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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING Patricia Volland MSW, ACSW
a
a
Director, Department of Social Work, The Johns Hopkins Hospital, Baltimore, MD, 21205 Published online: 26 Oct 2008.
To cite this article: Patricia Volland MSW, ACSW (1976) SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING, Social Work in Health Care, 1:3, 277-285, DOI: 10.1300/J010v01n03_03 To link to this article: http://dx.doi.org/10.1300/J010v01n03_03
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING
Downloaded by [University of Arizona] at 23:42 03 February 2015
Patricia Volland, MSW, ACSW
A B S T R A C T . Information and accountability systems for departmefits o f social work are a major concern for t h e profession, particularly within the heallh care sector. This paper describes the development of such a syslem within a large tiniversily hospital, the forces l h a t led t o its development, and the mulliple expectations for its usefulness in planning and implementing social work services m o s t effectively, within the lowest cost. I t includes potential for building research projects and is utilized as a communication mechanism for recording. Collaboration within l h e profession is essential for implementing objective standards t o be utilized in reviewing delivery o f professional social work services.
"To move forward in the coming decade, social work must make substantial progress in at least three tasks: (1)to find better ways to account for what it does, (2) to determine the effectiveness of its programs, and ( 3 ) to develop more potent means of effecting change in social problems."' To do what Dr. William Reid suggests, and to do it responsibly, the profession must continue to develop and perfect information and accountability systems that collect, store, and analyze a wide range of information to answer questions of program effectiveness, costs, and operating systems. It is to the credit of the profession that social work is asking these questions of itself in planning for a future where nothing will be taken for granted. All services in the health care sector are coming under critical scrutiny in an attempt to provide the highest level of care at the lowest possible cost. Health care providers are being asked to define and account for their services through cost-effective processes. Both third-party payers, including Mrs. Volland is Director, Department o f Social W o r k , T h e Johns Hopkins Hospital, Baltimore, Maryland 21205, and Assistant Professor, School o f Health Services. Johns Hookins University. T h e author acknowledees t h e ; o f Maryland School assistance o f Dr. Evelyn d g r e n , ~ s s i s t a n t~ r o f e s s o rUniversity o f Social W o r k and C o m m u n i t y Planning. Dr. Ogren acted as consultant in t h e development o f t h e systems reported here. Social W o r k in Health Care, V o l . 1 ( 3 ) , Spring 1976
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government agencies, and consumers are focusing on the escalating cost of health care and understanding the quality of the care provided.2 Where social work is part of a health care delivery system, the profession is participating in this process. This paper describes the design and implementation of an information and accountability system within a university hospital. It reviews the purposes of the system and relates these t o the needs of the profession in general, and social worlr in health care in particular.
Downloaded by [University of Arizona] at 23:42 03 February 2015
ACCOUNTABILITY AND SOCIAL WORK INFORMATION SYSTEMS There are forces at local and federal levels that sharpen the need for definitions of quality and quantity of work by the profession. In the state of Maryland, the Maryland Health Services Cost Review Commission has been e~tablished.~ This commission has responsibility for investigating, reviewing, and establishing rates of reimbursement for hospital services. In establishing a rate review methodology, this commission has accepted the Revenue Center as a means for defining service. Each revenue center makes bills and establishes relative value units. Departments of social work are not considered revenue centers. Rather, social work services are charged off through the per diem established within the revenue center where the service is provided. A relative value unit has been established for each professional service; for social work this unit of measure is total number of cases. This unit of measure does not accurately define quality or quantity of services provided or their benefit to patients. In response t o this, directors of social work departments, through the Maryland Chapter of the American Society for Hospital Social Work Directors, have taken responsibility for defining and ranking types of social work ~ e r v i c e s . ~ One approach to relative value is time spent in delivering each service with level of professional skill necessary to provide these services. On the federal level, passage of Professional Standards Review Organization (PSRO) regulations mandates the requirement for both concurrent and retrospective re vie^.^ The objectives of this legislation suggest that reduction of health care costs is compatible with increased effectiveness of service. Establishment of criteria for a standard for services for each health care professional addresses the possibility of reduced cost and increased effectiveness. One approach for the establishment of such criteria for social worlr is through defining service categories with minimum criteria necessary to deliver these services e f f e ~ t i v e l y ,a~ process that is part of an information system. In addition t o addressing accountability, a good information system has potential as the basis for research and evaluation of services.
