Discharge Planning Advisor
Do patients suffer if social work role is diluted?
LOS impact may be more than hospitals realize
Leaders in discharge planning are concerned that a cost-cutting measure that began in the early 90s may be compromising patient care at some of the nation’s hospitals.
One of the effects of the health care re-engineering fever that began spreading across the country in the past decade, says Jackie Birmingham, RN, MS, CMAC, has been the downsizing — and in some cases disbanding — of social work departments. Birmingham is vice president of network integration for Integrated Health Networks in Newton, MA. "Some hospitals do not have social workers, in discharge planning or in social service. Nurses are taking on all the roles, and if a family is in crisis or needs grief counseling or needs to apply for some kind of social service outside the hospital, it is just not being done. I fear that in order to be cost-conscious and do discharge planning, hospitals are getting rid of social workers."
The Medicaid population is particularly at risk in such a scenario, Birmingham suggests, as are patients in managed Medicare plans. "A lot of payers are pulling out of managed Medicare, where there are case managers that work with patients. Will that change what discharge planners need to do for Medicare patients?"
If the social work function is eliminated, she says, discharge planners may need to spend more time with Medicaid and Medicare patients. With shorter hospital lengths of stay, patients often have greater social service needs, as well as greater medical needs, Birmingham points out.
The former can include helping families adapt to major trauma, assisting stroke patients who need to change their lifestyle, and grief counseling, among other services, she says. "Some hospitals believe any patient in the intensive care unit needs to have family social support. Pastoral counselors are picking up some of the slack, and they are trained in that, but some families need more in-depth work than a pastoral counselor can provide."
"There is no doubt that there is an overall trend toward downsizing the social work [function]," says Sandra Lowery, RN, BSN, CRRN, CCM, president of the Case Management Society of America in Little Rock, AR. "It is in different phases at different hospitals. Some have completely eliminated social workers and had nurses [take over patient management]. I think that’s a very small percentage.
"Most commonly," adds Lowery, who also is president of the consulting firm CCMI Associates, based in Francestown, NH, "the nurses who are transitioned into these roles are not getting the training they need to assume these responsibilities. It’s a different dynamic. Just educationally, some registered nurses have two years of preparation for their role, while almost all social workers in hospitals have master’s degrees or more."
Most hospitals have brought social services under the case management department, with the social workers often reporting to the director of case management, she notes. Lowery cites four social work models she has seen:
1. Social work is still autonomous and hasn’t changed from its traditional role.
The norm until three or four years ago, this scenario is "very rare" today, Lowery notes. In fact, a call to a facility she described as having one of the strongest social work directors and departments revealed that the director no longer worked there, and the position had been downgraded to "manager."
2. Social workers share case management roles and responsibilities with nurses.
In this model, she says, parallel positions are drawn along the lines of either geography or population. "For example, if I had a population that needed long-term care placement or facility placement, those patients might be designated for social workers. Those who are going home and might need assistance for home care are under the auspices of a nurse case manager."
3. The social worker is a resource to the case manager and others, but is not really carrying a caseload.
"This is another common one," Lowery says. "The social worker is a resource for working with difficult patients or family dynamics or with families who have more intensive psychosocial needs." In this model, the social worker does crisis intervention and counseling, she adds, "really following the traditional role of the social worker. The discharge planning for care needs has been transitioned to the case manager, and the social worker is providing supporting and consulting services. It’s a very much smaller role — that’s where we’re seeing the downsizing."
4. Social worker/nurse teams provide case management.
"I’m seeing an increase is this kind of co-management,’" she says, "and that’s where I’m seeing the only growth [in the social work role]. It could be an outcome of hospitals’ realizing their mistake [in downplaying the social work function] and bringing it back, but not in the traditional role." In this model, Lowery adds, these teams may manage behavioral health patients, for example, or they may work in the emergency department. Certainly geriatrics will be included, she notes.
Like an amoeba’
The recent downsizing of the social work function in hospitals "is one of those phenomena that has been like an amoeba," says Kim Fuller, ACSW, director of social work at Research Hospital in Kansas City, MO. "It takes different shapes in different places. Sometimes it is more prevalent, and at other times, the status quo of social work staffing is maintained."
