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NASW Clinical Indicators for Social Work and Psychosocial Services in the Acute Psychiatric Hospital

Prepared and approved by the NASW Commission on Health and Mental Health, June 1990

Contents

Introduction

Monitoring the quality and appropriateness of psychosocial and social work services in acute psychiatric hospitals is an area of increasing concern to the health care field. Social workers and their supervisors desire specific measures of service delivery to monitor quality and to position the profession strategically as the mental 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 Workersí Commission on Health and Mental Health 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:

  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
  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

Clinical Indicators for Social Work and Psychosocial Services in the Acute Psychiatric 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. NASWís Commission on Health and Mental Health formally accepted the indicators in June 1990.

Scope of Practice for Social Work and Psychosocial Services

Mission

Social work services are provided to patients and their families to ensure that a patientís illness, recovery, and safe transition from one care setting to another are considered within the context of his or her biopsychosocial needs and the specific demands and opportunities of his or her environment. Social workers focus on psychosocial factors including family relationships; living arrangements; patientís developmental history; and economic, cultural, religious, educational, and vocational background as they impinge on the understanding, treatment, and relapse prevention of the psychiatric disorder. As members of interdisciplinary teams, social workers contribute to program development and treatment planning and review for all patients and collaborate in the development and maintenance of the therapeutic milieu.

Patients Served

Social work services are provided to all patients (and their families) ages 4 and older with all major psychiatric disorders, including schizophrenia, affective disorders, neuropsychiatric disorders, eating disorders, personality disorders, phobias, substance abuse, childhood disorders, and organic psychoses. Excluded from this patient population are those with severe mental retardation and acute health problems. Services are provided regardless of whether there is insurance coverage or whether the legal status of patients is categorized as voluntary, involuntary, or court referred.

Major Functions and Services Provided
  • Intake or admission evaluation (screening)
  • Psychosocial assessment and treatment planning and review
  • High social risk case finding
  • Patient and family education, support, and advocacy
  • Individual treatment, family therapy, group therapy, parental and marriage counseling
  • Information and referral
  • Crisis intervention
  • Consultation, liaison, and interdisciplinary collaboration
  • Expert testimony and mandated reporting of neglect and abuse
  • Discharge, transition, and aftercare planning
  • Postdischarge follow-up
  • Case management
  • Development, maintenance, and ongoing evaluation of community referral resources
Major Categories of Problems Addressed
  • Patient and family reactions and adjustments to illness and hospitalization
  • Vocational and educational problems
  • Legal problems
  • Financial problems
  • Family caregiving problems
  • Housing and living arrangement problems
  • Relationship problems
  • Problems related to physical, sexual, and emotional abuse
  • Problems related to substance abuse or other psychiatric or medical illness in family
Providers

The social work department comprises masterís degree graduates from accredited schools of social work and social work assistants who hold bachelorís degrees from accredited schools of social work. Social work staff at all levels are licensed and/or certified in accord with state licensing regulations.

Recommended Core Clinical Indicators for Social Work and Psychosocial Services in the Acute Psychiatric Hospital

Quality of Care Indicators (Process)
Indicator 1. Timely Psychosocial Screening. Patients with high-risk psychosocial circumstances are identified quickly.

Important aspect of care. High social risk case finding.

Rationale. Psychosocial information has bearing on the identification of immediate high-risk issues (for example, job loss, unattended children, treatment noncompliance, problematic discharge) and is needed for immediate intervention and expeditious and appropriate treatment planning. To be useful, such information should be identified and available in a timely manner.

Operational definition. The percentage of patients who received psychosocial screening within three days of admission.

Threshold. 95 percent.

Data elements. Number of patients with psychosocial screening in chart dated within three days of admission date divided by the total number of patients admitted.

Other influencing factors. Patient leaves before three days.

Indicator 2. Timely Psychosocial Assessment. Comprehensive patient evaluation occurs early in the hospitalization.

Important aspect of care. Assessment, evaluation, and treatment planning.

