Social Work Case Management Research Articles

The Importance of a Nurse Case Manager, a Personal Assistant, and a Strong Support System: A Case Scenario

We are members of the social work profession. The lead author, Gordon, directs the social work case management program for Paralyzed Veterans of America (PVA). Ellen is a social work educator whose most recent research has focused on professional roles and relationships in geriatric health care. Both of us believe that social workers have vital roles to play in community-based case management. That is our bias. This article, however, takes a different focus. For in the process of Gordon's having been case managed through a very complicated series of medical episodes, we recognized the pivotal role played by the nurse case manager representing his health plan. In addition, Gordon copublished an article in The Journal of Case Management on personal assistance services (Gilson & Casebolt, 1997) which was published in the spring of 1997. He had no idea that when that article would appear in print, he would actually be engaged in a scenario that would lead to his hiring a personal assistant for himself. Our support systems are already full of social workers and they brought a strength of professional and personal skills to the drama that unfolded. Our spouses (a social work educator/administrator and a hospice chaplain) and a host of other persons were engaged during the process, and when we could stop to look back we felt that what we had learned, both personally and professionally, was important to share with others. The combination of nurse case manager, personal assistant, and a strong social support system made a difference in what happened to Gordon. The roles and relationships of this vital combination is the subject of this article. The Hospital After much deliberation and given tremendous pain in his right leg, Gordon decided to have an elective operation. He entered an acute care hospital in April 1997 for the purpose of a routine knee replacement. The evening following surgery, Gordon reclined in bed. Our spouses, Ann and Karl, and we shared light conversation in a private hospital room as the newly reconstructed right knee was exercised mechanically. The plan was for a routine discharge home in 5 days after aggressive and immediate rehabilitation. The four of us were going to celebrate Gordon's birthday with dinner on Sunday night, the day after discharge. It was a plan. The following day, following extreme bouts with nausea, at first attributed to a reaction to pain medication, things were not going as planned. By 2:00 a.m. the following morning, Ellen and Karl received a call from Ann. They met in the family waiting room for the intensive care unit (ICU). Gordon had been transferred to ICU and the prognosis was frightening. The on-call physician feared that he had a clot in his lung. By noon the next day, it was determined that he had sustained a heart attack and an angioplasty was performed that afternoon. The results revealed serious blockage in four arteries, necessitating emergency surgery. But there was a problem. He now had pneumonia and his lungs needed to be clear before going to surgery. This was Friday. By Monday, a quadruple bypass was performed. Before anyone could fully feel relieved that this surgery had been successful, Gordon was wheeled back into the operating room. A blood clot had formed in the balloon pump which was designed to enhance poor circulation in his left leg. The clot had restricted circulation and a bilateral fasciotomy was performed, literally fileting his leg on both sides. This was his good left leg, and the knee replacement on his right leg had become an aside amid the more serious life-threatening scenario that was occurring. By this time, Gordon was on a ventilator. Thankfully he does not remember these events. Throughout this process, a nurse case manager representing Gordon's health plan worked with Ann and a multitude of professionals at the hospital. Beginning with a primary care physician and an orthopedist, by the time Gordon was ready to leave the hospital he had an entourage of physicians and assorted other professional staff engaged in his care. …

Reduction of hospital resources utilization in vascular surgery: A four-year experience

Purpose: Managed care whether through risk or through capitated contracts results in reduction in resources, reduced length of hospital stay, and reduced utilization of hospital resources (collectively referred to as resource reductions). These resource reductions will become even more noticeable as a greater proportion of Medicare patients who need vascular operations select a managed-care senior product. We examined the results of a 4-year experience with resource management in an academic vascular surgery practice during which best practice plans were developed and implemented. Methods: We analyzed hospital cost data, which included both total hospital and intensive care unit length of stay, average units per operation for laboratory, pharmacy, and radiology services and operating room and direct hospital costs for 257 carotid endarterectomies performed over fiscal years (FY) 1994, 1995, 1996, and 1997 (6 month data) and 175 infrainguinal bypass procedures performed during the same period. Results: For carotid endarterectomy, length of stay decreased 66% over the 4-year period to an average of 2.07 days in FY97. Both radiology and pharmacy utilization were reduced after the first year of institution of best practice plans (56% and 32% respectively) with 4-year total reductions of 86% and 55% by FY97. The most notable changes included elimination of routine postoperative laboratory testing, use of aspirin rather than low-molecular-weight dextran, emphasis on oral rather than intravenous vasoactive drugs, and routine use of duplex scanning alone rather than angiography for diagnosis after FY94-95. The length of operating room time for carotid endarterectomy remained relatively constant from FY94 to FY97. As a result of these multiple factors, our study showed a 30% decrease in total average direct hospital costs for carotid endarterectomy from $9974 to $7002 in this 4-year period. Infrainguinal bypass graft procedures showed a progressive decrease in total cost of 28% for patients without complications to $15,186 but remained unchanged for those with complications. Laboratory use, pharmacy use, and radiology use were not significantly different. Conclusions: Case management for patients undergoing carotid endarterectomy and infrainguinal bypass grafting involving an integrated team of vascular surgeons, surgical house staff, a dedicated vascular nurse, and a social work case manager resulted in dramatic reductions both in length of stay and hospital resource utilization. As these costs decreased, operating room expenses assumed increasing importance. Operating room costs account for 60% of the direct costs of carotid endarterectomy and a comparable percentage for uncomplicated infrainguinal bypass grafting. Further substantial reductions in direct hospital costs will depend primarily on reductions in operating room costs, particularly those related to length of time in the operating room.(J Vasc Surg 1998;27:1066-77.)

