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NASW/NKF Clinical Indicators for Social Work and Psychosocial Service in Nephrology Settings

Prepared and approved by the National Association of Social Workers and the Council of Nephrology Social Workers of the National Kidney Foundation, October 1994

Contents

Introduction

Monitoring and improving the quality and appropriateness of psychosocial and social work services for patients with end-stage renal disease is an area of increasing concern for practitioners in both dialysis and transplant settings. Social workers and their supervisors desire specific measures of service delivery and patient care outcomes to monitor quality and to position the profession strategically as the health care system evolves. Institutions and insurers call for quality services to enhance treatment, avoid expensive delays in discharge, and prevent unnecessary hospital admissions. Accrediting organizations seek consistency in data collection, analysis, and comparison across institutions.

In response to these concerns, the National Association of Social Workers, in conjunction with the Council of Nephrology Social Workers of the National Kidney Foundation, has established model clinical indicators to be used in the systematic monitoring of quality and appropriateness of patient care and in quality improvement activities. The application of clinical indicators is part of an ongoing process of quality assurance and improvement, encompassing testing, improvement, and innovation. These model 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. Without active follow-up, the gathering of data related to indicators is a meaningless exercise.

The following information is provided for each indicator:

  1. Rationale: an explanation of the logical connection between the "flag," social work functions, and an important dimension of quality.
  2. Operational definition: a definition of the indicator that allows for reliable measurement across practice settings.
  3. Threshold: the predetermined point at which the "flag goes up," precipitating closer scrutiny and evaluation. Although it can be argued that all thresholds are ideally 100 percent, this leaves little room for improvement and often results in the overweighting of "clutter" data.
  4. Data elements: the specific information needed to measure the indicator.
  5. Other influencing factors: factors beyond the control of the individual practitioner that influence the provision of care.

Within this group of indicators, both process and outcome measures are included. Process indicators assess whether factors such as the appropriate timelines and baseline professional practices have been met. Outcome indicators assess whether the stated goals of intervention have been achieved. As individual facilities select the measures they will use at any given point, it is important that a balance of measuring both process and outcome is achieved. Measurement of either factor alone will not provide a clear image of program quality.

Some of the indicators have been developed so that they are applicable across both inpatient and outpatient settings and include both dialysis and transplant patients, such as the indicators for timely initial contact and comprehensive psychosocial assessment. Other indicators, such as timely psychosocial assessment for dialysis patients, are written with a focus on a specific setting or population group. In general, these indicators can easily be modified for other populations or settings, provided that care is taken to keep the indicator narrowly focused and thus meaningful. By using at least some of the model indicators as written, facilities will position themselves to compare their data with those of similar facilities.

The Clinical Indicators for Social Work and Psychosocial Services in Nephrology Settings were developed by a panel of recognized expert practitioners from a variety of related settings and facilities and reviewed by practitioners in the field. The NASW work group and the Board of Directors of the Council of Nephrology Social Workers formally accepted the indicators in October 1994.

Scope of Practice for Social Work and Psychosocial Services in Nephrology Settings

Mission

Nephrology social work services support and maximize the psychosocial functioning and adjustment of patients who are experiencing end-stage renal disease (ESRD) and their families. These services are provided to ameliorate social and emotional stresses resulting from the interacting physical, social, and psychological concomitants of ESRD, including shortened life expectancy; altered lifestyle with changes in social, financial, vocational, and sexual functioning; and the demands of a rigorous, time-consuming, and complex treatment regimen. Social work functions as a part of the multidisciplinary team and is responsible for fostering a positive treatment environment policy and routines that are attuned to cultural, religious, and ethnic differences among patients and families and show respect for the individuality, independence, and choice of each patient.

Patients Served

Social work services are available to all patients and their families on diagnosis of ESRD and as they undergo dialysis or the transplantation process. Social work services are also available to live organ donors. Social workers serve ESRD patients of any age, race, sex, religion, ethnicity, and sexual orientation without regard to financial or socioeconomic status. Patients with greater need for social work intervention are those who lack an adequate social support system, are unable to gain access to community services, are over 60 or under 18, and have multiple medical problems or a recent hospitalization for acute illness.

