At the 53rd annual meeting and conference of the
Society for Social Work Leadership in Health Care (SSWLHC) in age-friendly Portland, more than half of the over 300 attendees were
new members, including yours truly. The four-day conference theme, Transforming Health Care Through Social Work
Leadership and Advocacy, covered the entire lifespan with emphasis on mental/behavioral
health and later life.
Older adults who are hospitalized often risk functional decline and more disabilities due to hospital routines such as bedrest (wastes
muscles, causes blood and other fluids to redistribute in ways that can cause
dizziness and balance problems, leads to pressure sores), sleep disruption
(contributes to delirium), sleeping pills (potential for polypharmacy and
falls), bladder catheter (risks infection and incontinence), etc. As part of the Affordable Care Act, Medicare’s
Independence at Home Medical Practice Demonstration Program is testing an innovative home-based primary care model targeting Medicare beneficiaries with multiple
chronic conditions and a substantial burden of functional limitations. In addition, Medicare’s Hospital Readmissions Reduction Program (HRRP) attempts to link payments to quality of
hospital care by penalizing acute-care hospitals with relatively high 30-day
readmission rates for targeted conditions.
However, social factors—such as poverty, living alone and
older age—may have a greater role in hospital readmissions than hospital quality
of care. Therefore, medical social workers/patient
advocates can address social determinants of health (SDOH) in care coordination/discharge planning with linkages to community resources (social, financial, nutritional,
logistical support). This social model
considers the person-in-environment context to promote holistic health (“complete
physical, mental and social well-being, and not merely the absence of disease
or infirmity” per World Health Organization)
and health equity, while the dominant medical model emphasizes diagnosis and
treatment of disease.
For example, I work with one resident who was admitted over
a year ago to a skilled nursing facility (SNF) following a cerebral infarction
(stroke). Under the medical model,
resident was diagnosed with dysthymia (persistent depressive disorder) and
treated with psychotropics and electroconvulsive therapy (ECT). In addition to adjusting to functional losses
on the right side of her body and life in a SNF, the resident has been grieving
over separation from her BFF (Best Friends Forever) dog. The social model
includes periodic dog visits by volunteers from SPCA Animal Assisted Therapy (AAT)
program in resident’s care plan. However, resident longs for more routine interaction
with a dog rather than pining for monthly dog visits, so I have been exploring
ways to make this happen (though I am allergic to most furry animals). After all, human-animal bonding interactions produce oxytocin,
endorphins and serotonin—all hormones that reduce stress and elevate moods, and may even improve motivation to participate in treatment protocols like physical
therapy. Mental health counselors incorporate AAT into traditional therapies to promote comfort and sense of safety, as well as
normalize life and add to quality of life. In long-term care environments, Dr. Bill
Thomas made the presence of house pets one feature of his Eden Alternative movement to de-institutionalize sterile nursing home culture.
The SSWHLC conference did not specifically address AAT, but
offered other practice ideas for the role of geriatric social workers within an
interdisciplinary health care team in addressing SDOH (home and community resources), integrating
behavioral health, discussing end-of-life (including medical aid-in-dying), understanding
“medical” conditions (pain, post-intensive care syndrome) relating to
behavioral changes for care coordination/discharge planning, etc. With mid-term elections just a month away,
there was no mention of politics at this conference as the focus was primarily clinical
social work (“micro”) than advocating for systemic/policy changes (“macro”). Conference presenters were mostly social
workers or health practitioners, instead of academic researchers, so gained
practical information for everyday practice.
As a newbie, I attended Orientation to learn the history of SSWLHC, which began in 1965
(Medicare and Medicaid passage!) for Hospital Social Work Directors and
expanded in 1997 to its current name to include all levels of social workers
who are leaders. In 1986, Medicare
Conditions of Participation required that hospitals provide social work
services and ongoing discharge planning program. Members took the stage to share testimonials
about membership benefits like networking and continuing education.
Hands on Greater Portland set-up station for DIY! Love
Letters for Meals On Wheels and Lift Urban Portland that deliver food to
homebound seniors and low-income residents – offering conference participants a
nice break from power point presentations to create personalized greeting cards
to cheer up food recipients!
Immediately after Orientation, enjoyed Reception which
featured build-your-own ramen bowl.
Kermit B. Nash Lecture, Keeping
Client at the Center: How Social Determinants of Health Have Driven One
Organization’s Growth & Innovation, presented by Associate Medical
Director Eowyn Rieke and Chief Housing and Strategy Officer Sean Hubert of
Portland-based Central City Concern (CCC). Since 1979, CCC has provided comprehensive solutions to ending homelessness by
integrating affordable housing (now 1,800 units), health care (including
primary care, substance use disorder treatment and behavioral health services),
and employment.
