NASW
Clinical Indicators for Social Work and Psychosocial Services in
the Acute Care Medical Hospital
Prepared
and approved by the NASW Commission on Health and Mental Health
and the Society for Hospital Social Work Directors, June 1990
Contents
- Introduction
- Scope
of Practice for Social Work and Psychosocial Services
- Recommended
Core Clinical Indicators for Social Work and Psychosocial Services
in the Acute Care Medical Hospital
Appropriateness of Care Indicators
- Quality of
Care Indicators (Process)
- Quality of
Care Indicator (Outcome)
- Recommended
Additional Indicators
Quality of Care Indicator (Process)
- Quality of
Care Indicator (Outcome)
Monitoring the
quality and appropriateness of psychosocial and social work services
in acute care medical hospitals is an area of increasing concern
to the health care field. Social workers and their supervisors
desire specific measures of service delivery and patient care outcome
to monitor quality and to position the profession strategically
as the health care system evolves. Institutions and insurers call
for quality services to avoid expensive delays in discharge and
to prevent the need for readmissions. Accrediting organizations
seek consistency in data collection, analysis, and comparison across
institutions.
In response to
these concerns, the National Association of Social Workers’ Commission
on Health and Mental Health, in conjunction with the Society of
Hospital Social Work Directors of the American Hospital Association,
has established clinical indicators to be used in the systematic
monitoring of the quality and appropriateness of patient care.
Indicator development is an ongoing process that encompasses testing,
improvement, and innovation. These indicators serve as broad guidelines
to allow for the varied needs of diverse institutions while encouraging
more uniformity in social work quality assurance.
Clinical indicators
are not intended as direct measures of the quality of clinical
performance. They are best thought of as "flags" that, at a predetermined
threshold, "go up" and signal the need for problem analysis or
peer review.
The following information
is provided for each indicator:
- Rationale: an
explanation of the logical connection between the "flag," social
work functions, and an important dimension of quality
- Operational
definition: a definition of the indicator that allows for reliable
measurement across practice settings
- Threshold: the
predetermined point at which the "flaggoes up," precipitating
closer scrutiny and evaluation
- Data elements:
the specific information needed to measure the indicator
- Other influencing
factors: factors beyond the control of the individual practitioner
that influence the provision of care
Clinical Indicators
for Social Work and Psychosocial Services in the Acute Care Medical
Hospital were developed by a panel of recognized expert practitioners
from a variety of related settings and facilities and reviewed
by practitioners in the field. NASW’s Commission on Health and
Mental Health and the Board of Directors of the Society of Hospital
Social Work Directors formally accepted the indicators in June
1990.
Mission
Social work services
are provided to patients and their families to meet their medically
related social and emotional needs as they impinge on their medical
condition, treatment, recovery, and safe transition from one care
environment to another.
Patients Served
Depending on individual
circumstances and need, social work services are available to all
patients and their families. Groups at high psychosocial risk include
frail elderly patients, chronically ill people, children and adults
with handicapping conditions, victims of maltreatment, and critically
ill patients. Social workers serve patients who are insured, uninsured,
and underinsured.
Major Functions
and Services Provided
- Psychosocial
assessment
- High social
risk case finding and screening
- Information
and referral Preadmission planning
- Discharge planning
Psychosocial counseling
- Financial counseling
- Health education
- Postdischarge
follow-up
- Consultation
- Outpatient continuity
of care
- Patient and
family conferences
- Case management
- Self-help and
emotional support groups for patients and families
- Patient and
family advocacy
Major Categories
of Problems Addressed
- Problems related
to care and activities of daily living
- Environmental
problems
- Patient and
family adverse reactions or dysfunctional adjustment to illness
and changes in functional status
- Problems related
to physical, sexual, and emotional maltreatment
- Relationship
problems
- Problems of
behavior and cognition and mental disorders, including substance
abuse
- Vocational and
educational problems
- Legal problems
Providers
Social work services
are performed by qualified social workers and others under the
supervision or direction of the social work department.
Recommended
Core Clinical Indicators for Social Work and Psychosocial Services
in the Acute Care Medical Hospital
Appropriateness
of Care Indicators
Indicator
1. Case Finding and Access. Patients needing social work
services receive them.
Important aspect
of care. Case finding.
Rationale. Patients
who need social work intervention must receive it for overall care
to be considered appropriate. The percentage of inpatients needing
social work in a hospital should remain similar over time unless
there is a change in case mix, scope of services, or the surrounding
environment. Thus, major shifts in the percentage of discharges
receiving social work services may be a sign that the case finding
mechanisms are not proper and that care may not be appropriate.
Operational
definition. Rate of social work discharges to total discharges.
Threshold. Needs
empirical determination.
Data elements. The
number of cases discharged from the hospital by social work in
one month divided by the total number of cases discharged by the
hospital in that month.
Other influencing
factors. Scope of service, case mix (social complexity),
hospital type.
Indicator
2. Discharge Delays. Patients remain in the hospital even
when it is no longer medically necessary.
Important aspect
of care. Discharge planning.
Rationale. One
aspect of appropriateness is that the amount of care received is
not excessive. Excessive care results when discharge is delayed
and patients remain at higher levels of care than are medically
necessary.
Operational
definition. The percentage of patients designated as below
acute level of care by utilization review (UR).
Threshold. Needs
empirical determination.
Data elements. Number
of patients staying beyond UR acute level of care divided by the
number of discharges in one month.
Other influencing
factors. Patient recertified.
