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NASW
Clinical Indicators for Social Work and Psychosocial Services in
the Acute Psychiatric Hospital
Prepared
and approved by the NASW Commission on Health and Mental Health,
June 1990
Contents
Monitoring the
quality and appropriateness of psychosocial and social work services
in acute psychiatric hospitals is an area of increasing concern
to the health care field. Social workers and their supervisors
desire specific measures of service delivery to monitor quality
and to position the profession strategically as the mental health
care system evolves. Institutions and insurers call for quality
services to avoid expensive delays in discharge and to prevent
the need for readmissions. Accrediting organizations seek consistency
in data collection, analysis, and comparison across institutions.
In response to
these concerns, the National Association of Social Workers’ Commission
on Health and Mental Health has established clinical indicators
to be used in the systematic monitoring of the quality and appropriateness
of patient care. Indicator development is an ongoing process that
encompasses testing, improvement, and innovation. These indicators
serve as broad guidelines to allow for the varied needs of diverse
institutions while encouraging more uniformity in social work quality
assurance.
Clinical indicators
are not intended as direct measures of the quality of clinical
performance. They are best thought of as "flags" that, at a predetermined
threshold, "go up" and signal the need for problem analysis or
peer review.
The following information
is provided for each indicator:
- Rationale: an
explanation of the logical connection between the "flag," social
work functions, and an important dimension of quality
- Operational
definition: a definition of the indicator that allows for reliable
measurement across practice settings
- Threshold: the
predetermined point at which the "flag goes up," precipitating
closer scrutiny and evaluation
- Data elements:
the specific information needed to measure the indicator
- Other influencing
factors: factors beyond the control of the individual practitioner
that influence the provision of care
Clinical Indicators
for Social Work and Psychosocial Services in the Acute Psychiatric
Hospital were developed by a panel of recognized expert practitioners
from a variety of related settings and facilities and reviewed
by practitioners in the field. NASW’s Commission on Health and
Mental Health formally accepted the indicators in June 1990.
Mission
Social work services
are provided to patients and their families to ensure that a patient’s
illness, recovery, and safe transition from one care setting to
another are considered within the context of his or her biopsychosocial
needs and the specific demands and opportunities of his or her
environment. Social workers focus on psychosocial factors including
family relationships; living arrangements; patient’s developmental
history; and economic, cultural, religious, educational, and vocational
background as they impinge on the understanding, treatment, and
relapse prevention of the psychiatric disorder. As members of interdisciplinary
teams, social workers contribute to program development and treatment
planning and review for all patients and collaborate in the development
and maintenance of the therapeutic milieu.
Patients Served
Social work services
are provided to all patients (and their families) ages 4 and older
with all major psychiatric disorders, including schizophrenia,
affective disorders, neuropsychiatric disorders, eating disorders,
personality disorders, phobias, substance abuse, childhood disorders,
and organic psychoses. Excluded from this patient population are
those with severe mental retardation and acute health problems.
Services are provided regardless of whether there is insurance
coverage or whether the legal status of patients is categorized
as voluntary, involuntary, or court referred.
Major Functions
and Services Provided
- Intake or admission
evaluation (screening)
- Psychosocial
assessment and treatment planning and review
- High social
risk case finding
- Patient and
family education, support, and advocacy
- Individual treatment,
family therapy, group therapy, parental and marriage counseling
- Information
and referral
- Crisis intervention
- Consultation,
liaison, and interdisciplinary collaboration
- Expert testimony
and mandated reporting of neglect and abuse
- Discharge, transition,
and aftercare planning
- Postdischarge
follow-up
- Case management
- Development,
maintenance, and ongoing evaluation of community referral resources
Major Categories
of Problems Addressed
- Patient and
family reactions and adjustments to illness and hospitalization
- Vocational and
educational problems
- Legal problems
- Financial problems
- Family caregiving
problems
- Housing and
living arrangement problems
- Relationship
problems
- Problems related
to physical, sexual, and emotional abuse
- Problems related
to substance abuse or other psychiatric or medical illness in
family
Providers
The social work
department comprises master’s degree graduates from accredited
schools of social work and social work assistants who hold bachelor’s
degrees from accredited schools of social work. Social work staff
at all levels are licensed and/or certified in accord with state
licensing regulations.
Recommended
Core Clinical Indicators for Social Work and Psychosocial Services
in the Acute Psychiatric Hospital
Quality of Care
Indicators (Process)
Indicator
1. Timely Psychosocial Screening. Patients with high-risk
psychosocial circumstances are identified quickly.
Important aspect
of care. High social risk case finding.
Rationale. Psychosocial
information has bearing on the identification of immediate high-risk
issues (for example, job loss, unattended children, treatment noncompliance,
problematic discharge) and is needed for immediate intervention
and expeditious and appropriate treatment planning. To be useful,
such information should be identified and available in a timely
manner.
Operational
definition. The percentage of patients who received psychosocial
screening within three days of admission.
Threshold. 95
percent.
Data elements. Number
of patients with psychosocial screening in chart dated within three
days of admission date divided by the total number of patients
admitted.
Other influencing
factors. Patient leaves before three days.
Indicator
2. Timely Psychosocial Assessment. Comprehensive patient
evaluation occurs early in the hospitalization.
Important aspect
of care. Assessment, evaluation, and treatment planning.
Rationale. Information
and conclusions of a comprehensive psychosocial assessment must
be available on a timely basis to guide ongoing treatment planning
and discharge and aftercare planning.
Operational
definition. Percentage of reviewed psychosocial assessments
dated within five days of the patient’s admission.
Threshold. 95
percent.
Data elements. Number
of reviewed charts that have comprehensive assessment dated within
five days of admission divided by the total number of charts reviewed.
