Social Work Practice in Home Health Care

Ruth Ann Goode-Chresos

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136380471
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Through Social Work Practice in Home Health Care, social workers will discover a unique "how-to" approach to social work practice in home health care agencies. You will find a historical perspective on home health care and clinical interventions to help you improve home health care for your patients. A wide range of clients, such as the developmentally disabled, post-hospitalization patients, the physically disabled and chronically impaired of all ages, the mentally ill, the terminally ill, newborn infants and their mothers, abused older adults, and abused children are in need of appropriate services that lead to positive and helpful results. Through Social Work Practice in Home Health Care, you will discover how to tailor your practice to meet the needs of individual clients and improve their quality of life.Current and comprehensive, Social Work Practice in Home Health Care provides you with successful methods and suggestions to find resources that clients need in order to face certain life challenges, such as abuse, neglect, poverty, malnutrition, uninhabitable housing, dysfunctional family situations, sensory deprivation, isolation, caregiver stresses, and alcohol and drug abuse. This unique book offers you techniques that can be used with any client base, including:

• learning from the successes and failures of others through case studies of twelve home health care agencies
• understanding problem areas of home health care and how clinical interventions can be used to help you make a difference in challenging situations
• analyzing staffing trends and clinical patient care policies regarding social work services to better assist individuals and their families in identifying, resolving, or minimizing the problems that often accompany an illness
• screening your clients who are in need of social work interventions, such as individuals suffering from depression over an amputation or debilitating heart attack
• implementing educational programs that provide systemic knowledge about medicare to improve your services to the elderlySocial Work Practice in Home Health Care provides you with insightful information on everything from staffing, recruiting, and training home health care workers to obstacles that you may encounter, such as the lack of knowledge about social workers among physicians and the public, to help you provide better services to your clients. You will discover how to improve your skills in psychosocial assessment, counseling and decision making, discharge planning, community resources, and supervision to help you adjust your practice and offer positive and effective suggestions to each individual client.

Chapter 1
Introduction to Home Health Care:
A Historical Perspective

The following vignettes reflect typical home health care situations across the United States:

Vignette #1

Ms. B, age fifty-two, was referred to the agency for high-risk diabetes after several emergency room visits at a local hospital. She was then referred to the social worker for an assessment and for community resources. The social worker observed that Ms. B lives alone in a low-income subsidized building. Ms. B is also feeling depressed, lonely, and has a limited social support system. The social worker assesses Ms. B and refers her to (a) a home health care agency for an evaluation of her depression, (b) a community-based waiver program for personal care and homemaker services and meals, and (c) arranges for her to go to the zoo with a group of residents from her building. The goal is to empower her and reduce her isolation and improve her overall medical status. Ms. B is very pleased with her social work services.

Vignette #2

Mrs. J, age eighty-one, was recently discharged from the hospital. She lives alone in an apartment, is ambulatory, uses a walker, and needs some assistance in activities of daily living. On a routine visit by a home health agency nurse, Mrs. J expresses to the nurse that she needs help with meals and cleaning. The nurse tells her that she can call the local Office for the Aging and they will help her. The nurse leaves and Mrs. J forgets to call the agency. The home health agency has no social worker and the nurse does what she is expected to do.

Both cases are characteristic of home health agencies. It is also common for some home health agencies to employ social workers or offer social work services to their clients. In agencies that do not offer social work services, many home health clients do not receive adequate psychosocial or team-oriented care.

Home health care is a rather diverse and dynamic service industry. More than 20,000 agencies provide home care services to some eight million individuals who require services because of an acute illness, long-term health problems, disability, or terminal illness. Annual costs for home care were $40 billion in 1997 and are expected to exceed $42 billion in 1998 (National Association of Home Care, 1999).

Medicare's enactment in 1965 accelerated the growth of the industry. In 1973, these services were made available to the disabled. Between 1967 and 1985, the number of agencies grew from 1,753 to over 5,983. In the 1980s, the number of agencies leveled off at about 5,900 and now has actually decreased because of paperwork, unreliable payment policies, and the move toward prospective payment (National Association of Home Care, 1999).

