n medical c o n d i t i o n
9.7%
*
8 0 c i a l work treatment
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0. S o c i a l worker busy
E.
No insurance coverage
F.
Family u n a v a i l a b l e
6.
Unable co c o n t a c t f a c i l i t y
H.
M.D.
undecided about plans
I.
M.D.
unavailable
J.
Unable t o o b t a i n information
12.1%
from c o m n i t y agency *Percentages s h n , r a t e o f occurrence f o r each impediment.
Any case s t u d i e d
m y have more than one impediment. 2.
Impediment occurred b e m e e n d a t e of social work r e q u e s t t o F a c i l i t y and discharge.
A.
No bed a v a i l a b l e
B.
Change i n medical c o n d i t i o n
C,
Family r e s i s t a n c e r e q u i r i n g
D.
F a c i l i t y which o r i g i n a l l y
E.
Necessary paperwork r e q u i r e d
s o c i a l work treatment
accepted p a t i e n t changed d e c i s i o n
one e x t r a day F.
N o i n s u r s n c e coverage
6. F a c i l i t y requested one e x t r a day
H.
Change i n dispositional p l a n s
I.
M.D. d e l a y i n r a k i n g necessary
J.
Family d e l a y
contact t o accepting f a c i l i t y
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SOCIAL WORK IN HEALTH CARE
Our hypothesis, however, that earlier referral to social work leads to a more timely discharge, was borne out by our findings. The average discharge date was earlier for the experimental group than for the control group. The average discharge came 20.38 days after admission for the experimental group versus 25.37 days for the control group. We also found that there was generally a shorter time from the date of referral to social work to the date of discharge for the experimental group. The average number of days from social-work referrai to patient discharge was 10.84 for the experimental group, contrasted with 13.31 for the control group. Adding strength to this tendency was the finding that the physicians had predicted longer hospital stays for the experimental group at the time of referral than for the control group. The average number of days the physician estimated before tha patients would be ready for discharge was 14.61 days for the control patients and 16.33 days for the experimental patients. There was found to be a low, but positive correlation between the length of time from admission to referral and the amount of time from referral to discharge. Possible reasons for the weakness of this relationship in out findings will be discussed later in the paper. There appeared to be no significant difference in the amount of time the social worker spent on cases between the control and experimental groups. The other main area of exploration concerned the various impediments to more expeditious discharge planning and the relative frequency with which they occurred. This information is summarized in Table 1.We grouped impediments by time of occurrence and sorted them into those that delayed the initiation of a request for nursing home admission and those that delayed transfer from the hospital, once a nursing home placement was requested. Needlesa to say, many cases were delayed by several factors both before and after the nursing home was contacted. There appeared to be little clear difference between the control and experimental groups in the relative frequency with which impediment factors occurred. In fact, there was a relatively strong correlation b e tween the two groups r = .376,n = 20)regarding the relative frequency with which each type of impediment occurred. There were three impediment factors that occurred significantly more often than the others. We noted the following as having occurred much more frequently than expected: (a) noncompletion of transfer forms by medical staff; (b)unavailability of appropriate nursing home bed at the time of request; and (c) change in the patient's medical condition after referral, thereby requiring reassessment of the patient's needs.
Jules Schrager, etal.
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DISCUSSION Several issues have arisen in this study that warrant some discussion; not only do these issues have importance for future study, but they are clearly relevant to all discharge planners in medical settings. I t has been shown that early referral to social work for discharge planning tends to result in shorter in-hospital stays for patients. One cannot infer a direct cause and effect relationship, however, as there are several factors that can impede the process, regardless of how early the referral was made. The three factors that delayed patients' discharge most often were: (a)lack of beds in appropriate nursing care facilities; (b)noncompletion of transfer forms by medical staff; and (c) change in. the patients' medical condition, necessitating continued hospital care. These findings point out that future study of the discharge planning process should include the complexity of the various factors that arise outside of social workers' direct control. Perhaps variables other than length of stay in the hospital can be used as a measure of the successfulness of a discharge plan. The impediments we noted could delay a discharge plan that was initiated by early referral as well as one by later referral, but the final outcome of the early referral case could well be seen as moresuccessful if other criteria were used for evaluating success. Future research in this area should be designed to show this effect clearly, despite the fact that length of stay may be the most convenient and easily available criterion. Other measures of the success of a discharge plan might include family and patient satisfaction with the outcome, the viability of the final plan over time, and the long-range cost-benefit of the plan after the patient leaves the hospital. Although the data suggest the importance of early social work involvement in the discharge plan, they also illustrate the problem that even early referral discharge plans can be slowed down by several factors. This is a crucial problem both because of the great financial cost of inordinately long hospitalizations and the intangible cost to the family and the patient of frustration and waiting that result from delayed discharges. The three main impediment factors found in this study are not factors that can be directly controlled by social work intervention; however, we feel that they are issues that must be addressed and influenced if possible. The lack of appropriate nursing home facilities in the community is well known to social workers and discharge planners in medical settings. I t is not so well known nor adequately appreciated, however, among other members of the health care team. Many physicians ex-
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SOCIAL WORK IN HEALTH CARE
