Academic journal article Health and Social Work

A High-Risk Screen for Psychiatric Discharge Planning

Academic journal article Health and Social Work

A High-Risk Screen for Psychiatric Discharge Planning

Article excerpt

As early as the mid-1970s, screening instruments were developed in medical inpatient settings to identify patients most likely to require social work interventions (Bates, Menzies, Behr, & Randall, 1976; Coulton, 1979; Cunningham, 1982; Inui, Stevenson, Plorde, & Murphy, 1981; Rehr, 1979). The impetus for such screens was the dependence of social work on other health care personnel for referral of patients and families requiring social work services. Rehr, Berkman, and Rosenberg (1980) stated, "Other professionals not only predetermined the timing of social work intervention but also prejudged the client's problems, thus introducing an obstacle to effective intervention".

In 1986 high-risk screens for patients likely to require social work intervention were mandated in New York State for all hospitals licensed by the Department of Health, and in 1991 the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) required that hospital social work departments have a mechanism for identifying patients and their families who require social work services (JCAHO, 1991; New York State Department of Health, 1986). With the implementation of regulatory requirements to reduce unnecessary hospital stays ("overstays") combined with third-party cost-containment measures, there has been increased pressure for rapid discharge and for priority setting within hospital social work departments. In response to these changes, the function of high-risk screens has expanded to include the early identification of patients who are deemed likely to require extraordinary amounts of social work time.

Patients and families at high risk of social work intervention have been defined as those individuals whose situations, stress, or predicted social and physical problems resulting from illness and hospitalization are likely to interfere with their ability to complete an optimum discharge plan or to cope with daily life expectations (Berkman, Rehr, & Rosenberg, 1980). This concept is closely related to that of psychosocial acuity, which refers to "the patient's psychosocial condition and the resulting degree of need for social work services" (Coulton, Keller, & Boone, 1985, pp. 35-36). People within the hospitalized high-risk population tend to be heavy users of hospital resources and to have delayed discharges, thus adding cost (usually unreimbursable) to the inpatient stay. In addition, leaving the hospital is frequently a traumatic event for high-risk patients, who must simultaneously cope with a changed environment, the loss of unit staff, and the long-term disabling effect of a chronic physical or mental condition.

Psychiatric social work has not kept pace with colleagues in medical settings in the development of high-risk screens for two major reasons. First, the typical psychiatric social work model has been to provide 100 percent coverage for all cases rather than service to selected groups. Therefore, developing a method to distinguish among risk groups for the purpose of triage and allocation of social work time has not been a pressing issue. Second, there are no standards for lengths of stay by diagnosis in psychiatry, because the field has been exempted from the national medical diagnosis related group (DRG) prospective pricing system. This lack of standards makes it difficult to identify which patients remain in house longer than clinically necessary because of environmental or resource issues. Nonetheless, with managed care, concurrent reviews, and very limited funds for in-hospital psychiatric care beyond the acute period, an accurate means to identify those patients who will be especially difficult to discharge from the institution is necessary and timely.

Coulton et al. (1985) demonstrated that discharge planning is the most time-consuming service provided by medical social workers. Therefore, if social workers have a means for predicting those patients who will require the most intensive discharge planning efforts, they may deploy resources differentially and offer targeted assistance to staff in their work with exceptionally challenging cases. …

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