Transcript Document

Team-based Social Work Staffing: Efficiency and Savings for Appropriate Populations
Dani Hackner MD, Robert I. Goodman MD, Carlie Galloway LCSW, Judy Mei Ng LCSW, La Kisha Hooker LCSW,
Shelly Mason RN MBA, David Esquith LCSW MPH, and Sharon Mass LCSW PhD
Cedars-Sinai, Los Angeles, CA
Study Overview (Introduction)
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Within the Case Management literature, qualitative
studies of RN-case manager and Clinical Social
Worker dyads have suggested improvements in
team-based collaborative care through
organizational change.
We undertook to study the assignment of a
dedicated Social Worker to a clinical hospitalist
team and its impact on length of stay, and
readmissions.
Would reorganization of social work staff to focus on
improvement of progression of care among
hospitalists improve efficiency and utilization?
Could we control for population and cohort
differences over time to identify efficiency related
to the role of the social worker on a hospitalist
team?
Background
Challenge
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At many centers, indigent and complex patient with
many difficulties in access to care or transitions of
care were under the care of faculty hospitalist
teams.
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Faculty had demonstrated their ability to improve
efficiency in the care of this patient population in
comparison to non-faculty physicians.
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What additional measures could be taken to further
improve faculty hospitalist efficiency without
additional staff?
Innovation?
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Within the Case Management literature, qualitative
studies of RN-case manager and Clinical Social
Worker dyads have suggested improvements in
team-based collaborative care through
organizational change.
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Would reorganization of social work staff to focus on
improvement of progression of care among faculty
hospitalist patients improve efficiency and
utilization?
Materials and Methods
Discussion
Summary
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In a large community, teaching hospital with faculty caring for indigent, Medicaid and unassigned patients, we undertook
to study reorganization of case management services to "support" collaborative faculty care.
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During two consecutive years, from April through October, we compared cohorts of patients under the care of faculty
hospitalists and control hospitalist groups
Cohort 1 – Faculty Hospitalists
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In one cohort during 2011, patients were admitted to faculty and residents with 'geographic' unit-based social workers and
case managers.
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In July 2012, patients were admitted to faculty and residents rounding daily with team-based social workers. In the teambased approach, Social Workers served as the main conduit to unit-based RN case managers.
Cohort 2 – Control Hospitalists
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In a second cohort during 2012, patients were admitted to hospitalist physicians with 'geographic' unit-based social
workers and case managers.
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In July 2012, patients were admitted to faculty and residents rounding daily with team-based social workers. In the teambased approach, Social Workers served as the main conduit to unit-based RN case managers.
All statistics were performed using Minitab® 16.2.3, 2012. Multivariate analysis was applied to adjust for severity, time and
interactions using log-transformed LOS. Mann-Whitney tests were applied to compare median LOS (2 sample Wilcoxon rank-sum).
Chi-Square tests were applied to compare proportions.
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After the reorganization from geographic staffing in 2012 to team-based staffing, over the course of two months we
observed a reduction of median length of stay from 6 days (in the 3 months prior, 528 cases) compared to 4 days (in the
two months following, 486 cases, p<0.01).
We also observed a significant reduction in median length of stay compared to a matched period in 2012 (p<0.01).
We did not observe significant changes in LOS between the corresponding periods in 2011 (475 and 518 cases, respectively,
p=NS) or among cases of a control hospitalist service (434, 384 cases in 2012, p=NS).
No statistically significant increases in readmission rates were observed for the intervention group.