press surprise and frustration when they are told that their patient is on a waiting list for a nursing home and cannot be discharged for another week or 2. As social workers, we have an obligation to try to educate the physicians we work with to the nature of the situation in the patient's community. Clearly the physicians need to be made aware that community resources are limited (orlacking),and they can then b e gin to plan with this constraint in mind. A keener awareness of the difficulty in obtaining care outside the hospital may help the doctor begin the discharge planning process earlier and try to mobilize other resources for the patient. One of the most obvious changes would be an increase in efforts to teach patient and family to provide the needed care a t home. This educative function of the social worker can also be performed with hospital administrators. With increased knowledge of the constraints upon the community support system, the hospital administrators may choose to adopt different strategies about discharge planning. For example, they may elect to establish a lower cost "holding" unit for nonacute care patients awaiting transfer to nursing homes. They may decide to contract for this sort of care with a local facility on a regular basis. The administration may establish internal policies that seek to minimize the impact of delayed discharge plans, such as increasing discharge planning staff or requiring early initiation of discharge planning. In addition to the educative function, social work may need to adopt and advocate role in the community to attempt to make available more of the needed resources. This would not necessarily be limited to seeking more of the traditional nursing home care, but could also include the development of more extensive homecare through homemaker services, chore services, visiting nurse services, meals-onwheels, and others. This need for aftercare resources for recently hospitalized patients is paralleled in the mental health and mental retardation fields. I t is not the function of this paper to describe how to organize support for these services, only to suggest the importance of this activity as an appropriate social work task. The other impediment factors also may need to be targets of our intervention. Enhancing physician cooperation in completing the necessary paperwork can be accomplished in several ways. Because we as social workers and discharge planners know what paperwork is needed, we must seek to educate the physicians and nurses of these requirements and the techniques to meet them. We must interpret, as fully as possible, what the health care team must do to effect a patient's transfer. Similarly, we need to educate the medical staff on how to complete these forms. This would serve the purposes of making sure they know when to begin the forms and how to complete them
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75
easily. I t is important for us to fulfill an informal educative function through providing regular feedback to staff about how well they are meeting their obligation in this area. Perhaps some formal mechanism for explaining the paperwork required of them to the staff should be part of their PSRO orientation (Professional Standards Review Organization orientation is the established mechanism for assuring quality control in medical care). Another approach to this problem is to enlist administrative support in our efforts to enhance the medical staff's cooperation with the time consuming tasks involved in discharge planning. The third obstacle that frequently delayed discharge was a change in the patient's medical condition. Obviously, there is little we can do to prevent this from occurring. Perhaps all that we can do is to urge that the medical staff be as certain as possible of the stability of the patient's condition and to document clearly the fact that the changing medical status has caused the delay.
CONCLUSIONS This study has tried to show that there is a relationship between early referral to social work for discharge planning and the length of time it will take to arrange for the patient to leave the hospital. The data suggest that there may be other areas (than the speediness of discharge) that are enhanced by early involvement of social work in the discharge planning process. It was also found that there are several other factors that often delay discharge or impede the planning process: (a) lack of appropriate extended care beds; (b) limited cooperation of medical staff in the necessary paperwork; and (c) change in the medical condition of the patient. We have suggested that since these factors may impede progress toward discharge so often, it appears necessary to make hospital administrators and the medical staff aware of these obstacles and begin to minimize them where possible while adopting different discharge planning strategies that take them into account. The urgency of this issue has increased because of the growing pressure on hospitals by third-party insurance carriers to discharge patients promptly when acute care is no longer required. Paraller to this is a growing concern on the part of patient-families and the community at large regarding the continued rise in the cost of medical care. Clearly, any facilitation of the discharge planning process can help to ease both of these pressures.
SOCIAL WORK IN HEALTH CARE
REFERENCE NOTE 1.Phillips, B. Hospita1discharge:By plan or by chance? Edited and adapted from a paper presented a t thecatholic Hospital Association Convention, AtlanticCity. New Jersey, June 9.1971.
REFERENCES American Hospital Association. Discharge planning for hospitals. Chicago: Author
--.
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1074 &.
Berkman. B. G., & Rehr. H. Early social service case finding for hospitalized patients: An experiment. New York: Mount Sinai Medical Center. 1972. Clark, E. Improving posbhospital care for chronically ill elderly patients. Social Work, January 1969.pp. 62-67. Crane, D. The sanctity of social life: Physicians treatment of critically ill patients. New York: Russell Sage Foundation. 1975. Cucuzzo. R. A. Method discharge planning. Supervisor Nurse, January 1976,pp. 43-45. Duff, R.S., & Hollingshead, A. B. Sickness and Society. New York: Harper. Row, 1968. Furbank, M. E. A nursing referral system: Admissions, transfers, and discharges to and from hospital. Nursing Times, March 18,1976,pp. 41-44. Gonnersrnan, A. M. Introduction of planned discharge coordinators in hospitals. Hospital Forum, January 1968.p~. 4-6;25. Greater Detroit Area Health Care Discharge Planning Task Force. Discharge Planning Task Force Committee report. Detroit: Author. February 1977. Ryder. C. F.. Elkin, W. F., & Doten. D. Patient assessment. An essential tool in placement and planning of care. Health Services in Mental Health Administration Health Reports, October 1971.86(10),923-932. Simpson, D. Patient discharge planning. - Journal of the Albert Einstein Medical Center, ~ i t u m 1969.17, n 120-128.- Taco, E. G. Patients, physicians and illness. New York: Free Press, 1958.
Jules Schrager, etal. APPENDM A
Patient:
NEED FOR DISCHARGE PlANNING 'Chi8 im
a
q u a s t i m n a i r e d e s i g n e d co a s s i s t you i n meting e e r l y r e f e r r a l s f o r
discharge plenning.
As we a r e aware t h a t t h i s type of i n t e r v e n t i o n m y i n c r e a s e
t h e nvmber of r e f e r r a l s
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I.
1.
s u b s t a n t i a l l y , we a s k t h a t you t r y t o r e f e r p a t i e n t s who:
Have nowhere t o l i v e
2.
