Models of care

At the 53^rd 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.

“There’s no psychiatrist in the world like a puppy licking your face.” – Sir Bernard Williams (1929-2003)   

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 

·       America’s affordable housing crisis is driving its homelessness crisis         

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 (1^st 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 (2^nd 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 

·       National Hospice and Palliative CareOrganization 

·       Mastering Communication with Seriously Ill Patients (2009) by Anthony Back, Robert Arnold, James Tulsy 

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!

Portland Chinatown Museum opened Descendent Threads – the first group exhibition by Asian American female artists in Portland!  My favorites by Roberta May Wong:

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) 

Second floor core exhibit, Discrimination and Resistance, An Oregon Primer 

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!

GrayDogz music at Saturday Portland Farmers Market on Portland State University campus.