Major Functions and Services Provided
  • Psychosocial evaluation (assessment for treatment plan)
  • Casework (counseling and conferences with patients, families, and support networks; crisis intervention; goal-directed counseling; discharge planning)
  • Groupwork (education, emotional support, self-help)
  • Information and referral
  • Facilitation of community agency referrals
  • Team care planning and collaboration
  • Advocacy on patientsí behalf within the setting and with appropriate local, state, and federal agencies and programs and programming
  • Patient and family education
Major Categories of Problems Addressed
  • Adjustment to chronic illness and treatment as they relate to quality of life
  • Physical, sexual, and emotional relationship problems
  • Educational, vocational, and activity of daily living problems
  • Crisis and chronic problem solving
  • Problems related to treatment options and setting transfers
  • Resource needs, including finances, living arrangements, transportation, and legal issues
  • Decision making regarding advance directives
Providers

A qualified social worker, as defined by the federal regulations governing ESRD facilities, must have a state license, if applicable, and must have completed a course of study with specialization in clinical practice leading to a masterís degree from an accredited graduate school of social work, unless hired one year before the effective date of the regulations (9/l/76). Those hired before 1976 must have had two years of social work experience, one year of which was in an ESRD setting, and must have a consultative relationship with a masterís -prepared social worker.

Recommended Core Clinical Indicators for Social Work and Psychosocial Services in Nephrology Settings

Indicator 1. Timely Initial Contact.

Important aspect of care. Psychosocial intervention.

Rationale. Initiation of ESRD treatment (dialysis or transplant) precipitates social and emotional stress for the patient. Early social work contact ensures immediate provision of psychosocial support and the opportunity to identify patients with high-risk psychosocial circumstances.

Operational definition. The percentage of patients seen within 48 hours of inpatient admission or within seven days of initiation of outpatient treatment.

Threshold. 90 percent.

Data elements. The number of patients with documentation of initial contact within the guideline divided by the number of patients initiating treatment for ESRD during the survey period.

Other influencing factors. Patient is transferred or dies within guideline period.

Indicator 2. Timely Psychosocial Assessment for Dialysis or Peritoneal Dialysis Patients.

Important aspect of care. Psychosocial intervention.

Rationale. Information and conclusions of a comprehensive psychosocial assessment must be available on a timely basis to guide ongoing treatment planning.

Operational definition. The percentage of reviewed charts containing psychosocial assessments dated within 30 days of initiating chronic outpatient treatment in a facility.

Threshold. 95 percent.

Data elements. The number of reviewed charts that have comprehensive psychosocial assessments dated within 30 days of initiating treatment in a facility divided by the total number of charts reviewed.

Other influencing factors. Patient dies or transfers facilities. Patient is frequently hospitalized during initial 30-day period.

Indicator 3. Comprehensive Psychosocial Assessment.

Important aspect of care. Assessment, evaluation, treatment planning, and collaborative input and awareness.

Rationale. To guide planning and decision making adequately, the comprehensive psychosocial assessment addresses both problems and strengths of the patient and his or her situation and spells out the implications of this information for treatment planning and delivery of care.

Operational definition. The percentage of reviewed psychosocial assessments that address the problems and strengths of the client, including physical, environmental, behavioral, emotional, economic, and social factors, and their implications for treatment. Areas to be evaluated by the social worker include mental health status; preexisting health or mental health problems; the clientís needs and the resources of the clientís informal support system; social role functioning; environmental issues, including economic situation, employment status, and other basic needs; substance abuse history; and relevant cultural and religious factors including sexual orientation. An intervention plan based on the findings of the assessment and mutually agreed on goals should be included as part of the assessment.

Threshold. 95 percent.