W i l l need s s u b s t a n t i a l amount o f core
3.
Hsve l i t t l e o r no family s u p p o r t
4.
Have no p l a n s p o s t - h o s p i t a l i r s t i o n
Where d i d t h e p a t i e n t come from? Home
-
Nursing home
-
Adult f o s t e r care hone 2.
Hone f o r t h e aged
-
R e l a t i v e ' s home
Other
-
Specify:
Where i s p a t i e n t going when h e l s h e l e a v e s t h e h o s p l t a l l Home
-
Nursing home
-
Adult f o s t e r care home 3.
-
Retirement c e n t e r
-
Retirement c e n t e r
-
Home f o r t h e aged
-
R e l a t i v e ' s home
-
Other
Specify:
Is s o d s 1 s e r v i c e needed f o r d l s c h s r g e p l e n n i n g ?
I f d i s c h a r g e p l a n n i n g i s needed, p l e a s e :
a.
P i l l o u t w r i t t e n r e f e r r a l and send t o s o c i a l s e r v i c h w i t h i n two days o f a d m i s s i o n
b.
-
Notify p e t i e n t ' a family t h s t discharge planning i s required
SOCIAL WORK IN HEALTH CARE
DEPARRDNT OF SOCIAL WORK DISCHARGE PIANNIX STUDY
DATA COLLECTION Date:
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Gcnerol P a t l e n t I n f o r r a t i o n NAXQ.:
REG. NIMBER:
ADD :
UARITAL STARIS :
AGE :
RACE:
SEX:
OCCUPATION :
RELIGION:
ADHISSION MTE:
EDUCATION: ( h i g h e s t l e v e l ~ c h i e v e d ) INCOne PER VAR: RESrnES
w1m:
WIATNES NEARBY: DIAGNDSIS : SERVICE ADHITIZD
m:
SIGNIPICAm PROCEDURES TO BE PER-: ExPECTEO L E N m W STAY: PATIEm
CAm PROn
PRIOR TO ADMSSION:
SOURCE 0 9 REPERR*I FOR PATIEm TO HOSPITAL:
LEVEL OP W T I O m N G : ( I n d e p e n d e n t , n e e d s s u p e r v i s i o n o n l y , needs o s s l s t o n c e ) SERIOUSNESS OP PATIBKP'S CONDITION:
PRINCLQAL SOURCE OF Self-pay.
-
Crltical
Poor
-P a l r -S s t t s f a c t o r y -
PAWNT:
Wortmsn's C m t p a n a e t i o n , H e d l c o r e , H e d i c s i d , B l u e C r o s s ,
C o m z e r c i a l Insurance, No charge ( f r e e , s p e c i e 1 research or t e a c h e r a ) Other (apeclfy) :
DISCHARGE PIANNINC INFmMTION 2.
1.
ADMISSION DATE:
3.
REFERRAL SOURCE: P h y s i c i a n -
4.
TYPT OF SERVICE REQUESTED: Adult Foster Care-
Nurse-
N u r s i n g Horn-
Home Care-
5.
DATE REQUEST MDE TO FACILITY:
6.
WHY ii5 DIFFERS FROM # 2 :
Worker busy
Can't g e t i n touchlsgreement w i t h :
DAlE OF REWRRAL:
S o c i a l WorkerRetirement
Ward clerk-
Other-
Center-
Home Far t h e Aged-
Other(spcify)-
physicianfamily-
facility-
patient-
Jules Schrager, etaL APPENDM B ( c o n t ' d ) n a n a f e r form not f l l l e d cut-
Have t o investigate coverage-
Have t o apply for ~ e d i c a r e / M e d i c a i d-
Other(spec1fy)
7.
ACTIVITIES PERFORK6D BY SOCIAL WORKER FOR DISCHARGE PIANNING: (see checklist)
8.
OUTCOME:
F ~ c l l l t a t e dmedical treatment-
Explaln:
F a ~ i l i t a t e dapproprlste u r i l i z e t l a n of f e e l l l t y Aeslered p a t l e n t / f a m i l y 9.
10.
Explain:
DAlE REQUEST COHI'LETED: W H Y 1 9 DIFFERS FUDn # 5 :
Physician ( s p c l f y ) : Hospltal ( e p e c i f y ) :
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PsClsnt/Femlly ( s p c l f y ) : Environmcncal ( s p c l f y ) : 11.
DAlE OF DISCHARGE:
12.
um
# I I DVFERS FROH $9: ~ h y m i c i a n ( e p c i f y ) : Hospltal ( s p c l f y ) : Patlsnthamlly (apeclfy): Environmentel (specify):
Explaln:
ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20
IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING Jules Schrager MSW, CSW , Marc Halman BSW , Diane Myers BSW , Rosemary Nichols BA & Lee Rosenblum BA To cite this article: Jules Schrager MSW, CSW , Marc Halman BSW , Diane Myers BSW , Rosemary Nichols BA & Lee Rosenblum BA (1978) IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING, Social Work in Health Care, 4:1, 65-79, DOI: 10.1300/J010v04n01_07 To link to this article: http://dx.doi.org/10.1300/J010v04n01_07
Published online: 12 Dec 2008.