Patricia Volland
Downloaded by [University of Arizona] at 23:42 03 February 2015
Attempts within the profession of social work to research adequately the content and effectiveness of services have tended t o be anecdotal and limited to case examples at best.' Predictions for future studies suggest that future focus will be on effectiveness of certain techniques, established in advance, rather than total review of process retrospectively.' Emphasis is on defining and testing observable changes or "hard" data. One approach to developing these data is t o categorize psychosocial problems that are frequently utilized to define cause and effect relationship t o illness and health. These psychosocial problems, frequently used to define need for social work interventions in health care, could form the basis for a taxonomy of "hard" data. Changes in The Johns Hopkins Hospital focused on decentralized management and implementation of "Management By Objectives" concepts. The Department of Social Work experienced a change in leadership. This resulted in overall goals being sharpened, as the new leadership was charged with defining program objectives and establishing effectiveness criteria while understanding the costs to a given revenue center. A cost system was needed t o establish this clearly. These developments reflect the situation faced by many departments of social work. ESTABLISHMENT OF SYSTEM OBJECTIVES
.
Having considered all of these factors, what then should the objectives of an information and accountability system in a large university hospital setting be? This author determined that a mulitfaceted system with the following objectives would be functional for the Department of Social Work at The Johns Hopkins Hospital: 1.To establish and define social work services. 2. To communicate these services t o all other health care professionals. 3. To measure the outcome of these services. 4. To develop an information system that lays a basis for developing and executing research projects on health care problems pertinent to social work interventions. The first approach was a review of developments in other hospital social work departments. In Maryland, one such program with potential for adaptation was developed at the Sinai Hospital of B a l t i m ~ r e .The ~ same consultant to that program was employed by our department to review our needs and to assist in the design of a workable system. The system that has been developed at The Johns Hopkins Hospital reflects and has similarities to the design developed at the Sinai Hospital of Baltimore. The system at The Johns Hopkins Hospital has been developed within
Downloaded by [University of Arizona] at 23:42 03 February 2015
SOCIAL WORK IN HEALTH CARE
the framework of problem identification, goal-directed services provided to alleviate the defined problem, and measurement of service outcome. In setting such a framework, services are defined into categories; each category has a set of criteria that will be utilized in the peer review p r o ~ e s s . ~Further " definition of services results from collection of demographic information on each patient. For example, review of patients who receive discharge planning services clearly establishes patients at risk for this service. Patients needing social work services can be defined and enter the social work system more effectively. This also leads to implementation of concurrent review2 as has already been demonstrated at The Johns Hopkins Hospital where patients "at risk" are automatically referred to the Department of Social Work by the Quality Assurance Office. Effective implementation of concurrent review is accomplished, and outcome of such service delivery benefits the patient (effective discharge planning) and the hospital (improved utilization of beds). Objective definition of services leads to a better understanding of social work services. Further, by comparing time spent and level of professional expertise necessary to provide said service, a relative value for each service category will be established. Service categories will then become the unit of measure for defining the cost of social work service, thus providing a more accurate cost base and a more effective means of comparing social work departments within like hospitals. The potential of charging for social work services, based on actual services provided, should have greater appeal for third-party payers in considering separate reimbursement for social work. Collection of data, both qualitative and quantitative, can lead to demonstration of cost-effectiveness. Fur example, when the commission or hospital administration questions the high cost of social work services in an outpatient clinic where service to patients in groups is focused on reducing somatic complaints while dealing with psychosocial problems of depression and social isolation, this service can be demonstrated as being less costly than utilization of physician time with patients individually. The above discussion of objective data collection also has value in working with hospital administration. Psychosocial problems that interfere with or complicate health and medical care are defined for a particular patient population. Such systematic problem identification combined with defined service categories and measurement of outcome of such services defines for hospital administration the type of program being implemented and the contribution it makes to the hospital's objective to provide quality care. Effectiveness of program planning is demonstrated by, comparing services with outcomes such as length of stay in the hospital. The potential for reducing length of stay in the hospital through early entry into the social work system can be demonstrated while providing comprehensive service to
Downloaded by [University of Arizona] at 23:42 03 February 2015
Patricia Volland
the patient. Through preliminary review, the Department of Social Work has demonstrated already that time is lost in planning when the patient's refusal to cooperate is disregarded.' Further, both service definition and outcome measures are better understood through the reporting of obstacles t o service. Internal and external obstacles such as late referral or lack of resources are known. This information can be utilized to define ways of saving health costs. Communication through objective methodologies and utilizing the concept of problem-oriented record keeping enhances understanding of social work services while leading to clarification of role responsibilities for patient care. Problems and service intent are clearly stated to enhance team responsibilities for patient care. Finally, there is great potential for such a system to lay a basis for developing and executing research projects. Demographic patient information, problem taxonomy, service goals and outcomes, and obstacles to service delivery can be compared and studied separately in evaluative as well as descriptive research projects. DESCRIPTION OF THE SYSTEM The Recording and Reporting System itself contains a standardized problem list and four recording forms. The problem list has two levels: 1. Initial problems represent the point of entry into the social work system from the overall health care system. Classifications include: (a) difficulties with medical regime; (b) acceptance/adjustment to conditions; (c) inadequatelharmful care; (d) personal adjustment/behavior problem; (e) environmental difficulties; and (f) terminal illness. 2. Follow-up or resultant problems are defined following a social work assessment. The problems here may coexist with health-related problems, or they may be the cause or result of these health-related problems. Classifications include the following: (a) individual function related t o illness; (b) family conflicts; (c) living conditions; (d) interpersonal relationship difficulties; (e) economic conditions; (f) other specific conditions; and (g) individual psychiatric disorders-behavioral symptomatology, thought and feeling disorders, and lifelong maladaptive behavioral patterns. Each is further broken down into specific problem area to aid in focusing for social work services. Each problem is numbered for computerization.