Other influencing
factors. Patient leaves hospital before five days.
Indicator
3. Comprehensive Psychosocial Assessment. Patients’ psychosocial
circumstances are assessed adequately.
Important aspect
of care. Assessment, evaluation, and treatment planning.
Rationale. To
guide planning and decision making adequately, the comprehensive
psychosocial assessment addresses both problems and strengths in
the patient and his or her situation and spells out the implications
of this information for treatment and posthospital planning.
Operational
definition. The percentage of reviewed psychosocial assessments
that meet the following criteria for comprehensiveness: address
problems and strengths in social role functioning; identify environmental
issues, including financial and other basic needs; consider problems
and strengths in the family and other social support systems
and cultural factors; spell out the implications of the first
three criteria for posthospital planning; and specify the social
work plan of intervention.
Threshold. 95
percent.
Data elements. The
number of reviewed charts that meet comprehensive criteria divided
by the total number of charts reviewed, on a sampling basis if
necessary.
Other influencing
factors. Patient leaves before five days.
Indicator
4. Timely Contact with Family and Significant Others. Patients’ families
and significant others receive social work services early in
the hospitalization.
Important aspect
of care. Psychosocial interventions.
Rationale. The
family and significant others are crucial to the accurate assessment
and appropriate treatment of each patient. Early contact by the
social worker ensures that the patient is considered in a biopsychosocial
context and that patient and family have sufficient time to deal
with the crisis of hospitalization and to plan for the transition
and discharge.
Operational
definition. The percentage of families or significant others
who are seen at admission or are contacted within three days
of the patient’s admission.
Threshold. 95
percent.
Data elements. The
number of patients whose families and significant others are contacted
within three days of admission divided by the total number of patients
admitted.
Other influencing
factors. Patient refuses to allow contact; patient leaves
before three days; family and significant others are unavailable.
Indicator
5. Teamwork. Patient care is informed by multidisciplinary
expertise.
Important aspect
of care. Assessment, evaluation, and treatment planning;
discharge, transition, and aftercare planning.
Rationale. Multidisciplinary
input and active collaboration in each patient’s treatment and
discharge planning ensures that all available information and expertise
is considered as decisions are made. If the social worker does
not attend the multidisciplinary planning conference, the opportunity
for input and collaboration is seriously diminished.
Operational
definition. The percentage of multidisciplinary planning
conferences attended by the social worker.
Threshold. 95
percent.
Data elements. The
number of conferences attended by the social worker in a month
divided by the total number of conferences held that month.
Other influencing
factors. None.
Recommended
Additional Indicators
These two outcome
indicators are highly desirable for use and provide direction for
future quality assurance efforts. It is recognized that barriers
in some hospitals may preclude their immediate implementation.
Quality of Care
Indicators (Outcome)
Indicator
1. Psychosocial Problem Resolution. Patients’ psychosocial
problems related to the hospitalization and aftercare are ameliorated.
Important aspect
of care. Psychosocial interventions.
Rationale. The
intent of social work intervention is to help resolve patients’ psychosocial
problems related to hospitalization and aftercare. Problem resolution
is an indicator of whether the intervention has achieved its goal.
Operational
definition. Percentage of planned results not achieved specific
to each problem.
Threshold. Needs
empirical determination.
Data elements. Number
of social work patients discharged from hospital in one month having
problem X with "not resolved" as outcome divided by the number
of social work patients discharged from hospital in that month
having problem X. This indicator requires a well-defined problem
list and reliable categories for problem resolution that are compatible
with a given hospital’s staffing ratio and average patient length
of stay.
Other influencing
factors. Case mix (social complexity).
Indicator
2. Continuity of Care. Patients’ planned aftercare occurs.
Important aspect
of care. Discharge, transition, and aftercare planning.
Rationale. The
patient and family making a connection to the next stage of care
is viewed as important for subsequent adjustment and more likely
if discharge planning has been adequate and appropriate.
Operational
definition. The percentage of patients who, two weeks after
discharge, have gained access to planned living arrangements
and planned treatment follow-up.
Threshold. Needs
empirical determination.
Data elements. Number
of patients discharged in one month who connected with planned
living arrangements and treatment follow-up (based on telephone
follow-up call to patient or family) divided by the total number
of discharged patients in that month who were reached for follow-up
call.
Other influencing
factors. Patient states nonagreement with discharge plans;
AMA (against medical advice) discharge; staff noncompliance with
discharge plan; case mix (social complexity).
Clinical
Indicators Psychiatric Hospital Work Group
- Philip Paulucci,
MEd, ACSW, Columbus, Ohio
- Doris T. Axelrod,
ACSW, Belmont, Massachusetts
- Barbara A. Graham,
ACSW, San Diego, California
- Ruth Corn, MSW,
New York, New York
- Phyllis Nash,
EdD, Lexington, Kentucky
- Phillip L. Rosenblum,
ACSW, Washington, DC
- Leslie Hargett,
ACSW, Lansing, Michigan
- Peggy A. Weil,
ACSW, MPA, Silver Spring, Maryland
- Betsy Vourlekis,
PhD, Catonsville, Maryland
NASW
Commission on Health and Mental Health
- Allyson Ashley,
ACSW, Springfield, Missouri
- Marvin A. Johnson,
MSW, Palatine, Illinois
- Gracie Mebane
Vines, MSSW, ACSW, Greenville, North Carolina
- Terry Mizrahi,
PhD, New York, New York
- James M. Karls,
DSW, ACSW, Sausalito, California
- Juan Ramos,
MSW, ACSW, Rockville, Maryland
- Della Wills,
MSW, ACSW, QCSW, Homer, Louisiana
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