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Date: 27 June 2016, At: 11:02
IMPEDIMENTS TO THE COURSE AND EFFECTIVENESS OF DISCHARGE PLANNING
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Jules Schrager, MSW. CSW Marc Halman, BSW Diane Myers, BSW Rosemary Nichols. BA Lee Rosenblum, BA
ABSTRACT. This paper ezamines the proposition that "timing" (of refeml) is a crucial element in determining the effectiveness of the discharge planningprocess. A brief review of the relevant literature is followed by the description of a study undertaken to assess the impact that various impediments had upon discharge planning pmctice in two matched ward populations of a large, acute care university hospital. Along with timing, three other impediments were identified and their influence assessed; (a) noncompletion of tmnsfer forms required; (b) unavailability of an appropriate ke., needed level of care) bed in an approved facility; and (c) unanticipated change in the patient's medical condition. Some implications of the findings are examined and discussed, and directions for future study are identified Appended are facsimiles o f the instruments employed T h u s there remained 134 (out of 157) survivors of hospitalization who had physical or psychosocial handicap; 13% were disabled for physical reasons. . 51% b y conditions primarily attributable t o psychosocial factors, and 22% b y a combination of physical and psychosocial. . . (Duff&
.
Hollingshead, 1968)
Aside from the physical illness that brings a person into hospital care, he brings with him a repertoire of strategies, developed over a lifetime, that have made it possible for him to cope with various kinds and degrees of stress. He carries with him, too, a personal and social history made uniquely significant by the events that have occurred in his lifetime, the "cast of characters" associated with those events, and remembrances of their outcome, both positive and negative. Mr. Schrager is Chief. Social Work Services. and Associate Professor. School o f Social Work. University o f Michigan, Ann Arbor, Michigan 48106. Mr. Halman. Ms. Myers, Ms. Nichols, and Mr. Rosenblum are social workers in the Department'of Social Work. University of Michigan Medical Center. The group is indebted t o Anne Brantley Malcolm, Nancy Shulman. and Deirdre Warren for their early contributions to the project. Soda1WorkiaHaalthCare.VoL 4(11,Falll978 O1918 by The Haworth h a . AUrightsnuerved.
SOCIAL WORK IN HEALTH CARE
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66
There is little in the life of the average person that will have prepared him to cope with hospitalization. The successful management of earlier events involving separation and loss will, of course, modulate the effects. The availability of a vjable economic and psychological support system will have a great effect on the posthospital outcome for the patient. Nevertheless, hospitalization for treatment of an acute illness or injury constitutes a psychosocially hazardous event and places the patient "at-risk." This observation had been widely studied and reported(see,for example, Crane. 1975;Taco, 1958). The design of the process of induction of the patient into the hospital and his passage through and out of the institution reflects a set of tasks which, poorly managed, can severely influence the posthospital career of the patient-family. Commonly, social workers have no control over events antecedent to admission to the hospital, modest influence on the nature and course of the management of the medical care program, but considerable opportunity to shape the process of discharge back into the community. I t is to the last of these that this paper addresses itself, attempting to identify those elements of patient-care management that interfere with the successful movement of the patient into appropriate, after-hospital-care settings.
BRIEF REVIEW OF SOME RELEVANT LITERATURE Continuity of care has become a prime issue in health care. There has been an increasing awareness that the total patient must be considered in planning medical treatment. The focus of this paper is on discharge planning, defined by the American Hospital Association (1974) as "the term given to the centralized, coordinated program developed by a health care institution to insure that each patient has a planned program for needed continuing care andlor follow-up." For the medical facility, discharge planning means "cost-effective use of resources to provide a continuum of care for individual patients based on their needs." (AmericanHospital Association, 1974).The hoped-for result of the planned discharge is that the patient will leave when medically ready and advised medical treatment will be carried out in the community, thereby reducing the cost of the hospital stay and avoiding possible rehospitalization and unnecessary clinic visits. For the hospital, this should result in greater efficiency in the use of beds and equipment; for the patient, a well-designed program meetine individual medical. social..and economic needs. There are several i m p o r k t elements that contribute to successful discharge planning. First, the physician, as the patient's primary planL 8
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Jules Schrager, etaL
67
ner, must be sensitive to his patient's total needs. Second, he should consult and collaborate with other health care professionals in developing and carrying through the plan for aftercare. Third, since collaborative work takes time, the physician must be alert to early indicators of patients' need for help in developing a discharge plan and facilitating its implementation. Most authors addressing the issue of discharge planning agree that early assessment, covering the psychosocial and economic situation as well as health history, is the most important step toward identifying patients who would require posthospitalization assistance. "Both the patient and relatives need support and skilled guidance at such a time, not only in locating and arranging for concrete aftercare services such as.nursing, physical therapy, health aide, homemaker, equipment rentals, etc.. but in the area of relationship counseling as well; old feelings and family problems are often brought to the surface at such times, and new feelings about health and living changes do influence and can adversely affect the health outcome unless skilled and timely intervention prevails" (Simpson, 1969). The timing of referral as crucial to success in discharge planning has been explored by several hospital task forces (Greater Detroit Area Health Care, 1977).Discussing this issue, the University of Minnesota's task group on discharge planning suggests that it should begin at time of admission, be strengthened by observations of the total patient and family needs, and be an ongoing part of the patient's health care treatment plan and goals. Another author exploring this issue described one of thebften seenproblem situations in discharge planning, the late referral: "To often the ~hvsiciancomments that he did not know until the last minute that the i n k y would be unwilling or unable to take care of the patient and needs an alternate plan" (Phillips, Note 1, pp. 23-26). Eleanor Clark (1969) disucsses the special situation of the elderly. as she describes the success of the Transfer Office instituted at Massachusetts General Hospital. In increasing communication and understanding b e tween the hospital and community facilities and awareness of the needs of the elderly, she states that "better understanding of the issues by hospital staff has cut down needless pressure and misunderstanding," resulting in more timely referrals. She goes on to state that "despite the 99 percent occupancy of nursing homes in the state, the average delay between the time patients are medically ready for transfer and the day of transfer was reduced approximately five days during 1967." A study showing the result of earlier discharge through earlier assessment is described by Berkman and Rehr (1972,pp. 257-263)in which a group of patients referred in the normal fashion were compared to a group of patients randomly selected at admission for an assessment of "need for service.'' A pertinent finding is that "those