While social workers historically have done most of the discharge planning in hospitals, that began to change in the mid to late 80s, with the advent of diagnosis-related groups (DRGs) and health maintenance organizations, adds Fuller, who is president of the Missouri-Kansas Chapter of the Society for Social Work Leadership in Health Care in Chicago.
"The model of having tighter clinical management of the patient came to the forefront. Is all the testing getting done? Is there duplication? A new dimension of patient management began to evolve and nursing began to be identified as the discipline that was able to track and manage some of those practice patterns," she explains.
Although Fuller says she agrees with the idea that nursing brings value to this level of patient management, her concern is that many hospitals are making decisions to reduce or eliminate services without a thorough analysis of the impact of those changes.
"Nursing and social work have tremendous contributions to make to patient care," she adds, "and it is possible to have a model that utilizes the strengths of both disciplines that is still cost efficient."
Kathleen Eaugh, RN, MN, an Atlanta-based manager in the health care consulting practice of Pricewaterhousecoopers, says her firm is sometimes called in to remedy the situation when hospitals fail to understand the implications of the changes they make in the care continuum.
Most hospitals with large social work departments have reduced them, and/or integrated them into the case management department, she says. "It is my opinion that through that evolution, some of the [social work function] has become diluted."
Although the concept of having someone at a higher level oversee the patient’s care is sound, the merging of jobs and multitasking that often take place under the case management heading are not always the best way to provide care, she notes. "It’s difficult to gain efficiency when you have someone doing all those functions.
"Maybe the discharge planning activity has now become the responsibility of the nurse at the bedside," she continues. "Given that the first priority at the bedside is to meet the physical needs of the patient and that the nurse may not have the knowledge base to access the necessary services, [discharge planning] is not done as effectively. The person is staying in the hospital longer than need be."
In some cases, she says, her firm’s recommendation has been that, instead of everyone being a generalist, there should be a group specializing in discharge planning. As for whether that means recommending the social work role be restored, she adds, the answer is "yes and no. Some of our recommendations have been for the hospital to do a better job of delineating functions, to say, Instead of having one case manager do 15 things, look at consolidating some of those functions.’
"Social work is a key component of taking care of patients, and the need for that hasn’t gone away," Eaugh says. "That is specialized knowledge. How we determine to package it has changed over time."
At Emerson Hospital in Concord, MA, the "packaging" of the social work function has changed a couple of times over the past five years. At that time, the hospital combined the formerly separate departments of social work, discharge planning, and utilization review into one social work/discharge planning department, says Mary Lou Cunningham, RN, MS, manager for the department of social work and care coordination for both the hospital and the Emerson Physician-Hospital Organization.
When she was hired three years ago, the mission was to create a case management department that also included the other functions. "We’re working on figuring out how it will look," Cunningham says.
"Case management is a nursing role, but we use our social work colleagues as consultants on difficult cases, such as a hospice case, or a difficult nursing home placement," she notes. "They are called in as needed."
The social work staff were downsized in the first reorganization, but there have been no cuts since her arrival, adds Cunningham, who now oversees 6.75 nurse case manager full-time equivalents (FTEs) and 2.75 social work FTEs. Social work is handled on the weekends with "beeper coverage," she says, and there may be a reduction in the hours the social worker is available by beeper.
Elderly patients often lack support of family
With today’s mobile society, where family support is often not available for elderly patients, the social work role is crucial, Cunningham says. "If there is no social worker available to deal with and sort out those situations, somebody has to do it. If it falls on nursing, then it takes nurses away from their responsibilities in delivering medical care.
"Nobody will be kicked out onto the parking lot because the family can’t figure out what to do," she points out, "so there could be a significant impact on a hospital’s average length of stay. These are not issues that are easily sorted out."
Despite the trend toward reducing or eliminating social work departments, Lowery points out, "there is a glimmer of hope" indicating the function will remain strong and viable, perhaps in a new form.
"I am seeing a resurgence in some hospitals that have recognized the value of social work, who have seen the light," she says. "They are starting to understand how to strike that balance, that they do need to have social workers." Some organizations, Lowery adds, are realizing that social workers have a real role to play in "prehospitalization" — assisting those who are high risk out in the community prior to their needing hospitalization.
"Other roles social workers are playing within the case management department are the development and management of support groups," she notes, "or working within community resource development. Social workers are also working as trainers for case managers who need to pick up their knowledge base in the area of community resources."
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