Recording Forms Patient case record. This form is completed by the social worker at the time of referral for assessment. It contains demographic information regarding the patient and his family, a medical
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SOCIAL WORK IN HEALTH CARE
diagnosis, as well as a description of the referring agent and the referring problem. This form never appears in the Medical Record, as all information contained on it should already be there. One copy of this form goes to data processing; the social worker beeps the other for his own records. Service plan. Following initial assessment where the social worker decides to open a case, this form is completed and a copy is placed in the Medical Record within 48 hours. The Service Plan Form contains specific problems identified for social work services. Service goals are defined, and activities to be performed are described. These are coded for computer analysis. Service completion form. At the completion of a service episode this form is completed. A copy is placed in the Medical Record. Problems worked, service goals and activities, and outcome achieved for each are recorded descriptively and coded. Obstacles that may have interfered with the social work services are described and coded. The worker then has the option of closing the case or redefining problems and new services t o be provided. Service plan change. When, in the process of providing service, the worker dekrmines a need to redefine problems and/or services, the Service Plan Change Form is completed. A copy is placed in the Medical Record. This represents either a shift in problem focus or in goal focus. The Service Plan Change is similar to the Service Plan. It is primarily an indicator of the shift. With the decision t o computerize this system, it becomes possible to store information indefinitely and to expand the number of variables to be compared. In devising and implementing this system, it was determined that a system was needed that served both recording and reporting purposes. Each suggested design was analyzed for its potential usefulness in collecting the necessary information and then was tested on limited staff. Attention was focused on creating a problem list that contained mutually exclusive items. The current problem list is close to this goal. A sample system was devised and implemented on a trial basis in ~ ~ r iofl '1975 and was utilized through August of 1975. Feedback was gathered from each of the staff members with suggestions for improving the system. The formal system was implemented in September 1975. IMPLEMENTATION AND POTENTIAL VALUE No formal system of recording existed previously. Therefore, worker response to this system was very ambivalent: There was excitement in developing and participating in a new system; however, the ulitmate expectation that each worker would be required to
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Patricia Volland
utilize it created concern. Time considerations in learning to use and maintain such a system are still being discussed. Social workers tend to view this process of record keeping as unnecessary paperwork. Time spent away from direct contact with patients and/or family is frequently seen as time wasted. Administrative staff spent much time attempting to resolve such concerns. The value of this system in planning and implementing comprehensive treatment services was stressed as was the responsibility for maintenance of profession accountability within the hospital. Since the administration of The Johns Hopkins Hospital views any attempt at objective definition and planning of sewices within realistic cost as positive, necessary funds to develop and build this system were readily available. The Medical Records Department was reluctant to approve still another form for the Medical Record. However, this was a minor o,bstacle, and the focus on problem-oriented records further reduced resistance as Medical Records would like the hospital to adopt this format. Building a foundation for future research projects posed a minor problem in that it was necessary to develop a system that combined a mutually exclusive problem list and collected relevant patient demographic information. Outcome measures, while somewhat objective, will need continued review. The value of this system can be stated in terms of how it benefits and relates to: (a) outside regulatory agencies such as the Maryland Health Services Cost Review Commission; (b) hospital administration; (c) the director and supervisory personnel of the social work department; (d) the social work profession, particularly as it has impact on PSRO regulations and research potential; and ( e )patients and families. As previously stated, the Department of Social Work's relationship to the Maryland Health Services Cost Review Commission is in establishing sewice categories as the unit of measure and of costing social work services more effectively. Future budgets will be built on this cost system, not on total number of cases or total number of staff. At any given time the director of the Department of Social Work is prepared to say, by revenue center, exactly what social work services are provided, to what population, with what problems, at what cost (time and money), with what outcome. Management information, for the director and supervisory staff, is gathered and disseminated in a useful form. The social work administrator utilizes this information to understand and evaluate the quality of work of each staff member. Sewices can be understood both as they alleviate problems for patients and their families and as they alleviate problems within the institution. Comparison of services for a given problem will aid in understanding which services for which problem are