Estimates show that as many as 9 million to 11 million Americans need home health care services. Most of the elderly population receive services from so-called informal caregivers—family members, friends, or others who provide uncompensated care. Some of this population receive formal services (i.e., purchased or compensated services from home health care providers) (National Association of Home Care, 1999). Reasons cited for this increased industry are many, including the increased graying of our population, increased long-term and health needs of the elderly population, changed consumer preference for home care, the adoption of sophisticated technology, and changed federal policy on deinstitutionalization. The diagnostic related groups (DRG) regulations for hospitals in the mid-1980s stimulated growth even more. Fewer agencies are losing money, and the industry has become extremely profitable (Health Care Financing Administration, 1992).

Home health care is the fastest-growing segment of the health service industry, and employment in home health care has doubled since 1988. The largest groups of employees include home health aides and registered nurses. Currently, approximately 7,000 social workers represent full-time equivalent employees. Many of these social workers also only work part time (as needed), or as independent contractors (National Association of Home Care, 1999). Upon completing my research, I found that many agencies are unable to employ enough social workers. Health care workers said they would expect higher utilization and more employment growth if agencies really understood the social work practice area and the benefits of having a program.

Home health care staff provide intermittent, skilled care visits to patients in their homes or natural environments. Medicare insists on a medically driven model, with nursing care being the focus. Nevertheless, Medicare does recognize the importance of allied services and the care is reimbursed. These services include physical therapy, speech therapy, occupational therapy, home health aide services, nutrition care, and medical social work services. Medicare reinforces a holistic approach to meeting medical, nursing, social, rehabilitative, psychological, and emotional needs of patients.

Medicare reimburses agencies for social work services and encourages a team-oriented approach to psychosocial care. In agencies that have social work staff, the social workers do psychosocial care, enabling the nurses to perform their tasks much more efficiently. Thus, these agencies bring in more revenue. When nurses have to perform both tasks, the agencies suffer in revenue and productivity.

The history of home health care is fascinating in that, traditionally, there are strong emphases on comprehensive psycho-social care for individuals and families. The Visiting Nurse Association (VNA) is the leader in this area.

The underlying policy that affects home health care services in the United States is very fragmented and is driven by funding mechanisms. Medicare, the major funding source, is medically oriented, requiring specific diagnosis and orders by a physician, and the service is on a short-term, intermittent visit basis. To date, the social worker's role is secondary and limited, and Medicare does not mandate that patients be assessed or followed up. The nurse, or case manager, and physician decide which patients to refer and which patients to discharge. When the patient's care medically closes, the social worker's responsibility also closes, often prematurely. This severely limits meeting the psychosocial needs of the patient. The National Association of Social Workers (NASW, 1991) formed a Home Health Care Task Force, conducted a study, and found three major problem areas:

1. Social work is not a skilled, independent, reimbursed service, and there are no mandatory guidelines, even though data suggest that social work intervention expedites treatment compliance and prevents rehospitalization.

2. There are no consistent state or regional guidelines. One regulatory agency in the study allowed and reimbursed limited visits, and another agency only allowed three to four visits. Therefore, patients living in one geographic area were receiving excellent psychosocial care and those in another area were neglected. The state and regional intermediaries contradicted Medicare rules.

3. Some regulatory agencies are reimbursing for assessment-only visits. Also, since Medicare expanded medical social work (MSW) services in July, 1989 to include counseling, it is not clear whether there has been an impact.

MEDICAL SOCIAL SERVICES

Medical social services have been an integral part of the provision of health service since 1905. In 1955, the U.S. Public Health Services endorsed a physician-oriented organized home health care team designed to provide medical and social services to patients within their homes. The team consisted of a physician, nurse, and social worker. Since 1965, Medicare has provided reimbursement for medical social work services in home health care equal to or greater than that for nursing. Medicare recognizes services that are needed for patients' total functioning. An interdisciplinary approach is necessary to aid patients in regaining their independence and highest level of functioning. Social workers assist patients and their families to adapt and plan their home environments. Social work services help relieve stress; provide crisis intervention; assist with financial problems; and provide advocacy, community services, information and referral, emotional support, appropriate counseling, and education. Even though social work is not recognized as a primary service, visits are reimbursed and, as of July 1, 1989, counseling visits are covered (NASW, 1991). Agencies are not required to provide social work services; they decide which ancillary services to offer.