Not surprising, housing is the greatest of social needs:
·
National research shows a connection
between rent increases and homelessness: $100 increase in rent is associated
with a 6% to 32% increase in homelessness
This Recuperative Care Program (RCP) is an intervention addressing SDOH with the basics after hospital discharge: low-barrier short-term housing and intensive
case management for homeless people with a severe medical condition that could
benefit from stabilization. In 2016, CCC
launched its Housing is Health project: six health organizations providing
funding for a new clinic and 379 new units of housing, which are scheduled to
be completed by July 2019.
Oregon’s Death with Dignity Law: Twenty-One
Years and Lessons Learned keynote presented by Susan Hedlund,
Manager of Patient and Family Support Services at Oregon Health & Sciences
University (OHSU), which developed POLST. Oregon made history by passing its controversial law (which didn’t take effect
until 1997 when repeal referendum defeated) allowing terminally ill Oregonians
to obtain medication to end their lives.
To date, six other states (Washington and Montana 2009,
Vermont 2015,
Colorado 2016,
California 2016 but pending appeal, Hawaii 2018)
and the District of Columbia (2015)
allow medical aid-in-dying (MAID).
Lawmakers and health care professionals often look to Oregon
to guide the process of MAID implementation.
Yet the Pacific Northwest is unique, with its pioneer spirit, rugged
individualism, very white population, least “Churched” state in the nation, and
end-of-life practices (88.6% die at home, 88.7% enrolled in hospice, 99.2% had
some form of health insurance; first state to combine Advance Directive and
Healthcare Power of Attorney in 1980; Right to Hospice and Comfort Care in
1989; Right to Pain Relief in 1993; and Right to Refuse/Withdraw Treatment in
1993).
17% of Oregonians potentially interested in Death With
Dignity Act (DWDA), only 1-2% actually request it—mostly for reasons related to
maintain independence, self-care and quality of life. Significantly depressed patients seem to lack
wherewithal to follow through process. Some
practice take-aways:
·
If patient inquires about, or indicates
desire to pursue, Oregon’s DWDA, then this offers the opportunity to explore
more deeply: reasons for request, meaning behind it, other issues that need to
be addressed (symptom management), existential concerns, etc.
·
Desire to die in terminally ill people
may be expressions of depression, suicidal intent, or coping
·
Person’s desire to die talk as coping:
used to promote feelings of control, invite discussion of existential concerns,
elicit help, express “readiness”
·
Professional must be aware of own
reactions to desire to die statements because these will influence
conversations: if unable to support MAID, important to refer (last year, family of deceased cancer patient Judy Dale filed lawsuit against UCSF for its alleged "backtracking" in obtaining medication to help her die under California's End of Life Option Act);
find meaning in patient’s words and continue to assess concerns, mental health
and intent; “sit with suffering,” bear witness to questions and concerns, and
tolerate not being able to fix everything
Transforming Mental Health Care in
Emergency Room, presented by Amal Elanouari and Ashley
Hartoch, discussed Stanford Hospital Emergency Department (ED)’s 2015 introduction
of a new model of collaborative case management and integrative care by
replacing its nurse case manager/social worker team with a mental health
complex care manager (MH-CCM), a LCSW with expertise in mental health to
provide comprehensive crisis intervention services to those with psychiatric
illnesses. This MH-CCM model addresses
the growing challenge of treating patients with mental health conditions who
visit hospital ED, and has facilitated improved patient flow to inpatient
psychiatric units or community placements, reduced patient lengths of stay in
the ED, and greater satisfaction for patients and family member.
Comic relief: Groovy Guy in tie-dye shirt welcomed us Beautiful People to
the Commune of Portland, inviting us to free food and join love-in at Mellow
Marriott, so don’t be a Conscientious Objector, buy tickets before they sell
out to Funky Foundation fundraiser event with lava lamps, brownie recipes and lifetime
membership to Sierra Club. Go with the
flow!
Networking and roundtable topics lunch: nothing geriatric so joined
mental health table.