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most effective within the shortest time and the least cost t o the patient and the institution. The teaching of medical students and other health care professionals about patient and family psychosocial needs is more clearly focused. Subjective assessment of quality of work is reduced as is assessment of clinical social work skills. Activities can be reviewed regularly, and innumerable variable comparisons can be retrieved. When cost reduction programs are begun, the social work administrator is prepared to define what these potential reductions will mean. Conversely, when fiscal year budgets are submitted the administrator is prepared to demonstrate need and value (outcome) for additional services. Thus by defining costs for each service the administrator can compare this with the potential cost to the institution when a service is not provided. Future program planning becomes a process of defining services necessary within a given patient population. These objective data presented to the chief of a medical division allow him to establish a value for these services, plan for quality patient care, and analyze where dollars will be most effectively spent. For the social work professional the system's problem, service, and outcome criteria are readily adaptable for PSRO requirements. It represents a conceptual framework through which social workers in a health care setting can function effectively. This framework is not new. With the focus on objectifying problems and goal expectations it allows the social worker to anticipate service effectiveness and validate this by outcome measures. The social worker must contract with a patient and/or his family for specific service focused on clearly defined problems, which reinforces the social work principle of self-determination. Such a system tends, as well, to reduce jargon and to clarify role responsibilities for social work within the health care team. Services provided for the psychosocial needs of patients, from a variety of health care professionals, can be compared in terms of process as well as outcome effectiveness. The profession has labored diligently to establish a role as evaluator and treater of psychosocial factors that affect health and medical care. The medical profession has struggled to understand the effect of these factors on illness and health. Objectifying problems in a systematic taxonomy can establish a basis through which we view psychosocial factors as they affect or cause illness. A standardized problem list is a beginning step for building a system taxonomy as a scientific framework through which social work research can focus in the future on specific etiologies of medical problems. Collection of demographic information regarding population served establishes potential for reviewing and comparing populations within a given health care system. Comparisons between the population receiving social work service and the population that is not can prove
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Patricia Volland
invaluable for understanding the effectiveness and the future of social work programs in health care planning. Definitions of social work sewices with outcome measures established are the basis of evaluation.of effectiveness. The sekice categories are defined objectively, and standardized outcomes have been established. Evaluative research projects can be conducted easily, where population allows, emphasizing objective factors to be considered. This article has described the forces that moved a department of social work toward an experimental information and recording system and has emphasized the potential in such a system. This effort is being paralleled in many other departments of social work within health care settings. It is essential that those experiences be shared with the social' work community in health settings with the goal of a single system combining the most productive components of each system.
REFERENCES Reid. William. "Developments in the Use of Organized Data." Social Worh 5 (1974):585-93. Department of Hcallh, Education, and Welfare, PSRO Program Manual. Washington, D.C.: United States Government Printing Office, 1974. State o f Marvland. Health Services Cost Review Commission. "Position Paoer on Selected ~ r o h e m s ' a n dIssues." Ballimore, Maryland, May 1975. American Society for Hospital Social Work Directors, Maryland Chapter, Ad HOC Comrnittec o n Peer Review. Final Report in process. Documentation available in minutes of chapter mcetings from September 1 9 7 5 through present. Unpublished. Fischer, Joel. "Is Casework Effective: A Review." Social Worh 18 (1973):5-20. Fassett, Jacqueline D. Paper presenled a t the 1974 Annual Meeting o f the Society for Hospital Social Work Directors, Atlanta, Georgia. Unpublished. National Association of Social Workers. PSRO Basic Information for Social Workers A c t ~ o nGuide. Washington, D.C.: NASW, 1975. The Johns Hopkins Hospilal, Department of Social Work. "Nine Month Report from Continuity of Care Office." Baltimore, Maryland, September 1975. Unpublished.