Development of a social work case management guideline and model.

This article describes the process that a team of Department of Veterans Affairs social work service department heads went through as they developed national guidelines for social work case management. Many of the concepts and findings of this team apply to case managers in any profession.

Case Management with Families Receiving Public Assistance: Results from an Empirical Evaluation

ABSTRACT This article describes the results from a family-based case management demonstration program which served families in North Carolina during the period of 1990 to 1993. The model for the program was based on the family investment initiative strategy developed by the George Washington University Center for Policy Studies. Entitled the Family Investment Initiative, the goal of the program was to assist families receiving AFDC to reach economic self-sufficiency. Results indicate that this family-based case management approach has promise for helping AFDC-dependent families achieve economic self-sufficiency. Implications of the results for social work case management practice with families are discussed.

Psychosocial Concerns and Strengths of Women with HIV Infection: An Empirical Study

The authors examine the psychosocial concerns, needs, and strengths of 67 adult women living with HIV in the Philadelphia area. Personal interviews revealed that the majority of women in the study were nonwhite mothers who relied on public assistance, had a drug-abuse history, and had a T-cell count less than 500/mm. More than half reported some utilization of social services (i.e., social work case management, support groups, drug treatment). Informal supports tended to come from extended family, friends, parents, and partners. Financial concerns and housing were more often ranked as one of the three primary concerns than was HIV disease. Many respondents were able to use their HIV diagnosis to reestablish priorities, especially with regard to their parenting roles, relationships, and drug use. Implications for social services are suggested.

Integrating Geriatric Case Management into Primary Care Physician Practices

As the delivery of health and human services has become more complicated, fragmented, and expensive, case management has gained popularity. Various case management models have emerged in social work (Loomis, 1987), nursing (Gerber, 1994; Swindle, Weyant, & Mar, 1994), and medicine (Like, 1988). Multiple population groups are being served, and practice guidelines have been published (Geron & Chassler, 1994; Kaye, 1992). Geriatric case management targets frail clients who are at risk of being high consumers of health care services. Case managers who work with elderly clients often come into contact with primary care physicians and a plethora of other health care providers. The case manager's involvement may vary from just knowing the name of the client's physician to being directly involved in the physician's practice (White, Gundrum, Shearer, & Simmons, 1994). Relationships between physicians and social workers have been studied as an acute care interaction with discharge planning elements (Mizrahi & Abramson, 1994). However, as health care services move more and more into community-based settings, the potential conflict and need for collaboration between social work case managers and physicians also move. Some group practices are using social workers (Kramer, Fox, & Morgenstern, 1992). In addition, nurses, physician's assistants, and other health care personnel are assuming expanded roles in geriatric case management. Relationships between social workers and physicians date back to the early years of the profession. In 1919 the physician who appointed the first full-time paid social worker at Massachusetts General Hospital reported, needed information about the patient which I could not secure from him as I saw him in the dispensary - information about his home, his lodgings, his work, his family, his worries, his nutrition (Cabot, cited in Mullaly, 1988, p. 5). This description reveals acknowledgment of the physician's need to view the person in his or her environment and the importance of the social worker's role in assessing home- and community-based factors. Today older people continue to turn to primary care physicians for assistance with their concerns and problems. However, cost pressures and the growth of managed care limit the time physicians can spend with patients. As physicians encounter more and more older patients, they often question just how far the scope of their medical practice extends into the broader social, economic, and environmental problems of their patients. It is too easy for physicians to limit their attention to monthly 15-minute office visits that are focused on medications to relieve symptoms. It is out of such changing and complex health care environments that demonstration projects emerge. The project reported here reflects the larger issues of health care delivery and the potential for collaboration between physicians and geriatric case managers. PROJECT Background In 1992 the John A. Hartford Foundation's Generalist Physician Initiative was started. Between 1992 and 1993, nine demonstration sites were funded across the United States. These projects were designed to enhance primary care physicians' care of frail elderly people by integrating geriatric case managers and caregivers into their practices. Although each site was required to have a well-designed evaluation, it was not mandated that each site use identical tools to measure outcomes or select patients in exactly the same way. Each site designed its own intervention; for example, in New Hampshire physicians were supported with educational resources so that they could become their own case managers, and in other projects various professionals (nurses, nurse practitioners, social workers, physician assistants, and paraprofessionals) acted as intervention agents. Depending on the credentials of each agent, roles and responsibilities varied. For example, nurse practitioners in inner-city Detroit remained clinic based, whereas paraprofessionals in South Carolina visited rural elderly people in their homes. …

Setting new standards for social work case management.