'
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68
SOCIAL WORK IN HEALTH CARE
patients in the experiment who were helped by social worker from time of admission had stays that were 10 days shorter on the average, than those patients in the traditional referral system, who were referred late in their hospitalization." They suggest that "social workers may have had decided effect on shortening lengths of stay" and that "it is possible that patients whose hospitalizations might have extended beyond the need for acute medical care because of complex posthospital-planning needs may have had shorter stays because social workers intervened early." They conclude that "social work intervention in the predischarge period may come too late to enable the worker to offer the full range of sound, comprehensive services needed by the patient and his family." Other sources have revealed an increased awareness of the need for early referrals to facilitate timely discharge and successful planning (Cucuzzo, 1976; Furbank, 1976). Establishing a nurisng referral system whereby nursing staff are responsible for admission assessment and appropriate referral suggests one way of changing hospital policy in order to assure more effective discharge planning. Gonnersman (1968)suggests a planned discharge coordinator who makes regular rounds a t the nursing station for identification of patients requiring discharge planning. A Transfer Office, which communicates discharge planning concerns between the hospital and the community, is described by Clark (1969).and the use of an extensive patient assessment questionnaire is submitted by Ryder, Elkin, and Doten (1971). HYPOTHESIS I t is our hypothesis that timing of referral for social work assistance is a major influence upon the course of discharge planning. We theorize that early referral to social work leads to a greater incidence of success in discharge planning. Discharge planning, in our view, is the process of conceptualizing and initiating a plan whereby a patient is transferred from the acute care hospital to an extended care facility, to home, or an alternative living arrangement. The discharge plan is contingent upon the patient's being able to receive whatever medical or nonmedical assistance is deemed necessary. From the hospital's standpoint, all discharge plans are a success when the patient has left the hospital. However, one might judge how successful the discharge plan was by the expeditiousness with which the process was completed without any negative sequelae.
Jules Schrager, etaL
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METHOD Subjects This study was conducted a t the University of Michigan Medical Center, which is an acute care referral facility sewing patients from all parts of Michigan and surrounding areas. The patients on the Internal Medicine Unit were chosen as the population for this study for two reasons: (a) the patients on this unit tend to require more discharge planning services involving social work intervention than other units available to this study; (b) this unit is geographically divided into two sections (6 East and 6 West), lendingitself to the controYexperimentaldesignof this study. Patients are admitted to either 6 East or 6 West on a rotating basis; for example, the first four patients go to 6 East, the second four go to 6 West, and so on. There are no demonstrable differences between the types of patients by diagnosis, level of care, or medical staffing on the two areas. Six East has a capacity of 47 patients and was designated as the control population. Six West has a capacity of 46 patients and became the experimental population. Only those patients who were referred to the Department of Social Work for discharge planning were used as subjects. There was a total of 29 cases in this study, 16 from the control population and 13 from the experimental group. They ranged in age from 51 to 85 years, except for one subject who was under 30. Fifteen of the subjects were males and 14 were females. Fifteen subjects (over half) were married, 6 were widowed. 6 were divorced, and 2 were single. Of the 29 cases, 24 were Caucasian and 5 were Negro patients. Other information was gathered on each case, including whom the patients resided with prior to admittance to the hospital, primary diagnosis, and level of functioning as assessed prior to discharge. Process On the experimental side, interns, resident physicians, and nurses from 6 West were briefed on the study's objective and methodology and were asked to participate by referring within 2 days after admission to the hospital those patients who might need discharge planning assistance. The referral system on these units included both formal and inforfial contact with interns, residents, and nurses by the social workers on the unit. Formal requests were written on referral sheets, and the appropriate social worker was notified. Informal requests might be initiated during daily Kardex rounds (where the medical staff discuss the patient's plan for care and treatment) or more casual meetings with doctors, nurses, occupational therapists, physical therapists, and other disciplines. Occasionally, families of patients would initiate social work involvement prior to a referral from a medical staff member. Sometimes, too, the social worker on the unit might identify the needful patient and seek sanction from the physician for initiating social work contact. To assist the interns (who made the majority of referrals) with making an early referral, a questionnaire was placed on the front of the patient's chart by the desk clerk at the time of admission. This questionnaire (see Appendix A) outlined four criteria for assessing the need of social work in-
SOCIAL WORK IN HEALTH CAFiE
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70
tenrention. Three questions were asked concerning where the patient came from prior to admission, what posthospital plans the patient might have already formulated, and whether the doctor saw a need for social work intervention. These questionnaires were taken off the chart by the social worker a day or 2 after admission. The interns then followed the usual procedure for referring a patient to a social worker on a written referral sheet. On the control side, 6 East, the medical staff were simply to continue to follow the referral system as in the past. The social worker responded to all referrals for discharge planning and documented the procedure for each case on the data collection sheet (see Appendix B).These data collection sheets were then collated by the members of the research study group. These contained demographic, social, and medical information, the process of discharge planning, and significant dates such as date of admission, referral to social worker, and anticipated discharge date.