'
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING Patricia Volland MSW, ACSW
a
a
Director, Department of Social Work, The Johns Hopkins Hospital, Baltimore, MD, 21205 Published online: 26 Oct 2008.
To cite this article: Patricia Volland MSW, ACSW (1976) SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING, Social Work in Health Care, 1:3, 277-285, DOI: 10.1300/J010v01n03_03 To link to this article: http://dx.doi.org/10.1300/J010v01n03_03
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
SOCIAL WORK INFORMATION AND ACCOUNTABILITY SYSTEMS IN A HOSPITAL SETTING
Downloaded by [University of Arizona] at 23:42 03 February 2015
Patricia Volland, MSW, ACSW
A B S T R A C T . Information and accountability systems for departmefits o f social work are a major concern for t h e profession, particularly within the heallh care sector. This paper describes the development of such a syslem within a large tiniversily hospital, the forces l h a t led t o its development, and the mulliple expectations for its usefulness in planning and implementing social work services m o s t effectively, within the lowest cost. I t includes potential for building research projects and is utilized as a communication mechanism for recording. Collaboration within l h e profession is essential for implementing objective standards t o be utilized in reviewing delivery o f professional social work services.
"To move forward in the coming decade, social work must make substantial progress in at least three tasks: (1)to find better ways to account for what it does, (2) to determine the effectiveness of its programs, and ( 3 ) to develop more potent means of effecting change in social problems."' To do what Dr. William Reid suggests, and to do it responsibly, the profession must continue to develop and perfect information and accountability systems that collect, store, and analyze a wide range of information to answer questions of program effectiveness, costs, and operating systems. It is to the credit of the profession that social work is asking these questions of itself in planning for a future where nothing will be taken for granted. All services in the health care sector are coming under critical scrutiny in an attempt to provide the highest level of care at the lowest possible cost. Health care providers are being asked to define and account for their services through cost-effective processes. Both third-party payers, including Mrs. Volland is Director, Department o f Social W o r k , T h e Johns Hopkins Hospital, Baltimore, Maryland 21205, and Assistant Professor, School o f Health Services. Johns Hookins University. T h e author acknowledees t h e ; o f Maryland School assistance o f Dr. Evelyn d g r e n , ~ s s i s t a n t~ r o f e s s o rUniversity o f Social W o r k and C o m m u n i t y Planning. Dr. Ogren acted as consultant in t h e development o f t h e systems reported here. Social W o r k in Health Care, V o l . 1 ( 3 ) , Spring 1976
2 77
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government agencies, and consumers are focusing on the escalating cost of health care and understanding the quality of the care provided.2 Where social work is part of a health care delivery system, the profession is participating in this process. This paper describes the design and implementation of an information and accountability system within a university hospital. It reviews the purposes of the system and relates these t o the needs of the profession in general, and social worlr in health care in particular.
Downloaded by [University of Arizona] at 23:42 03 February 2015
ACCOUNTABILITY AND SOCIAL WORK INFORMATION SYSTEMS There are forces at local and federal levels that sharpen the need for definitions of quality and quantity of work by the profession. In the state of Maryland, the Maryland Health Services Cost Review Commission has been e~tablished.~ This commission has responsibility for investigating, reviewing, and establishing rates of reimbursement for hospital services. In establishing a rate review methodology, this commission has accepted the Revenue Center as a means for defining service. Each revenue center makes bills and establishes relative value units. Departments of social work are not considered revenue centers. Rather, social work services are charged off through the per diem established within the revenue center where the service is provided. A relative value unit has been established for each professional service; for social work this unit of measure is total number of cases. This unit of measure does not accurately define quality or quantity of services provided or their benefit to patients. In response t o this, directors of social work departments, through the Maryland Chapter of the American Society for Hospital Social Work Directors, have taken responsibility for defining and ranking types of social work ~ e r v i c e s . ~ One approach to relative value is time spent in delivering each service with level of professional skill necessary to provide these services. On the federal level, passage of Professional Standards Review Organization (PSRO) regulations mandates the requirement for both concurrent and retrospective re vie^.^ The objectives of this legislation suggest that reduction of health care costs is compatible with increased effectiveness of service. Establishment of criteria for a standard for services for each health care professional addresses the possibility of reduced cost and increased effectiveness. One approach for the establishment of such criteria for social worlr is through defining service categories with minimum criteria necessary to deliver these services e f f e ~ t i v e l y ,a~ process that is part of an information system. In addition t o addressing accountability, a good information system has potential as the basis for research and evaluation of services.