Carby lunch of pasta and veggies
AARP table offered age-friendly publications
Community Care Management: Keeping our
Patients Safe at Home, presented by June Simmons, President/CEO/Founder
of Partners in Care Foundation. She also appeared
on The Journal of America’s Physician Groups (APG) cover story, “Letting
Doctors Focus on Medicine,” discussing APG’s partnership with her organization’s
network that provides SDOH services. Thanks
to the Creating High-Quality Results and Outcomes
Necessary to Improve Chronic (CHRONIC) Care/Advancing Chronic Care, Extenders,
and Social Services (ACCESS) Act of 2018, Centers for Medicare and
Medicaid Services (CMS) allow Medicare Advantage plans to provide SDOH
services, such as home modifications/renovations, transportation, nutrition,
care management, and evidence-based health promotion and disease prevention
programs.
June reminded us that health happens at home, so Community
Integrated Health Care System 3.0 seeks integration of medical care and home/community-based
social services to address SDOH. Community-based organizations (CBOs) are the
“eyes and ears” in the home:
· gathering
data and information typically not shared in a medical setting (comprehensive
psychosocial and functional assessment, home safety and fall risk evaluation,
link medication issues with evidence-based pharmacist intervention, advance
directives)
·
service coordination and connection to
benefits/discounts
·
attention to caregivers:
education/training, support, respite
·
evidence-based health self-management
and fall prevention workshops to empower consumers
Engaging Social Work in Social
Determinants of Health Screening Initiative, presented by
Meredith Brink of Nationwide Children's Hospital in Columbus. Because SDOH influence
about 80% (40% socioeconomic factors + 30% health behaviors + 10% physical
environment) of health outcomes, social work leadership at Nationwide Children’s
Hospital rolled out a universal SDOH screen to all ambulatory and inpatients
once a year to identify needs, compile and analyze data, and offer resources in
one-page handout. Four questions asked:
1. Food:
Within the past 6 months, you worried that your food would run out before you
had money to buy more? If urgent, do you
need help getting food now? Do you need emergency food today?
2. Housing:
Do you think you are at risk of becoming homeless? If urgent, are you currently homeless?
3. Transportation:
In the past 12 months, has lack of transportation kept you from medical
appointments or from getting medications?
If urgent, do you need help with transportation today? Do you have a
plan to get home today?
4. Utilities:
In the past year, has the utility company shut off your service for not paying
your bills? If urgent, are your
utilities shut off now?
Post-Intensive Care Syndrome (PICS):
What Social Workers Need to Know plenary presented by Kimberly Joseph,
MD, from Society for Critical Care Medicine (SCCM).
Roughly 30-50% of Intensive Care Unit (ICU) survivors may
not be able to return to work after a year due to cognitive (problems with
memory and attention, nightmares), physical (weakness, low energy, pain,
trouble walking, breathing problems) and psychological (depression, anxiety,
PTSD) impairments from PICS. Patients with PICS may go to rehabilitation facilities or home with significant
home care needs after discharge. Social
workers can promote resilience, coping and recovery strategies that capitalize
on existing strengths, and coordinate continuity of care. (Aging and PICS covered at AAGP conference.) In particular, social workers in ICU can
advocate for patient and family, help healthcare providers recognize discharge
issues, encourage communication between ICU team and those who will care for
patient after ICU (primary care physician, nurse practitioner, rehab team,
etc.).
Putting the “Medical” in Medical Social
Work, presented by Rachel Union from Dell Children's Medical Center in Austin.
Many behavioral changes may have medical etiologies that are often
overlooked by medical providers and mistakenly diagnosed as psychiatric
disorders. (See Missing the Diagnosis:
The Hidden Medical Causes of Mental Disorders, by William Matteson.) Psychosocial stressors can result from medical illness, so ask about the
patient’s medical history. In conducting
holistic “bio-psycho-social-spiritual” assessments of patients, medical social
workers can consult with medical professionals to rule out possible medical
conditions that may otherwise be missed (“Is it possible …?”) Rachel provided presented several case studies
to illustrate examples of how multiple medical illnesses can manifest through
psychological symptoms, such as anxiety, speech irregularity and
hallucinations. For example, an older
adult with a bladder infection, which is hard to detect, might present as delirium.
Piloting a Hospital Social Work Liaison
to a Medical Home to Address ER “Super-Users”: A Stanford Health
Care-Ravenswood Family Health Center Collaboration,
presented by Loretta Sun. She shared her experience as a social worker to reduce
over-usage of the ED and avoid unnecessary readmissions of ED “super-users” by
care coordination (health, behavioral health, social services), patient and
family engagement and empowerment as patients were assigned to Ravenwood for
primary care and Stanford for specialty care.