RESULTS Two groups of data generated by this study will be examined here: (a) the effects of time of referral t o social work on discharge planning; and (b)the areas in which impediments occurred in the discharge planning process. We found that referrals t o social work tended to come earlier in the patients' stay on the experimental unit than on the control unit (see Table 1).The average number of days into th.e hospital stay a t the time of referral was 12.06 on the control unit, compared to 8.76 days for the experimental unit. There was a considerable degree of variation b e tween individual cases within the study, with the earliest referrals coming on the 2nd day of stay and the latest coming on the 52nd. Due t o the wide variability and the small sample size, the difference between the control and experimental groups (for time to referral) was not found to be statistically significant.
I. TLms Pastors Refer
~ i s c h e r g eE x p e c t e d Number of S o c .
Difference
Jules Schrager, eta1 TABLE 1 (coat'd) 11.
Impedimencs 1.
Impedimant occurred bemeen d a t e of r e f e r r a l t o s o c i a l work end dace
worker made r e q u e s t t o h c i l i t y . Control A.
T r a n s f e r form not completed
8.
Family r e s i s t a n c e r e q u i r i n g
C.
Change i n medical c o n d i t i o n
9.7%
*
8 0 c i a l work treatment
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0. S o c i a l worker busy
E.
No insurance coverage
F.
Family u n a v a i l a b l e
6.
Unable co c o n t a c t f a c i l i t y
H.
M.D.
undecided about plans
I.
M.D.
unavailable
J.
Unable t o o b t a i n information
12.1%
from c o m n i t y agency *Percentages s h n , r a t e o f occurrence f o r each impediment.
Any case s t u d i e d
m y have more than one impediment. 2.
Impediment occurred b e m e e n d a t e of social work r e q u e s t t o F a c i l i t y and discharge.
A.
No bed a v a i l a b l e
B.
Change i n medical c o n d i t i o n
C,
Family r e s i s t a n c e r e q u i r i n g
D.
F a c i l i t y which o r i g i n a l l y
E.
Necessary paperwork r e q u i r e d
s o c i a l work treatment
accepted p a t i e n t changed d e c i s i o n
one e x t r a day F.
N o i n s u r s n c e coverage
6. F a c i l i t y requested one e x t r a day
H.
Change i n dispositional p l a n s
I.
M.D. d e l a y i n r a k i n g necessary
J.
Family d e l a y
contact t o accepting f a c i l i t y
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72
SOCIAL WORK IN HEALTH CARE
Our hypothesis, however, that earlier referral to social work leads to a more timely discharge, was borne out by our findings. The average discharge date was earlier for the experimental group than for the control group. The average discharge came 20.38 days after admission for the experimental group versus 25.37 days for the control group. We also found that there was generally a shorter time from the date of referral to social work to the date of discharge for the experimental group. The average number of days from social-work referrai to patient discharge was 10.84 for the experimental group, contrasted with 13.31 for the control group. Adding strength to this tendency was the finding that the physicians had predicted longer hospital stays for the experimental group at the time of referral than for the control group. The average number of days the physician estimated before tha patients would be ready for discharge was 14.61 days for the control patients and 16.33 days for the experimental patients. There was found to be a low, but positive correlation between the length of time from admission to referral and the amount of time from referral to discharge. Possible reasons for the weakness of this relationship in out findings will be discussed later in the paper. There appeared to be no significant difference in the amount of time the social worker spent on cases between the control and experimental groups. The other main area of exploration concerned the various impediments to more expeditious discharge planning and the relative frequency with which they occurred. This information is summarized in Table 1.We grouped impediments by time of occurrence and sorted them into those that delayed the initiation of a request for nursing home admission and those that delayed transfer from the hospital, once a nursing home placement was requested. Needlesa to say, many cases were delayed by several factors both before and after the nursing home was contacted. There appeared to be little clear difference between the control and experimental groups in the relative frequency with which impediment factors occurred. In fact, there was a relatively strong correlation b e tween the two groups r = .376,n = 20)regarding the relative frequency with which each type of impediment occurred. There were three impediment factors that occurred significantly more often than the others. We noted the following as having occurred much more frequently than expected: (a) noncompletion of transfer forms by medical staff; (b)unavailability of appropriate nursing home bed at the time of request; and (c) change in the patient's medical condition after referral, thereby requiring reassessment of the patient's needs.
Jules Schrager, etal.