Patricia Volland
Downloaded by [University of Arizona] at 23:42 03 February 2015
Attempts within the profession of social work to research adequately the content and effectiveness of services have tended t o be anecdotal and limited to case examples at best.' Predictions for future studies suggest that future focus will be on effectiveness of certain techniques, established in advance, rather than total review of process retrospectively.' Emphasis is on defining and testing observable changes or "hard" data. One approach to developing these data is t o categorize psychosocial problems that are frequently utilized to define cause and effect relationship t o illness and health. These psychosocial problems, frequently used to define need for social work interventions in health care, could form the basis for a taxonomy of "hard" data. Changes in The Johns Hopkins Hospital focused on decentralized management and implementation of "Management By Objectives" concepts. The Department of Social Work experienced a change in leadership. This resulted in overall goals being sharpened, as the new leadership was charged with defining program objectives and establishing effectiveness criteria while understanding the costs to a given revenue center. A cost system was needed t o establish this clearly. These developments reflect the situation faced by many departments of social work. ESTABLISHMENT OF SYSTEM OBJECTIVES
.
Having considered all of these factors, what then should the objectives of an information and accountability system in a large university hospital setting be? This author determined that a mulitfaceted system with the following objectives would be functional for the Department of Social Work at The Johns Hopkins Hospital: 1.To establish and define social work services. 2. To communicate these services t o all other health care professionals. 3. To measure the outcome of these services. 4. To develop an information system that lays a basis for developing and executing research projects on health care problems pertinent to social work interventions. The first approach was a review of developments in other hospital social work departments. In Maryland, one such program with potential for adaptation was developed at the Sinai Hospital of B a l t i m ~ r e .The ~ same consultant to that program was employed by our department to review our needs and to assist in the design of a workable system. The system that has been developed at The Johns Hopkins Hospital reflects and has similarities to the design developed at the Sinai Hospital of Baltimore. The system at The Johns Hopkins Hospital has been developed within
Downloaded by [University of Arizona] at 23:42 03 February 2015
SOCIAL WORK IN HEALTH CARE
the framework of problem identification, goal-directed services provided to alleviate the defined problem, and measurement of service outcome. In setting such a framework, services are defined into categories; each category has a set of criteria that will be utilized in the peer review p r o ~ e s s . ~Further " definition of services results from collection of demographic information on each patient. For example, review of patients who receive discharge planning services clearly establishes patients at risk for this service. Patients needing social work services can be defined and enter the social work system more effectively. This also leads to implementation of concurrent review2 as has already been demonstrated at The Johns Hopkins Hospital where patients "at risk" are automatically referred to the Department of Social Work by the Quality Assurance Office. Effective implementation of concurrent review is accomplished, and outcome of such service delivery benefits the patient (effective discharge planning) and the hospital (improved utilization of beds). Objective definition of services leads to a better understanding of social work services. Further, by comparing time spent and level of professional expertise necessary to provide said service, a relative value for each service category will be established. Service categories will then become the unit of measure for defining the cost of social work service, thus providing a more accurate cost base and a more effective means of comparing social work departments within like hospitals. The potential of charging for social work services, based on actual services provided, should have greater appeal for third-party payers in considering separate reimbursement for social work. Collection of data, both qualitative and quantitative, can lead to demonstration of cost-effectiveness. Fur example, when the commission or hospital administration questions the high cost of social work services in an outpatient clinic where service to patients in groups is focused on reducing somatic complaints while dealing with psychosocial problems of depression and social isolation, this service can be demonstrated as being less costly than utilization of physician time with patients individually. The above discussion of objective data collection also has value in working with hospital administration. Psychosocial problems that interfere with or complicate health and medical care are defined for a particular patient population. Such systematic problem identification combined with defined service categories and measurement of outcome of such services defines for hospital administration the type of program being implemented and the contribution it makes to the hospital's objective to provide quality care. Effectiveness of program planning is demonstrated by, comparing services with outcomes such as length of stay in the hospital. The potential for reducing length of stay in the hospital through early entry into the social work system can be demonstrated while providing comprehensive service to
Downloaded by [University of Arizona] at 23:42 03 February 2015
Patricia Volland
the patient. Through preliminary review, the Department of Social Work has demonstrated already that time is lost in planning when the patient's refusal to cooperate is disregarded.' Further, both service definition and outcome measures are better understood through the reporting of obstacles t o service. Internal and external obstacles such as late referral or lack of resources are known. This information can be utilized to define ways of saving health costs. Communication through objective methodologies and utilizing the concept of problem-oriented record keeping enhances understanding of social work services while leading to clarification of role responsibilities for patient care. Problems and service intent are clearly stated to enhance team responsibilities for patient care. Finally, there is great potential for such a system to lay a basis for developing and executing research projects. Demographic patient information, problem taxonomy, service goals and outcomes, and obstacles to service delivery can be compared and studied separately in evaluative as well as descriptive research projects. DESCRIPTION OF THE SYSTEM The Recording and Reporting System itself contains a standardized problem list and four recording forms. The problem list has two levels: 1. Initial problems represent the point of entry into the social work system from the overall health care system. Classifications include: (a) difficulties with medical regime; (b) acceptance/adjustment to conditions; (c) inadequatelharmful care; (d) personal adjustment/behavior problem; (e) environmental difficulties; and (f) terminal illness. 2. Follow-up or resultant problems are defined following a social work assessment. The problems here may coexist with health-related problems, or they may be the cause or result of these health-related problems. Classifications include the following: (a) individual function related t o illness; (b) family conflicts; (c) living conditions; (d) interpersonal relationship difficulties; (e) economic conditions; (f) other specific conditions; and (g) individual psychiatric disorders-behavioral symptomatology, thought and feeling disorders, and lifelong maladaptive behavioral patterns. Each is further broken down into specific problem area to aid in focusing for social work services. Each problem is numbered for computerization.