Setting new standards for social work case management.

Contact and Collaboration with General Practitioners: A Comparison of Social Workers and Community Psychiatric Nurses

SUMMARY For some years good communication and collaboration between health and welfare pro fessionals has been emphasized as a desirable goal by both official reports and relevant professions. This is as much the case in mental health as other areas. This paper compares communication and collaboration between social workers and general practitioners (GPs) with that between community psychiatric nurses (CPNs) and GPs. Both social workers and CPNs were based at a community mental health centre, and the contact was inter agency (with primary health care). Major differences were found between social workers and CPNs. CPNs were far more likely to contact GPs than social workers, although GPs very rarely initiated contact themselves. Differences reflected different 'philosophies of contact'. Social workers contacted GPs when this could be purposively related to their case management. In addition to this contact, CPNs also made contact to provide GPs with information, reflecting awareness of GPs' long-term continuing care responsibility. The excess of CPN contacts was not limited, but involved a wide range of problems. GPs, however, when contacted, exerted greater influence on social work case management. The article concludes by explaining differences between CPNs and social workers in terms of occupational culture. It suggests, furthermore, that the results arise at least in part from assumptions of team leadership by GPs, and that social workers' and CPNs' behaviour represents different responses to this.

Serving Rural Families of Developmentally Disabled Children: A Case Management Model

Family-centered, community-based case management is a key feature of new federal legislation mandating educational and preschool services for all developmentally disabled children. Social work skills, including counseling, planning, coordination, and knowledge of family and community dynamics, are germane to this task. The goal of family-centered case management is the empowerment of parents as caretakers and planners for their children. Highly skilled case managers will be particularly needed in rural areas where families must deal with scarce resources and other environmental constraints. The authors describe a program employing master's-level social work case managers who serve rural Appalachian families with developmentally disabled children. Included is a case illustration that delineates both case management activities and the contextual elements important in working in an Appalachian rural community.

Hospital Case Management: Bridging Acute And Long-Term Care

Since the early 1980s, policymakers and analysts have urged hospitals to be more active in managing the care of their patients beyond the hospital walls. In particular, hospitals have been criticized for failing to address the postdischarge needs of elderly patients with chronic health problems. An influential essay in The New England Journal of Medicine observed that “most of these institutions have no comprehensive geriatric program geared to the long-term medical, rehabilitative, and social needs that are linked to acute illness. To provide quality care, hospitals must make a commitment to long-term care for the chronically ill elderly patient. It is becoming apparent that no one else can.” As part of a strategy for addressing this perceived shortcoming, the authors argued, “Unlike other providers, hospitals could offer comprehensive case management of patients, from home care to acute care, thus ensuring continuity of services.” Under this approach, hospital-based case managers would identify clients, assess their needs, develop care plans, coordinate service delivery, and monitor results. Since many of these activities would take place after the patient left the hospital, hospital-based case management would be a considerable extension of hospitals’ typical discharge planning activities. In part, it was expected that the costs of hospital-based case management programs would be covered through user fees. If the hospital also offered long-term care services, hospital-based case management could generate additional revenues through increased use of these services. If it facilitated the earlier discharge of Medicare patients and reduced Medi-

A Social Work Practice Model of Case Management: The Case Management Grid

Case management is a major component of the current mainstream of social work practice. Nevertheless, the field has failed to adequately conceptualize case management. The first step in defining case management practice is to separate it from the administrative structure that forms the context of practice. The next step is to delineate the two basic dimensions of case management--enabling and facilitating. The role of the social work case manager is to integrate formal systems of care with the activities of families and primary groups. Case management practice focuses on enabling individuals and primary groups to reach their full potential and on facilitating more effective interaction with the larger social environment. The case management grid illustrates how social work practitioners integrate enabling and facilitating into their practice approaches.

The clinical social worker and current psychiatric drugs: Some introductory principles

This paper persents some common social work clinical and case management issues with respect to psychiatric drug treatment. The roles of the psychiatrist and the social worker are distinguished. Three types of negative treatment drug effect are described-physical, psychological, and social-with case examples. Techniques to prevent or reduce negative drug effects are presented. The paper emphasizes the need for greater social work professional attention being paid to drug therapy.