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

Operational definition. Percentage of reviewed psychosocial assessments dated within five days of the patientís admission.

Threshold. 95 percent.

Data elements. Number of reviewed charts that have comprehensive assessment dated within five days of admission divided by the total number of charts reviewed.

Other influencing factors. Patient leaves hospital before five days.

Indicator 3. Comprehensive Psychosocial Assessment. Patientsí psychosocial circumstances are assessed adequately.

Important aspect of care. Assessment, evaluation, and treatment planning.

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

Operational definition. The percentage of reviewed psychosocial assessments that meet the following criteria for comprehensiveness: address problems and strengths in social role functioning; identify environmental issues, including financial and other basic needs; consider problems and strengths in the family and other social support systems and cultural factors; spell out the implications of the first three criteria for posthospital planning; and specify the social work plan of intervention.

Threshold. 95 percent.

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

Other influencing factors. Patient leaves before five days.

Indicator 4. Timely Contact with Family and Significant Others. Patientsí families and significant others receive social work services early in the hospitalization.

Important aspect of care. Psychosocial interventions.

Rationale. The family and significant others are crucial to the accurate assessment and appropriate treatment of each patient. Early contact by the social worker ensures that the patient is considered in a biopsychosocial context and that patient and family have sufficient time to deal with the crisis of hospitalization and to plan for the transition and discharge.

Operational definition. The percentage of families or significant others who are seen at admission or are contacted within three days of the patientís admission.

Threshold. 95 percent.

Data elements. The number of patients whose families and significant others are contacted within three days of admission divided by the total number of patients admitted.

Other influencing factors. Patient refuses to allow contact; patient leaves before three days; family and significant others are unavailable.

Indicator 5. Teamwork. Patient care is informed by multidisciplinary expertise.

Important aspect of care. Assessment, evaluation, and treatment planning; discharge, transition, and aftercare planning.

Rationale. Multidisciplinary input and active collaboration in each patientís treatment and discharge planning ensures that all available information and expertise is 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 planning conferences attended by the social worker.

Threshold. 95 percent.

Data elements. The number of conferences attended by the social worker in a month divided by the total number of conferences held that month.

Other influencing factors. None.

Recommended Additional Indicators

These two outcome 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 Indicators (Outcome)
Indicator 1. Psychosocial Problem Resolution. Patientsí psychosocial problems related to the hospitalization and aftercare are ameliorated.

Important aspect of care. Psychosocial interventions.

Rationale. The intent of social work intervention is to help resolve patientsí psychosocial problems related to hospitalization and aftercare. Problem 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 that are compatible with a given hospitalís staffing ratio and average patient length of stay.

Other influencing factors. Case mix (social complexity).

Indicator 2. Continuity of Care. Patientsí planned aftercare occurs.

Important aspect of care. Discharge, transition, and aftercare planning.

Rationale. The patient and family making a connection to the next stage of care is viewed as important for subsequent adjustment and more likely if discharge planning has been adequate and appropriate.

Operational definition. The percentage of patients who, two weeks after discharge, have gained access to planned living arrangements and planned treatment follow-up.

Threshold. Needs empirical determination.

Data elements. Number of patients discharged in one month who connected with planned living arrangements and treatment follow-up (based on telephone follow-up call to patient or family) divided by the total number of discharged patients in that month who were reached for follow-up call.

Other influencing factors. Patient states nonagreement with discharge plans; AMA (against medical advice) discharge; staff noncompliance with discharge plan; case mix (social complexity).

Clinical Indicators Psychiatric Hospital Work Group

  • Philip Paulucci, MEd, ACSW, Columbus, Ohio
  • Doris T. Axelrod, ACSW, Belmont, Massachusetts
  • Barbara A. Graham, ACSW, San Diego, California
  • Ruth Corn, MSW, New York, New York
  • Phyllis Nash, EdD, Lexington, Kentucky
  • Phillip L. Rosenblum, ACSW, Washington, DC
  • Leslie Hargett, ACSW, Lansing, Michigan
  • 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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