Recording Forms Patient case record. This form is completed by the social worker at the time of referral for assessment. It contains demographic information regarding the patient and his family, a medical
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diagnosis, as well as a description of the referring agent and the referring problem. This form never appears in the Medical Record, as all information contained on it should already be there. One copy of this form goes to data processing; the social worker beeps the other for his own records. Service plan. Following initial assessment where the social worker decides to open a case, this form is completed and a copy is placed in the Medical Record within 48 hours. The Service Plan Form contains specific problems identified for social work services. Service goals are defined, and activities to be performed are described. These are coded for computer analysis. Service completion form. At the completion of a service episode this form is completed. A copy is placed in the Medical Record. Problems worked, service goals and activities, and outcome achieved for each are recorded descriptively and coded. Obstacles that may have interfered with the social work services are described and coded. The worker then has the option of closing the case or redefining problems and new services t o be provided. Service plan change. When, in the process of providing service, the worker dekrmines a need to redefine problems and/or services, the Service Plan Change Form is completed. A copy is placed in the Medical Record. This represents either a shift in problem focus or in goal focus. The Service Plan Change is similar to the Service Plan. It is primarily an indicator of the shift. With the decision t o computerize this system, it becomes possible to store information indefinitely and to expand the number of variables to be compared. In devising and implementing this system, it was determined that a system was needed that served both recording and reporting purposes. Each suggested design was analyzed for its potential usefulness in collecting the necessary information and then was tested on limited staff. Attention was focused on creating a problem list that contained mutually exclusive items. The current problem list is close to this goal. A sample system was devised and implemented on a trial basis in ~ ~ r iofl '1975 and was utilized through August of 1975. Feedback was gathered from each of the staff members with suggestions for improving the system. The formal system was implemented in September 1975. IMPLEMENTATION AND POTENTIAL VALUE No formal system of recording existed previously. Therefore, worker response to this system was very ambivalent: There was excitement in developing and participating in a new system; however, the ulitmate expectation that each worker would be required to
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Patricia Volland
utilize it created concern. Time considerations in learning to use and maintain such a system are still being discussed. Social workers tend to view this process of record keeping as unnecessary paperwork. Time spent away from direct contact with patients and/or family is frequently seen as time wasted. Administrative staff spent much time attempting to resolve such concerns. The value of this system in planning and implementing comprehensive treatment services was stressed as was the responsibility for maintenance of profession accountability within the hospital. Since the administration of The Johns Hopkins Hospital views any attempt at objective definition and planning of sewices within realistic cost as positive, necessary funds to develop and build this system were readily available. The Medical Records Department was reluctant to approve still another form for the Medical Record. However, this was a minor o,bstacle, and the focus on problem-oriented records further reduced resistance as Medical Records would like the hospital to adopt this format. Building a foundation for future research projects posed a minor problem in that it was necessary to develop a system that combined a mutually exclusive problem list and collected relevant patient demographic information. Outcome measures, while somewhat objective, will need continued review. The value of this system can be stated in terms of how it benefits and relates to: (a) outside regulatory agencies such as the Maryland Health Services Cost Review Commission; (b) hospital administration; (c) the director and supervisory personnel of the social work department; (d) the social work profession, particularly as it has impact on PSRO regulations and research potential; and ( e )patients and families. As previously stated, the Department of Social Work's relationship to the Maryland Health Services Cost Review Commission is in establishing sewice categories as the unit of measure and of costing social work services more effectively. Future budgets will be built on this cost system, not on total number of cases or total number of staff. At any given time the director of the Department of Social Work is prepared to say, by revenue center, exactly what social work services are provided, to what population, with what problems, at what cost (time and money), with what outcome. Management information, for the director and supervisory staff, is gathered and disseminated in a useful form. The social work administrator utilizes this information to understand and evaluate the quality of work of each staff member. Sewices can be understood both as they alleviate problems for patients and their families and as they alleviate problems within the institution. Comparison of services for a given problem will aid in understanding which services for which problem are
