NASW/NKF
Clinical Indicators for Social Work and Psychosocial Service in
Nephrology Settings
Prepared
and approved by the National Association of Social Workers and
the Council of Nephrology Social Workers of the National Kidney
Foundation, October 1994
Contents
Monitoring and
improving the quality and appropriateness of psychosocial and social
work services for patients with end-stage renal disease is an area
of increasing concern for practitioners in both dialysis and transplant
settings. Social workers and their supervisors desire specific
measures of service delivery and patient care outcomes to monitor
quality and to position the profession strategically as the health
care system evolves. Institutions and insurers call for quality
services to enhance treatment, avoid expensive delays in discharge,
and prevent unnecessary hospital admissions. Accrediting organizations
seek consistency in data collection, analysis, and comparison across
institutions.
In response to
these concerns, the National Association of Social Workers, in
conjunction with the Council of Nephrology Social Workers of the
National Kidney Foundation, has established model clinical indicators
to be used in the systematic monitoring of quality and appropriateness
of patient care and in quality improvement activities. The application
of clinical indicators is part of an ongoing process of quality
assurance and improvement, encompassing testing, improvement, and
innovation. These model 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. Without active follow-up, the gathering of data related
to indicators is a meaningless exercise.
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. Although it can be argued that
all thresholds are ideally 100 percent, this leaves little room
for improvement and often results in the overweighting of "clutter" data.
- 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.
Within this group
of indicators, both process and outcome measures are included.
Process indicators assess whether factors such as the appropriate
timelines and baseline professional practices have been met. Outcome
indicators assess whether the stated goals of intervention have
been achieved. As individual facilities select the measures they
will use at any given point, it is important that a balance of
measuring both process and outcome is achieved. Measurement of
either factor alone will not provide a clear image of program quality.
Some of the indicators
have been developed so that they are applicable across both inpatient
and outpatient settings and include both dialysis and transplant
patients, such as the indicators for timely initial contact and
comprehensive psychosocial assessment. Other indicators, such as
timely psychosocial assessment for dialysis patients, are written
with a focus on a specific setting or population group. In general,
these indicators can easily be modified for other populations or
settings, provided that care is taken to keep the indicator narrowly
focused and thus meaningful. By using at least some of the model
indicators as written, facilities will position themselves to compare
their data with those of similar facilities.
The Clinical Indicators
for Social Work and Psychosocial Services in Nephrology Settings
were developed by a panel of recognized expert practitioners from
a variety of related settings and facilities and reviewed by practitioners
in the field. The NASW work group and the Board of Directors of
the Council of Nephrology Social Workers formally accepted the
indicators in October 1994.
Mission
Nephrology social
work services support and maximize the psychosocial functioning
and adjustment of patients who are experiencing end-stage renal
disease (ESRD) and their families. These services are provided
to ameliorate social and emotional stresses resulting from the
interacting physical, social, and psychological concomitants of
ESRD, including shortened life expectancy; altered lifestyle with
changes in social, financial, vocational, and sexual functioning;
and the demands of a rigorous, time-consuming, and complex treatment
regimen. Social work functions as a part of the multidisciplinary
team and is responsible for fostering a positive treatment environment
policy and routines that are attuned to cultural, religious, and
ethnic differences among patients and families and show respect
for the individuality, independence, and choice of each patient.
Patients Served
Social work services
are available to all patients and their families on diagnosis of
ESRD and as they undergo dialysis or the transplantation process.
Social work services are also available to live organ donors. Social
workers serve ESRD patients of any age, race, sex, religion, ethnicity,
and sexual orientation without regard to financial or socioeconomic
status. Patients with greater need for social work intervention
are those who lack an adequate social support system, are unable
to gain access to community services, are over 60 or under 18,
and have multiple medical problems or a recent hospitalization
for acute illness.
Major Functions
and Services Provided
- Psychosocial
evaluation (assessment for treatment plan)
- Casework (counseling
and conferences with patients, families, and support networks;
crisis intervention; goal-directed counseling; discharge planning)
- Groupwork (education,
emotional support, self-help)
- Information
and referral
- Facilitation
of community agency referrals
- Team care planning
and collaboration
- Advocacy on
patients’ behalf within the setting and with appropriate local,
state, and federal agencies and programs and programming
- Patient and
family education
Major Categories
of Problems Addressed
- Adjustment to
chronic illness and treatment as they relate to quality of life
- Physical, sexual,
and emotional relationship problems
- Educational,
vocational, and activity of daily living problems
- Crisis and chronic
problem solving
- Problems related
to treatment options and setting transfers
- Resource needs,
including finances, living arrangements, transportation, and
legal issues
- Decision making
regarding advance directives
Providers
A qualified social
worker, as defined by the federal regulations governing ESRD facilities,
must have a state license, if applicable, and must have completed
a course of study with specialization in clinical practice leading
to a master’s degree from an accredited graduate school of social
work, unless hired one year before the effective date of the regulations
(9/l/76). Those hired before 1976 must have had two years of social
work experience, one year of which was in an ESRD setting, and
must have a consultative relationship with a master’s -prepared
social worker.
Recommended
Core Clinical Indicators for Social Work and Psychosocial Services
in Nephrology Settings
Indicator
1. Timely Initial Contact.
Important aspect
of care. Psychosocial intervention.
Rationale. Initiation
of ESRD treatment (dialysis or transplant) precipitates social
and emotional stress for the patient. Early social work contact
ensures immediate provision of psychosocial support and the opportunity
to identify patients with high-risk psychosocial circumstances.
Operational
definition. The percentage of patients seen within 48 hours
of inpatient admission or within seven days of initiation of
outpatient treatment.
Threshold. 90
percent.
Data elements. The
number of patients with documentation of initial contact within
the guideline divided by the number of patients initiating treatment
for ESRD during the survey period.
Other influencing
factors. Patient is transferred or dies within guideline
period.
Indicator
2. Timely Psychosocial Assessment for Dialysis or Peritoneal
Dialysis Patients.
Important aspect
of care. Psychosocial intervention.
Rationale. Information
and conclusions of a comprehensive psychosocial assessment must
be available on a timely basis to guide ongoing treatment planning.
Operational
definition. The percentage of reviewed charts containing
psychosocial assessments dated within 30 days of initiating chronic
outpatient treatment in a facility.
Threshold. 95
percent.
Data elements. The
number of reviewed charts that have comprehensive psychosocial
assessments dated within 30 days of initiating treatment in a facility
divided by the total number of charts reviewed.
Other influencing
factors. Patient dies or transfers facilities. Patient is
frequently hospitalized during initial 30-day period.
Indicator
3. Comprehensive Psychosocial Assessment.
Important aspect
of care. Assessment, evaluation, treatment planning, and
collaborative input and awareness.
Rationale. To
guide planning and decision making adequately, the comprehensive
psychosocial assessment addresses both problems and strengths of
the patient and his or her situation and spells out the implications
of this information for treatment planning and delivery of care.
Operational
definition. The percentage of reviewed psychosocial assessments
that address the problems and strengths of the client, including
physical, environmental, behavioral, emotional, economic, and
social factors, and their implications for treatment. Areas to
be evaluated by the social worker include mental health status;
preexisting health or mental health problems; the client’s needs
and the resources of the client’s informal support system; social
role functioning; environmental issues, including economic situation,
employment status, and other basic needs; substance abuse history;
and relevant cultural and religious factors including sexual
orientation. An intervention plan based on the findings of the
assessment and mutually agreed on goals should be included as
part of the assessment.
Threshold. 95
percent.
Data elements. The
number of reviewed charts that meet the criteria for comprehensiveness
divided by the total number of charts reviewed, on a sample basis
if necessary.
Other influencing
factors. Patient leaves treatment before completion of period
for timely assessment.
Indicator
4. Teamwork and Interdisciplinary Collaboration. Psychosocial
input is a component of informed multidisciplinary patient care.
Important aspect
of care. Assessment, evaluation, treatment planning, and
collaborative input and awareness.
Rationale. Multidisciplinary
input and active collaboration in each patient’s treatment and
discharge planning ensures that all available information and expertise
are 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 patient care
planning meetings attended by the social worker in a given month.
Threshold. 95
percent.
Data elements. The
number of team meetings held divided by the number of times a social
worker is present as documented in the team meeting notes for the
survey period.
Other influencing
factors. None.
Indicator
5. Psychosocial Problem Resolution. Patients’ psychosocial
problems related to ESRD and treatment are ameliorated.
Important aspect
of care. Psychosocial intervention.
Rationale. The
intent of social work intervention is to improve or resolve the
patient’s psychosocial problems related to his or her medical condition
and treatment. Problem improvement or resolution is an indicator
of whether the intervention has achieved its goal.
Operational
definition. The percentage of problems ameliorated within
90 days of problem identification.
Threshold. To
be determined based on problem being tracked.
Data elements. The
number of patients experiencing problem X with ameliorated as the
outcome divided by the number of social work patients experiencing
problem X as identified within a 30-day period.
Other influencing
factors. Problem is identified within seven days of end of
review period.
Indicator
6. Primary Caregiver Satisfaction.
Important aspect
of care. Psychosocial counseling (individual, group, and
family).
Rationale. Primary
caregivers of ESRD patients struggle with profound lifestyle changes
and challenges to growth and development. Information, education,
and help in coping with the implications and consequences of these
challenges are important to the long-term success of treatment.
Operational
definition. The percentage of caregivers indicating satisfaction
with supportive services.
Threshold. To
be determined based on the sensitivity of the social work assessment
tool.
Data elements. The
number of caregivers indicating satisfaction divided by the number
of caregivers surveyed.
Other influencing
factors. None.
Indicator
7. Pretransplant Counseling for ESRD Patients. Potential
transplant recipients should be referred for social work services
before transplant.
Important aspect
of care. Psychosocial counseling.
Rationale. Transplant
recipients need information regarding the social and emotional
ramifications of transplant to participate in informed decision
making.
Operational
definition. The percentage of patients who have received
pretransplant counseling.
Threshold. 95
percent.
Data elements. The
number of charts of patients with transplant completed containing
documentation of pretransplant counseling by a social worker divided
by the number of transplants.
Other influencing
factors. None.
Indicator
8. Pretransplant Counseling for Live Organ Donors. Potential
transplant donors should be referred for social work services
before transplant.
Important aspect
of care. Psychosocial counseling.
Rationale. Donors
need information regarding, and the opportunity to discuss and
resolve, issues related to the social and emotional ramifications
of organ donation to participate in informed decision making.
Operational
definition. The percentage of live organ donors who have
received pretransplant counseling.
Threshold. 95
percent.
Data elements. The
number of charts for live organ donors containing documentation
of pretransplant counseling by a social worker divided by the number
of live organ transplants.
Other influencing
factors. None.
Clinical
Indicators for Nephrology Settings Work Group
- Chair: Rosa
Rivera-Mizzoni, LCSW, Chicago, Illinois
- Beth Witten,
LSCSW, Lenexa, Kansas
- Karen Cornell,
CISW, Torrington, Connecticut
- Cheryl Jacobs,
ACSW, Minneapolis, Minnesota
- Mary Beth Callahan,
CSW, Carrollton, Texas
- Project Consultant:
Betsy Vourlekis, PhD, ACSW, Washington, DC
- NASW Staff:
James P. Brennan, MSW, Washington, DC
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