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DISCUSSION Several issues have arisen in this study that warrant some discussion; not only do these issues have importance for future study, but they are clearly relevant to all discharge planners in medical settings. I t has been shown that early referral to social work for discharge planning tends to result in shorter in-hospital stays for patients. One cannot infer a direct cause and effect relationship, however, as there are several factors that can impede the process, regardless of how early the referral was made. The three factors that delayed patients' discharge most often were: (a)lack of beds in appropriate nursing care facilities; (b)noncompletion of transfer forms by medical staff; and (c) change in. the patients' medical condition, necessitating continued hospital care. These findings point out that future study of the discharge planning process should include the complexity of the various factors that arise outside of social workers' direct control. Perhaps variables other than length of stay in the hospital can be used as a measure of the successfulness of a discharge plan. The impediments we noted could delay a discharge plan that was initiated by early referral as well as one by later referral, but the final outcome of the early referral case could well be seen as moresuccessful if other criteria were used for evaluating success. Future research in this area should be designed to show this effect clearly, despite the fact that length of stay may be the most convenient and easily available criterion. Other measures of the success of a discharge plan might include family and patient satisfaction with the outcome, the viability of the final plan over time, and the long-range cost-benefit of the plan after the patient leaves the hospital. Although the data suggest the importance of early social work involvement in the discharge plan, they also illustrate the problem that even early referral discharge plans can be slowed down by several factors. This is a crucial problem both because of the great financial cost of inordinately long hospitalizations and the intangible cost to the family and the patient of frustration and waiting that result from delayed discharges. The three main impediment factors found in this study are not factors that can be directly controlled by social work intervention; however, we feel that they are issues that must be addressed and influenced if possible. The lack of appropriate nursing home facilities in the community is well known to social workers and discharge planners in medical settings. I t is not so well known nor adequately appreciated, however, among other members of the health care team. Many physicians ex-
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74
SOCIAL WORK IN HEALTH CARE
press surprise and frustration when they are told that their patient is on a waiting list for a nursing home and cannot be discharged for another week or 2. As social workers, we have an obligation to try to educate the physicians we work with to the nature of the situation in the patient's community. Clearly the physicians need to be made aware that community resources are limited (orlacking),and they can then b e gin to plan with this constraint in mind. A keener awareness of the difficulty in obtaining care outside the hospital may help the doctor begin the discharge planning process earlier and try to mobilize other resources for the patient. One of the most obvious changes would be an increase in efforts to teach patient and family to provide the needed care a t home. This educative function of the social worker can also be performed with hospital administrators. With increased knowledge of the constraints upon the community support system, the hospital administrators may choose to adopt different strategies about discharge planning. For example, they may elect to establish a lower cost "holding" unit for nonacute care patients awaiting transfer to nursing homes. They may decide to contract for this sort of care with a local facility on a regular basis. The administration may establish internal policies that seek to minimize the impact of delayed discharge plans, such as increasing discharge planning staff or requiring early initiation of discharge planning. In addition to the educative function, social work may need to adopt and advocate role in the community to attempt to make available more of the needed resources. This would not necessarily be limited to seeking more of the traditional nursing home care, but could also include the development of more extensive homecare through homemaker services, chore services, visiting nurse services, meals-onwheels, and others. This need for aftercare resources for recently hospitalized patients is paralleled in the mental health and mental retardation fields. I t is not the function of this paper to describe how to organize support for these services, only to suggest the importance of this activity as an appropriate social work task. The other impediment factors also may need to be targets of our intervention. Enhancing physician cooperation in completing the necessary paperwork can be accomplished in several ways. Because we as social workers and discharge planners know what paperwork is needed, we must seek to educate the physicians and nurses of these requirements and the techniques to meet them. We must interpret, as fully as possible, what the health care team must do to effect a patient's transfer. Similarly, we need to educate the medical staff on how to complete these forms. This would serve the purposes of making sure they know when to begin the forms and how to complete them
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Jules Schrager, etaL
75
easily. I t is important for us to fulfill an informal educative function through providing regular feedback to staff about how well they are meeting their obligation in this area. Perhaps some formal mechanism for explaining the paperwork required of them to the staff should be part of their PSRO orientation (Professional Standards Review Organization orientation is the established mechanism for assuring quality control in medical care). Another approach to this problem is to enlist administrative support in our efforts to enhance the medical staff's cooperation with the time consuming tasks involved in discharge planning. The third obstacle that frequently delayed discharge was a change in the patient's medical condition. Obviously, there is little we can do to prevent this from occurring. Perhaps all that we can do is to urge that the medical staff be as certain as possible of the stability of the patient's condition and to document clearly the fact that the changing medical status has caused the delay.
CONCLUSIONS This study has tried to show that there is a relationship between early referral to social work for discharge planning and the length of time it will take to arrange for the patient to leave the hospital. The data suggest that there may be other areas (than the speediness of discharge) that are enhanced by early involvement of social work in the discharge planning process. It was also found that there are several other factors that often delay discharge or impede the planning process: (a) lack of appropriate extended care beds; (b) limited cooperation of medical staff in the necessary paperwork; and (c) change in the medical condition of the patient. We have suggested that since these factors may impede progress toward discharge so often, it appears necessary to make hospital administrators and the medical staff aware of these obstacles and begin to minimize them where possible while adopting different discharge planning strategies that take them into account. The urgency of this issue has increased because of the growing pressure on hospitals by third-party insurance carriers to discharge patients promptly when acute care is no longer required. Paraller to this is a growing concern on the part of patient-families and the community at large regarding the continued rise in the cost of medical care. Clearly, any facilitation of the discharge planning process can help to ease both of these pressures.
SOCIAL WORK IN HEALTH CARE
REFERENCE NOTE 1.Phillips, B. Hospita1discharge:By plan or by chance? Edited and adapted from a paper presented a t thecatholic Hospital Association Convention, AtlanticCity. New Jersey, June 9.1971.
REFERENCES American Hospital Association. Discharge planning for hospitals. Chicago: Author
--.
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1074 &.
Berkman. B. G., & Rehr. H. Early social service case finding for hospitalized patients: An experiment. New York: Mount Sinai Medical Center. 1972. Clark, E. Improving posbhospital care for chronically ill elderly patients. Social Work, January 1969.pp. 62-67. Crane, D. The sanctity of social life: Physicians treatment of critically ill patients. New York: Russell Sage Foundation. 1975. Cucuzzo. R. A. Method discharge planning. Supervisor Nurse, January 1976,pp. 43-45. Duff, R.S., & Hollingshead, A. B. Sickness and Society. New York: Harper. Row, 1968. Furbank, M. E. A nursing referral system: Admissions, transfers, and discharges to and from hospital. Nursing Times, March 18,1976,pp. 41-44. Gonnersrnan, A. M. Introduction of planned discharge coordinators in hospitals. Hospital Forum, January 1968.p~. 4-6;25. Greater Detroit Area Health Care Discharge Planning Task Force. Discharge Planning Task Force Committee report. Detroit: Author. February 1977. Ryder. C. F.. Elkin, W. F., & Doten. D. Patient assessment. An essential tool in placement and planning of care. Health Services in Mental Health Administration Health Reports, October 1971.86(10),923-932. Simpson, D. Patient discharge planning. - Journal of the Albert Einstein Medical Center, ~ i t u m 1969.17, n 120-128.- Taco, E. G. Patients, physicians and illness. New York: Free Press, 1958.