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most effective within the shortest time and the least cost t o the patient and the institution. The teaching of medical students and other health care professionals about patient and family psychosocial needs is more clearly focused. Subjective assessment of quality of work is reduced as is assessment of clinical social work skills. Activities can be reviewed regularly, and innumerable variable comparisons can be retrieved. When cost reduction programs are begun, the social work administrator is prepared to define what these potential reductions will mean. Conversely, when fiscal year budgets are submitted the administrator is prepared to demonstrate need and value (outcome) for additional services. Thus by defining costs for each service the administrator can compare this with the potential cost to the institution when a service is not provided. Future program planning becomes a process of defining services necessary within a given patient population. These objective data presented to the chief of a medical division allow him to establish a value for these services, plan for quality patient care, and analyze where dollars will be most effectively spent. For the social work professional the system's problem, service, and outcome criteria are readily adaptable for PSRO requirements. It represents a conceptual framework through which social workers in a health care setting can function effectively. This framework is not new. With the focus on objectifying problems and goal expectations it allows the social worker to anticipate service effectiveness and validate this by outcome measures. The social worker must contract with a patient and/or his family for specific service focused on clearly defined problems, which reinforces the social work principle of self-determination. Such a system tends, as well, to reduce jargon and to clarify role responsibilities for social work within the health care team. Services provided for the psychosocial needs of patients, from a variety of health care professionals, can be compared in terms of process as well as outcome effectiveness. The profession has labored diligently to establish a role as evaluator and treater of psychosocial factors that affect health and medical care. The medical profession has struggled to understand the effect of these factors on illness and health. Objectifying problems in a systematic taxonomy can establish a basis through which we view psychosocial factors as they affect or cause illness. A standardized problem list is a beginning step for building a system taxonomy as a scientific framework through which social work research can focus in the future on specific etiologies of medical problems. Collection of demographic information regarding population served establishes potential for reviewing and comparing populations within a given health care system. Comparisons between the population receiving social work service and the population that is not can prove
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Patricia Volland
invaluable for understanding the effectiveness and the future of social work programs in health care planning. Definitions of social work sewices with outcome measures established are the basis of evaluation.of effectiveness. The sekice categories are defined objectively, and standardized outcomes have been established. Evaluative research projects can be conducted easily, where population allows, emphasizing objective factors to be considered. This article has described the forces that moved a department of social work toward an experimental information and recording system and has emphasized the potential in such a system. This effort is being paralleled in many other departments of social work within health care settings. It is essential that those experiences be shared with the social' work community in health settings with the goal of a single system combining the most productive components of each system.
REFERENCES Reid. William. "Developments in the Use of Organized Data." Social Worh 5 (1974):585-93. Department of Hcallh, Education, and Welfare, PSRO Program Manual. Washington, D.C.: United States Government Printing Office, 1974. State o f Marvland. Health Services Cost Review Commission. "Position Paoer on Selected ~ r o h e m s ' a n dIssues." Ballimore, Maryland, May 1975. American Society for Hospital Social Work Directors, Maryland Chapter, Ad HOC Comrnittec o n Peer Review. Final Report in process. Documentation available in minutes of chapter mcetings from September 1 9 7 5 through present. Unpublished. Fischer, Joel. "Is Casework Effective: A Review." Social Worh 18 (1973):5-20. Fassett, Jacqueline D. Paper presenled a t the 1974 Annual Meeting o f the Society for Hospital Social Work Directors, Atlanta, Georgia. Unpublished. National Association of Social Workers. PSRO Basic Information for Social Workers A c t ~ o nGuide. Washington, D.C.: NASW, 1975. The Johns Hopkins Hospilal, Department of Social Work. "Nine Month Report from Continuity of Care Office." Baltimore, Maryland, September 1975. Unpublished.
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