Knowledge - Students should be able to describe and define:
Skills - Students should be able to demonstrate the following skills:
Attitudes and Professional Behavior
DISCHARGE HIGH RISK INDICATOR* (APPENDIX 1)
ELDERLY, LIVING ALONE
ELDER ABUSE OR NEGLECT
NO HOUSING OR FINANCIAL RESOURCES
PROGRESSIVE CHRONIC DISEASE
LIMITED OR NO SUPPORT SYSTEMS
FAILURE TO THRIVE, MALNUTRITION, DEHYDRATION
EXTENDED IV ANTIBIOTICS
MAJOR SURGICAL PROCEDURES
END STAGE DISEASE
NEW DIAGNOSIS OR TERMINAL DIAGNOSIS
*Source: AEP (Acute Evaluation Protocol), Melody Drew-Connor
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AFTER DISCHARGE LEVELS OF CARE: (APPENDIX 2)
Sometimes it is necessary to continue your recovery with services provided at home or in a specialized facility. These services may include:
|Home care agencies provide medical assistance to the home bound patient. Through the services of registered nurses, home health aides, social workers, chaplain, and/or physical therapist/occupational therapists, a specialized home care plan is designed to meet the patient 's needs.|
|Hospice care addresses the physical, spiritual, social and economic needs of the terminally ill patient. The care is provided by family, friends, health care professionals and trained volunteers. Most hospice care takes place in the familiar and comfortable surroundings of the patient s home.|
Nursing homes provide room and board, personal care, protection, supervision and medical care for those unable to be cared for at home. Some nursing homes can provide hospice and subacute rehabilitation.
|Rehabilitative services are recommended to patients when they need to relearn skills needed to live independently and productively. There are three different levels of rehabilitative services: Acute Rehabilitation; Subacute Rehabilitation and Day Rehabilitation. The level of rehabilitation needed is recommended by the doctor and physical therapist.|
|Acute Rehabilitation: Is recommended for a patient who requires an intensive medical program and more than three hours of physical therapy a day. Acute rehabilitation is provided in a special rehabilitation facility.|
Subacute Rehabilitation: The care provided is individually designed for patients needing a highly structured rehabilitation program of less than three hours of physical therapy per day. Subacute rehabilitation units may be located in designated rehabilitation facilities and/or in qualified nursing homes.
|Day Rehabilitation: Rehabilitation services are provided in an outpatient rehabilitation setting. Depending on the patient s needs, the patient will participate in physical therapy for a full or half day, three to five days per week.|
If your doctor recommends follow-up home care, hospice or rehabilitation services, a social worker will assist you with the referral at that time.
The above listed facilities are regulated by federal and state agencies. A list of home care agencies in your area is available and will be provided by the social worker and/or nurse on request.
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History Taking & ADL Assessment Guide (APPENDIX 3)
Mobility: Walking Set-up of Home?
Range of Motion Bathroom
Assistive Device Telephone
Perception: Consciousness/mental status oriented to time
Activities: Meals How do you spend the day?
Any agencies involved?
Who is available to help?
Any cultural reactions that need to be part of patient's care?
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Communication Hints* ( APPENDIX 4)
How to Engage Your Patient
PREPARATION: Helping yourself to be ready, cognitively and effectively, to give help.
Tuning in, or putting yourself in the client's shoes.
Tuning in to oneself: what this client or problem stirs up in oneself. Possible other concerns which need to be set aside in order to present to this client.
Tuning in to context: impact upon both of you of this agency services, policies, ambiance,
broad social issues, or other factors.
Reviewing prior contacts with oneself or other helpers, records, etc. (Sometimes a decision is deliberately made not to review records before first session, to avoid prejudging the client.)
Considering potential foci and purposes of meeting from your point of view to be re-evaluated upon meeting client.
CONTACT: Helping applicant become a client.
Communicating caring, concern, interest
Offering clarification and structure
Making a clear statement of agency function and your role
Trying to help client feel comfortable
Asking each client about his/her concerns
EXPLORATION: Helping the client tell his/her story
Communicating accurate empathy interest in how client might be feeling, as well as facts and events; everyone s perceptions and experiences in multiple person interviews
Asking questions which encourage elaboration
Keeping interruptions of the client s spontaneousness as few as possible (unless a torrent of words and feelings, which need limits)
Enabling people to talk to each other
Searching to understand client s personal and cultural ways of communicating
CONTRACT: Helping the client engage with you in working together
Restating and summarizing your understanding of the problem
Expressing your contract using client s unique language
Offering hope and resources
Eliciting client s ideas on how you can work together
Partializing and prioritizing needs and concerns
Identifying next steps and allocating tasks
Planning next meeting time, etc.
*Source: Simmons College School of Social Work, Clinical Practice I Summary of article entitled, Patient and Family Satisfaction with Discharge Plans by Proctor,
Morrow-Howell, Albaz and Weir. Medical Care, March, 1992, Vol. 30, #3, pp 262-275.
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(for all answers)
This study explores various factors, which affect patient and family satisfaction with discharge plans. It defines discharge planning as an inter-disciplinary, hospital-wide process that should be available to all patients. It is important to evaluate consumer satisfaction because: 1) we must comply with Medicare's perspective payment system; 2) efficient use of continuum of care services will decrease costly re-admissions; 3) documentation of reasonable discharge efforts
protects the healthcare industry legally and; 4) discharge planners can impact patient and family satisfaction through their close contact. Increased patient satisfaction with discharge plans contributes to continued use of the hospital system s health services, decrease in malpractice suits and increased compliance with regimens.
Primary conclusions of this study are as follows:
Patients have more person-oriented concerns, such as their ability to function and who will provide their care. When these concerns were addressed and patients were involved in the decision-making process, their satisfaction with the discharge plan was increased.
Families have more process-oriented concerns, such as amount of time spent by discharge planner on their case, the number of options considered, and the involvement of the patient in decisions.
The implications of the above are that health professions can increase patient/family satisfaction with increased communication and relationship-building interventions which involve empowering patients to make decisions and being sensitive to their feelings and concerns.
It is not surprising that patient/family satisfaction was lowest when the discharge was to nursing homes; however, the study indicates that even here, the Social Worker can impact satisfaction by spending more time, increasing professional attention and demonstrating that we have undertaken
a thorough planning process on the patient s behalf.