Quality of Care
Indicators (Process)
Indicator
3. Patient and Family Involvement in Planning. Patients and
families are involved in discharge planning.
Important aspect
of care. Discharge planning.
Rationale. The
standard of practice is that social workers must involve patients
and their families in making their own decisions about posthospital
care. Involvement must include, at a minimum, discussion of patient
and family preferences.
Operational
definition. Patient and family preferences are recorded in
the social work discharge plan.
Threshold. 95
percent.
Data elements. The
number of cases with patient and family preferences recorded in
social work discharge plan divided by the number of social work
discharges with social work discharge plan.
Other influencing
factors. Incompetent patient, no family members available.
Indicator
4. Timeliness. Patients receive social work services early
in the hospitalization.
Important aspect
of care. All.
Rationale. Patients
and families need sufficient time to make decisions and adapt to
illness, and shortened lengths of hospital stay limit the availability
of time. Therefore, the standard of practice is that most patients
in need of social work services must receive their initial service
early in their hospital stay.
Operational
definition. The percentage of patients receiving their first
social work service in the first quartile of their length of
stay (in most cases, in the first 48 hours).
Threshold. Needs
empirical determination.
Data elements. Date
of admission, date of discharge, date of first social work contact
after admission.
Other influencing
factors. Patient stay is less than three days.
Indicator
5. Teamwork. Patient discharge occurs with the knowledge
of the social worker coordinating discharge planning.
Important aspect
of care. Coordination of discharge planning.
Rationale. Social
workers are responsible for coordination of patients’ discharge
plans, especially when posthospital care is required. When discharge
of a patient receiving social work services occurs without the
social worker’s knowledge, this may indicate poor quality of the
coordination process.
Operational
definition. Social work patients discharged without social
worker’s knowledge.
Threshold. 0
percent.
Data elements. Number
of social work patients discharged without social worker’s knowledge
divided by the number of social work discharges.
Other influencing
factors. Service is information and referral only, consultation
only, or psychosocial assessment only.
Quality of Care
Indicator (Outcome)
Indicator
6. Readmissions with Social Complications. Patients are readmitted
with social complications.
Important aspect
of care. All.
Rationale. Social
workers are responsible for ensuring that patients receive the
immediate posthospital care they need and adapt to the posthospital
setting. Readmission of too many patients due to social complications
suggests either that they did not receive social work services
or that these services were inadequate.
Operational
definition. Percentage of discharges readmitted within 15
days with social complications or problems with posthospital
care.
Threshold. Needs
empirical determination.
Data elements. Number
of patients readmitted with social complications divided by the
number of hospital discharges.
Other influencing
factors. Complications occurring after the primary discharge,
case mix.
Recommended
Additional Indicators
These indicators
are highly desirable for use and provide direction for future quality
assurance efforts. It is recognized that barriers in some hospitals
may preclude their immediate implementation.
Quality of Care
Indicator (Process)
Indicator
1. Follow-up. Patient discharge care is assessed following
discharge.
Important aspect
of care. Discharge planning and follow-up.
Rationale. Patients
who are at high risk for developing problems with postdischarge
care should receive a follow-up assessment after discharge to determine
whether the aftercare plan is being implemented as planned.
Operational
definition. Percentage of discharged patients who received
social work discharge planning who receive postdischarge follow-up
within seven days.
Threshold. 95
percent.
Data elements. Number
of discharged patients receiving social work postdischarge follow-up
within seven days divided by the number of discharged patients
receiving social work discharge planning.
Other influencing
factors. Patient dies, case mix (social complexity).
Quality of Care
Indicator (Outcome)
Indicator
2. Problem Resolution. Patients’ medically related psychosocial
problems are ameliorated.
Important aspect
of care. All.
Rationale. The
intent of social work intervention is to improve or resolve patients’ psychosocial
problems related to their medical care. Problem improvement or
resolution is an indicator of whether the intervention has achieved
its goal.
Operational
definition. Percentage of planned results not achieved specific
to each problem.
Threshold. Needs
empirical determination.
Data elements. Number
of social work patients discharged from hospital in one month having
problem X with "not resolved" as outcome divided by the number
of social work patients discharged from hospital in that month
having problem X. This indicator requires a well-defined problem
list and reliable categories for problem resolution.
Other influencing
factors. Patient dies, case mix (social complexity).
Clinical
Indicators Medical Hospital Work Group
- Barbara Berkman,
DSW, Boston, Massachusetts
- Claudia Coulton,
PhD, ACSW, Cleveland, Ohio
- Susan Haikalis,
MSW, San Francisco, California
- Karen Kaplan,
PhD, ACSW, Silver Spring, Maryland
- Shirley M. Keller,
ACSWI LISW, Akron, Ohio
- Helen Rehr,
DSW, New York, New York
- Peggy A. Weil,
ACSW, MPA, Silver Spring, Maryland
- Betsy Vourlekis,
PhD, Catonsville, Maryland
NASW
Commission on Health and Mental Health
- Allyson Ashley,
ACSW, Springfield, Missouri
- Marvin A. Johnson,
MSW, Palatine, Illinois
- Gracie Mebane
Vines, MSSW, ACSW, Greenville, North Carolina
- Terry Mizrahi,
PhD, New York, New York
- James M. Karls,
DSW, ACSW, Sausalito, California
- Juan Ramos,
MSW, ACSW, Rockville, Maryland
- Della Wills,
MSW, ACSW, QCSW, Homer, Louisiana
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