Box Plot of LOS
Faculty
2011 (pre)
Faculty
2012 (post)
Controls
2011 (pre)
DISPOSITION
Against Medical Advice
Expired
Home
Home with Home Health
Home with Hospice
Acute Hospital Transfer
Psychiatric Facility
Inpatient Rehabilitation
Long Term Acute Care
Nursing Facility
Other Facility
Expired or Hospice
2011
3.83%
1.91%
77.03%
6.70%
1.91%
1.67%
0.72%
2.15%
0.24%
3.11%
0.72%
3.83%
2012
5.25%
1.66%
79.01%
6.35%
0.28%
2.76%
0.83%
1.10%
0.00%
1.93%
0.83%
1.93%
Demographics
Age
Race
2011
SD
47.82 16.90
2012 SD P value
47.68 17.50 p=0.11
p=0.47
2.76%
22.38%
0.28%
0.28%
73.76%
0.55%
p=0.24
44%
56%
2011 – pre
2012 - pre
Asian 4.31%
Black 25.84%
Pacific Islander 0.48%
Native American 0.00%
White/Other 69.38%
Unavailable 0.00%
Sex
Female
Male
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45%
55%
2012 – post
reorganization
SEVERITY OF ILLNESS
2011
2012
APRDRG
1
22.25%
28.73%
2
41.63%
42.27%
3
28.47%
24.86%
4
7.66%
4.14%
With the addition of service-based social workers,
faculty hospitalists and new residents appear to show
improvements in LOS while preserving low readmission
rates and mortality.
Similar findings were not observed during a six month
period (3 pre-intervention months and 3 post
intervention months) among non-faculty hospitalist
cases.
The findings for faculty hospitalist populations raises
questions about which populations are best suited to
dedicated service-based social work staffing. Do
indigent and difficult to place patients benefit more
from embedded social workers on hospitalist teams?
This report adds to the medical literature that
explores determinants of efficiency in hospitalist care- including the role of faculty, the value of team-based
coordinators, the impact of lower physician-patient
ratios, and yield of difficult patient teams.
In the face of regional staffing shortages and the
reductions in support for teaching services by Federal
and State payers, the "solution" of adding nursing staff
or physicians to academic hospitalist teams may not be
feasible or achievable.
Conclusions
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In this study, accounting for potential confounding
variables, we report that faculty may show preserved
or improved efficiency with the addition of teambased social workers--a less costly resource when
added versus alternative staffing models.
With reallocation from unit-based models to servicebased teams, faculty social work staffing offers a lean,
zero net staffing cost opportunity--one that may
produce large savings of hospital costs and improved
patient flow.
Whether further gains can be made in general
populations of patients versus particular social and
demographic subpopulations remains to be seen.
Learning Objectives
2011 – pre
2012 - pre
www.PosterPresentations.com
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p=0.24
Controls
2012 (post)
Study Question
RESEARCH POSTER PRESENTATION DESIGN © 2012
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Results
2012 – post
reorganization
We undertook to study the reorganization of a dedicated
Social Worker to a clinical hospitalist team and its impact on
length of stay, mortality and readmissions.
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P value
p=0.29
Does team-based social work staffing improve length of stay in a
hospitalist cohort? Preliminary data suggests yes.
Does team-based inpatient social work staffing affect hospital
readmissions? We have insufficient power to conclude.
What can a hospitalist service do to improve coordination of care
with the help of case managers and social workers? Possibly in
appropriate populations with physician alignment.
Acknowledgements
The Case Management Staff including Social Workers and Case
Managers (RNs).
Special thanks to Carolyn Sharp RN and Sarah Morrison LCSW who
helped to conceptually develop the clinical project.
The General Internal Medicine Medical Staff and Faculty:
Robert Goodman MD, William Stanford MD, Leon HendersonMcLennan MD, Anish Desai MD, Joya Favreau MD, Peggy Miles MD,
Karl Wittnebel MD, Doran Kim MD, Claude Killu MD, Genise Fraiman
MD, Tricia Len MD, Julia Wegge MD, Anna Stewart MD, Amanda
Ewing MD, Mark Noah MD, and Brian Kan MD.
Our leadership team including Linda Procci PhD,Glenn Braunstein,
MD, Zab Mosenifar MD, and Paul Noble, MD.