Jules Schrager, etal. APPENDM A
Patient:
NEED FOR DISCHARGE PlANNING 'Chi8 im
a
q u a s t i m n a i r e d e s i g n e d co a s s i s t you i n meting e e r l y r e f e r r a l s f o r
discharge plenning.
As we a r e aware t h a t t h i s type of i n t e r v e n t i o n m y i n c r e a s e
t h e nvmber of r e f e r r a l s
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I.
1.
s u b s t a n t i a l l y , we a s k t h a t you t r y t o r e f e r p a t i e n t s who:
Have nowhere t o l i v e
2.
W i l l need s s u b s t a n t i a l amount o f core
3.
Hsve l i t t l e o r no family s u p p o r t
4.
Have no p l a n s p o s t - h o s p i t a l i r s t i o n
Where d i d t h e p a t i e n t come from? Home
-
Nursing home
-
Adult f o s t e r care hone 2.
Hone f o r t h e aged
-
R e l a t i v e ' s home
Other
-
Specify:
Where i s p a t i e n t going when h e l s h e l e a v e s t h e h o s p l t a l l Home
-
Nursing home
-
Adult f o s t e r care home 3.
-
Retirement c e n t e r
-
Retirement c e n t e r
-
Home f o r t h e aged
-
R e l a t i v e ' s home
-
Other
Specify:
Is s o d s 1 s e r v i c e needed f o r d l s c h s r g e p l e n n i n g ?
I f d i s c h a r g e p l a n n i n g i s needed, p l e a s e :
a.
P i l l o u t w r i t t e n r e f e r r a l and send t o s o c i a l s e r v i c h w i t h i n two days o f a d m i s s i o n
b.
-
Notify p e t i e n t ' a family t h s t discharge planning i s required
SOCIAL WORK IN HEALTH CARE
DEPARRDNT OF SOCIAL WORK DISCHARGE PIANNIX STUDY
DATA COLLECTION Date:
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Gcnerol P a t l e n t I n f o r r a t i o n NAXQ.:
REG. NIMBER:
ADD :
UARITAL STARIS :
AGE :
RACE:
SEX:
OCCUPATION :
RELIGION:
ADHISSION MTE:
EDUCATION: ( h i g h e s t l e v e l ~ c h i e v e d ) INCOne PER VAR: RESrnES
w1m:
WIATNES NEARBY: DIAGNDSIS : SERVICE ADHITIZD
m:
SIGNIPICAm PROCEDURES TO BE PER-: ExPECTEO L E N m W STAY: PATIEm
CAm PROn
PRIOR TO ADMSSION:
SOURCE 0 9 REPERR*I FOR PATIEm TO HOSPITAL:
LEVEL OP W T I O m N G : ( I n d e p e n d e n t , n e e d s s u p e r v i s i o n o n l y , needs o s s l s t o n c e ) SERIOUSNESS OP PATIBKP'S CONDITION:
PRINCLQAL SOURCE OF Self-pay.
-
Crltical
Poor
-P a l r -S s t t s f a c t o r y -
PAWNT:
Wortmsn's C m t p a n a e t i o n , H e d l c o r e , H e d i c s i d , B l u e C r o s s ,
C o m z e r c i a l Insurance, No charge ( f r e e , s p e c i e 1 research or t e a c h e r a ) Other (apeclfy) :
DISCHARGE PIANNINC INFmMTION 2.
1.
ADMISSION DATE:
3.
REFERRAL SOURCE: P h y s i c i a n -
4.
TYPT OF SERVICE REQUESTED: Adult Foster Care-
Nurse-
N u r s i n g Horn-
Home Care-
5.
DATE REQUEST MDE TO FACILITY:
6.
WHY ii5 DIFFERS FROM # 2 :
Worker busy
Can't g e t i n touchlsgreement w i t h :
DAlE OF REWRRAL:
S o c i a l WorkerRetirement
Ward clerk-
Other-
Center-
Home Far t h e Aged-
Other(spcify)-
physicianfamily-
facility-
patient-
Jules Schrager, etaL APPENDM B ( c o n t ' d ) n a n a f e r form not f l l l e d cut-
Have t o investigate coverage-
Have t o apply for ~ e d i c a r e / M e d i c a i d-
Other(spec1fy)
7.
ACTIVITIES PERFORK6D BY SOCIAL WORKER FOR DISCHARGE PIANNING: (see checklist)
8.
OUTCOME:
F ~ c l l l t a t e dmedical treatment-
Explaln:
F a ~ i l i t a t e dapproprlste u r i l i z e t l a n of f e e l l l t y Aeslered p a t l e n t / f a m i l y 9.
10.
Explain:
DAlE REQUEST COHI'LETED: W H Y 1 9 DIFFERS FUDn # 5 :
Physician ( s p c l f y ) : Hospltal ( e p e c i f y ) :
Downloaded by [University of California, San Diego] at 11:02 27 June 2016
PsClsnt/Femlly ( s p c l f y ) : Environmcncal ( s p c l f y ) : 11.
DAlE OF DISCHARGE:
12.
um
# I I DVFERS FROH $9: ~ h y m i c i a n ( e p c i f y ) : Hospltal ( s p c l f y ) : Patlsnthamlly (apeclfy): Environmentel (specify):
Explaln:
