Medical Social Worker (MSW) as case manager for high risk neurology patients

Abstract

Background: Neurological conditions account for a high percentage of disability within Brunei’s population. Individuals with these conditions often experience wide ranges of complex needs and limitations especially those who are considered high risk patients. One key feature of our Neurology Unit is access to a multi-disciplinary team which aims to acknowledge problems and support safe discharge of the patient through multi-disciplinary meetings and case conferences as well as setting and meeting appropriate goals. However, there remain many challenges for reintegrating patients with neurological illness into the community. Purpose: This paper explores the role of Medical Social Worker (MSW) as case manager for the changing demographics of high risk Neurology patients together with identifying the gaps in service needs with regards to the primary objectives of the Neurology multi-disciplinary team. Methodology: Registry database of patients referred to MSW was used to identify in-patient Neurology patients at RIPAS Hospital referred to Medical Social Work Unit from 1st January 2013 to 31st December 2013. Patients who were referred again on subsequent admission during this time period were considered a new referral. Having identified these patients, the reasons for referrals were looked at and only those with markedly complex needs and limited resources including financial and caregiver resources referred for discharge planning were extracted. Documentation reviews were done to explore differences within and between cases using a systematic review of multiple-case studies analysis. Demographic and diagnostic data were also collected. Results: 30 referrals out of 450 patients (7%) patients admitted to the Neurology ward in 2013 were referred to MSW. 27 cases (6%) met the inclusion criteria. The findings of the study indicate that economic issues, lack of community resources and limited social services intervention were the greatest barriers in community re-integration. Conclusion: The consequences of a Neurological illness are profound and debilitating with a significant number requiring complex social intervention. People who sustain these illnesses experience alterations to the cognitive, behavioural, physical and psychosocial aspects of their life. These changes are often difficult to adapt to causing difficulties for them to successfully reintegrate into their community. Barriers identified by this study will need to be properly addressed World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116659– http://www.ijic.org/ in order to achieve successful community reintegration. This study has contributed to a better understanding of the role of the MSW as case manager in assisting Neurology patients in Brunei Darussalam as well as in identifying factors that impede successful re-integration into the community despite interventions made. This exploratory work suggests that the role of the MSW is holistic and has a pivotal role in developing integrated care into health care policy in Brunei. This creates opportunities for further research into health and social systems planning for the future.