Implementing a Complex Discharge and Transition
Team for the Hardest to Discharge Patients: Using a Centralized Model to
Efficiently Manage Resource Intensive Cases to Reduce Length of Stay,
presented by Ashley McLoud from University of Washington Medical Center, which
piloted a Complex Discharge and Transition Team (CDTT) with the goal of
reducing length of stay for the hospital’s most resource intensive
patients. LACE (Length of stay, Acuity
of Comorbid Emergency visits) + risk assessment tool to predict
pre-admission risk based on factors such as homelessness, polysubstance, ESL,
high risk meds, social isolation, no funding, estimated stay > 30 days,
undocumented.
Reducing Mental Health Readmissions-Hospital,
Post-Hospital & Collaborative Community Interventions,
presented by Janis Seiders, RN Coordinator of READY Program and Karen Sandnes,
LCSW Manager of Social Services from Pennsylvania Psychiatric Institute, which
provides a continuum of care (ages 65+ are called “mature adult”). Of the top 10 most common Medicaid 30-day
readmissions for patients age 18-64 in 2011, four involved behavioral health:
·
#1 Mood disorders – 41,600 total
readmissions at cost of $286 million
·
#2 Schizophrenia & other psychotic
disorders – 35,800 total readmissions at $302 million
·
#5 Alcohol-related disorders – 20,500
total readmissions at $141 million
·
#10 Substance-related disorders –
15,200 total readmissions at $103 million
Janis and Karen adapted evidence-based processes (AHRQ Re-Engineered
Discharge Tool Kit)
used with medical patients to a mental health population in a Discharge READY
(Resources Education Aftercare Direction Your recovery) Manual: patient input, follow-up services within 7
days of discharge, medication and illness education, medication reconciliation,
supportive calls after discharge (information absorbed, services started,
barriers reduced/eliminated), warm line to call, resources to support recovery
(e.g., pill boxes, fridge magnets to hold reminders, recovery tools developed
in hospital using natural and formal supports).
They provided a handout of 5 things to consider to reduce the likelihood
of readmission:
1. Assess
for suicidality or homicidality, use Columbia or PHQ-9 for depression
screening.
2. Assess
if issue is relationship that could be resolved.
3. Assess
if there are issues that if solved, would reduce feelings of hopelessness. Identify needs and work to resolve top 1 or
2.
4. Assess
for substance abuse issues.
5. Educate
on Meds, Diagnosis, and Recovery.
Development of an Innovative Palliative
Care Program, presented by Keisha Berglund of Mount
Sinai Palliative Care Institute in New York. She shared her experience of starting an early palliative care intervention to
support patients at diagnosis, with social work’s role in promoting ongoing
communication and information sharing between family and medical team during the
illness trajectory. This service can
improve patient quality of life, reduce length of stay in the hospital and
avoid re-hospitalization after discharge. Three step process:
1. Explore
(1st visit) – prior to meeting
patient, review with primary team for medical background, understand
medical condition, treatment options including benefits/burdens, prognosis
with/without therapies, recommended plan and expected timeline for
hospitalization; next, patient assessment of advance care planning
(ACP) for conversation preferences, understanding, impact of disease on
quality of life, priorities, treatment preferences, current goals and
limitations (“Given this, what are you hoping for as you look toward the
future?”), feedback to interdisciplinary team; refer to additional in-house
supports
2. Align
(2nd visit) – interdisciplinary patient and family discussion of
medical update, facilitate discussion regarding patient goals, align treatment
goals to these long-term goals, complete ACP documents
3. Confirm
(subsequent visits) – follow-up meeting; assess understanding; continue
collaboration; transition planning support; grief/bereavement support
Educational resources:
·
Center to Advance Palliative Care
(CAPC)
·
State-by-state advance directives: EverPlans
Older adults are more likely to have higher levels of pain
compared to younger populations,
so looked forward to last session on Increasing
Social Work’s Role in Chronic Pain Care, presented by Katie Levy of
University of Washington Medical Center for Pain Relief. She facilitates a support group for patients
living with chronic pain and explained social work’s roles in pain care:
psychosocial assessment (incorporating pain-specific questions), education
about chronic pain (retrain the brain), mental health training for co-occurring
disorders, crisis management (suicidal ideation), care coordination and
resources (psychology, physical therapy, and insurance barriers).
Since 1990s, opioid has become treatment of choice: however,
after 90 days, benefits of opioids shrink and can cause opioid-induced
hyperalgesia; instead, buprenorphine treats pain as well as opioid use
disorder. She shared assessment tools
for pain, both physical and psychological.