What encourages or discourages agencies from providing social work services is not known. Are agencies afraid of nonreimbursement? Are there staff shortages? Are agencies knowledgeable about Medicare regulations? Are agencies aware of the revenue they are missing? Are nurses providing the services? These are questions I examine.

HOME HEALTH CARE SERVICES

The continuum of care for the homebound or semihomebound elderly in the community begins with services such as friendly visiting, meals-on-wheels (or volunteers to deliver meals), escort, chores, lifeline-type programs that provide a mechanical means of communication with service providers or emergency response systems, daily friendly telephone calls, and daily personal checks by the Postal Service.

Mid-range home health care services are provided by semiprofessional personnel, including home attendants, homemakers, home health aides, and personal care assistants. These individuals' responsibilities range from purely household support functions, such as meal preparation, shopping, laundry, and cleaning, to personal care and hands-on functions, such as assistance with grooming, dressing, toileting, and eating, to social-therapeutic forms of help, such as supportive companionship. Traditionally, designated ancillary or supplemental services are frequently combined to form the central core of the home health care agency's available array of services.

Home health care entails the delivery of an expanding array of more traditional professional service functions, including, more frequently, visiting nurse services and home visits by local social workers and, less frequently, periodic assistance from recreational therapists, occupational therapists, physical therapists, dentists, physicians, psychiatrists, speech and language pathologists, nutritionists, psychologists, legal specialists, and clergy (Kaye, 1992).

Most often, the missing ingredient is case management or service coordination. This function is usually performed by a medical social worker, if an agency offers the service. Home health care, by definition, assumes a more sophisticated repertoire of services than any single intervention described above. Because home health care is more often than not only part of a service package, case management becomes a particularly important ingredient (Kaye, 1992). Often, social workers are needed to assume this role.

Currently the most sophisticated and comprehensive form of home health care available is probably long-term home health care programs. These programs offer, in addition to a home health aide or home attendant, regular nursing service, social service, meals-on-wheels, and, when necessary, physical therapists; all are part of the basic service package. Naturally, the case management role is explicit under such circumstances and often includes the overseeing of services other than those provided by the home health care agency itself. Information and referral services may be standard components of long-term home health care.

APPROPRIATE CLIENTS AND THEIR PROBLEMS

The range of potential home health care service recipients is large and diverse. It encompasses the developmentally disabled, post-hospitalization patients, the disabled and chronically impaired of all ages, the mentally ill, the terminally ill requiring hospice care at home, newborn infants and their mothers, and abused children and older adults.

Home health care has a long tradition of responding to the needs of older adults. Many argue, however, that the aged, by virtue of the extended period of time in which they have lived, represent a particularly heterogeneous group, presenting a seemingly endless variety of needs and requests for support. This diversity dictates the importance of establishing a wide range of flexible interventions and programs in the home health care situation.

Many situations, both personal and environmental, require the initiation of home health care services for older adults. The presence of one or more of these risk factors dramatically increases the likelihood that home health care is needed. Health care professionals involved in the referral process need to keep an especially keen eye on elderly adults in the community who have any of the following ri...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• CONTENTS
• ABOUT THE AUTHOR
• Foreword
• Preface
• Chapter 1. Introduction to Home Health Care: A Historical Perspective
• Chapter 2. The Utilization of Social Work Services in Twelve Home Health Care Agencies: A Research Study
• Chapter 3. Problem Areas for Clinical Intervention
• Chapter 4. Staffing Models
• Chapter 5. Clinical Patient Care Policies Regarding Social Work Services
• Chapter 6. Appropriate Clients for Social Work Intervention
• Chapter 7. Medicare Standards for Social Work Practice in Home Health Care
• Chapter 8. Review of Medical Social Work Literature
• Chapter 9. Conclusions and Implications for Future Applications and Research
• Looking Toward the Future
• Appendix A: Recruitment Letter for Research Participants
• Appendix B: Interview Questions
• Appendix C: Consent Form
• Appendix D: Home Health Care Agencies Who Participated in the Study
• Appendix E: Documentation System for Social Workers
• Glossary
• References
• Index