Data elements. The number of reviewed charts that meet the criteria for comprehensiveness divided by the total number of charts reviewed, on a sample basis if necessary.

Other influencing factors. Patient leaves treatment before completion of period for timely assessment.

Indicator 4. Teamwork and Interdisciplinary Collaboration. Psychosocial input is a component of informed multidisciplinary patient care.

Important aspect of care. Assessment, evaluation, treatment planning, and collaborative input and awareness.

Rationale. Multidisciplinary input and active collaboration in each patientís treatment and discharge planning ensures that all available information and expertise are considered as decisions are made. If the social worker does not attend the multidisciplinary planning conference, the opportunity for input and collaboration is seriously diminished.

Operational definition. The percentage of multidisciplinary patient care planning meetings attended by the social worker in a given month.

Threshold. 95 percent.

Data elements. The number of team meetings held divided by the number of times a social worker is present as documented in the team meeting notes for the survey period.

Other influencing factors. None.

Indicator 5. Psychosocial Problem Resolution. Patientsí psychosocial problems related to ESRD and treatment are ameliorated.

Important aspect of care. Psychosocial intervention.

Rationale. The intent of social work intervention is to improve or resolve the patientís psychosocial problems related to his or her medical condition and treatment. Problem improvement or resolution is an indicator of whether the intervention has achieved its goal.

Operational definition. The percentage of problems ameliorated within 90 days of problem identification.

Threshold. To be determined based on problem being tracked.

Data elements. The number of patients experiencing problem X with ameliorated as the outcome divided by the number of social work patients experiencing problem X as identified within a 30-day period.

Other influencing factors. Problem is identified within seven days of end of review period.

Indicator 6. Primary Caregiver Satisfaction.

Important aspect of care. Psychosocial counseling (individual, group, and family).

Rationale. Primary caregivers of ESRD patients struggle with profound lifestyle changes and challenges to growth and development. Information, education, and help in coping with the implications and consequences of these challenges are important to the long-term success of treatment.

Operational definition. The percentage of caregivers indicating satisfaction with supportive services.

Threshold. To be determined based on the sensitivity of the social work assessment tool.

Data elements. The number of caregivers indicating satisfaction divided by the number of caregivers surveyed.

Other influencing factors. None.

Indicator 7. Pretransplant Counseling for ESRD Patients. Potential transplant recipients should be referred for social work services before transplant.

Important aspect of care. Psychosocial counseling.

Rationale. Transplant recipients need information regarding the social and emotional ramifications of transplant to participate in informed decision making.

Operational definition. The percentage of patients who have received pretransplant counseling.

Threshold. 95 percent.

Data elements. The number of charts of patients with transplant completed containing documentation of pretransplant counseling by a social worker divided by the number of transplants.

Other influencing factors. None.

Indicator 8. Pretransplant Counseling for Live Organ Donors. Potential transplant donors should be referred for social work services before transplant.

Important aspect of care. Psychosocial counseling.

Rationale. Donors need information regarding, and the opportunity to discuss and resolve, issues related to the social and emotional ramifications of organ donation to participate in informed decision making.

Operational definition. The percentage of live organ donors who have received pretransplant counseling.

Threshold. 95 percent.

Data elements. The number of charts for live organ donors containing documentation of pretransplant counseling by a social worker divided by the number of live organ transplants.

Other influencing factors. None.

Clinical Indicators for Nephrology Settings Work Group

  • Chair: Rosa Rivera-Mizzoni, LCSW, Chicago, Illinois
  • Beth Witten, LSCSW, Lenexa, Kansas
  • Karen Cornell, CISW, Torrington, Connecticut
  • Cheryl Jacobs, ACSW, Minneapolis, Minnesota
  • Mary Beth Callahan, CSW, Carrollton, Texas
  • Project Consultant: Betsy Vourlekis, PhD, ACSW, Washington, DC
  • NASW Staff: James P. Brennan, MSW, Washington, DC
 
 
 
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