Evidence-based treatments are multidisciplinary involving medical
doctors, complementary medicine, physical therapy, pain psychology, care
coordination, cognitive behavioral therapy (gold standard), dialectical
behavioral therapy, acceptance and commitment therapy, hypnosis, mindfulness
based stress reduction, and support groups.
Age-friendly
Portland!
Portland was
the only U.S. city to collaborate with the World Health Organization (WHO) in
its Global Age-Friendly Cities project in 2006, and then a pioneer member of
the WHO Global Network of Age-Friendly Cities in 2011.
As usual, I skipped the conference site hotel in favor of
lodging at a hostel ($33 per night, plus complimentary breakfast and live music
like traditional American old time jam).
Located 1.5 miles away from conference site, so very walkable even in
the rain. Trimet 1-day pass was $5.
Design Museum Portland is a nomadic museum with no gallery space, dedicated to design exhibits all
over town to bring communities together. StreetSeats: Urban Benches for Vibrant Cities was exhibited at the World Trade Center Portland, within walking distance from
the conference venue. Fern bench designer Jingyie Liang of
Helsinki said, “To some extent, a bench to a city is just like the fern plants to an
area of forest. They are growing lower on the ground, and everywhere.”
Portland-based Kyle and Alyssa Trulen designed A Quiet Place to Sit and Rest, referring to the an old man’s use of a tree stump after the tree had given
fruit and building materials for a house and ship during his lifetime, inspired
by Shel Silverstein’s The Giving Tree
book. The couple designed their stump
with a protective ring, made of thermally treated pine and ash, to reflect hope
for a healthier, reciprocal relationship between people and a tree.
B_tween
(“celebrating diversity one bench at a time”) focuses
on inclusivity to enable a wheelchair user to sit in the middle rather than on
the side, designed by Gamma Concepts and inspired by Benji Borastero, a Paralympian and accessibility
advocate. B_tween also gets bonus points
for its use of sustainable building materials: scavenged, recyclable steel and
reclaimed wood.
Folio team designed this colorful LOOPLAY, engaging people
of all ages and activities to sit, lie down, crawl or play.
Several museums offered free admission on first Thursday of
the month!
All
Orientals Look Alike (1984) in funerary setting to mourn the
loss of identity imposed by stereotypes but shows collective power of
individuals to shatter stereotypes by the middle interwoven image, a composite
of the four individual portraits.
Red,
White and Blue (2004) represents occupations by
Chinese immigrants: three aprons soiled by cooks hanging below folded aprons
cleaned by laundry workers. All-American (2003) cleaver chopping
braided queue on round block represents immigrants who sacrifice part of their
cultural identity to become hyphenated Americans.
Chinks
III (2004) is wall of books whose foundations built on
encyclopedia sets from 1950s purchased by artist’s immigrant father but books
were full of “chinks” – missing histories of racial minorities.
Oregon
Jewish Museum and Center for Holocaust Education
(OJMCHE)
Home … Who are you? How do you express your culture?
Three dozen donuts fit inside this coffin at 15-year-old
Voodoo doughnut shop
Old Dirty Bastard with decadent chocolate frosting, oreo
cookies and peanut butter
Keep Portland Weird? Make Portland Age-Friendly!
I’ve
been indulging in slow space …in life review with older adults, while incorporating Mister Rogers’ kindness, openness ("feelings are mention-able and manage-able") and
unconditional positive regard (“Those who try to make you feel less than you
are is the greatest evil” and “No person in the whole world is just like you,
and I like you just the way you are”) … much needed, given longer and more
complex lives. I also love the company
of fellow introverts and models of civility and humility, PBS TV personality Fred Rogers and Supreme Court Justice Ruth Bader Ginsburg,
who are subjects of my two favorite films this year, Won’t You Be My Neighbor? (95 minutes) and RBG (98 minutes, plus DVD extras). I admire RBG's gender equality advocacy and Olmstead decision; wish her complete recovery from lung surgery, as 85-year-old RBG expects to serve at least 5 more years on the Supreme Court!
Well, I never relied on my looks and libraries are my favorite hangout! I love the San Francisco Main Library's current exhibit, Visual Poetry: A Lyrical Twist. While I missed the opening event last month while
homebound, SF Public
Library recorded the event, which included readings by 85-year-old poet Jack Hirschman: “One
day I’m gonna give up writing and just paint! … I’m gonna give up sitting and
just breathe! I’m gonna give up breathing and just die! I’m gonna give up dying
and just love! I’m gonna give up loving and just write!" 
