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