The Social Work Role in Reducing 30-Day Readmissions: The Effectiveness of the Bridge Model of Transitional Care

The hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. Novel approaches to addressing the complexities of transitional care are emerging as possible solutions. The Bridge Model is a person-centered, social work-led, interdisciplinary transitional care intervention that helps older adults safely transition from the hospital back to their homes and communities. The Bridge Model combines 3 key components—care coordination, case management, and patient engagement—which provide a seamless transition during this stressful time and improve the overall quality of transitional care for older adults, including reducing hospital readmissions. The post Affordable Care Act (ACA) and managed care environment’s emphasis on value and quality support further development and expansion of transitional care strategies, such as the Bridge Model, which offer promising avenues to fulfil the triple aim by improving the quality of individual patient care while also impacting population health and controlling per capita costs.     

“Unexpected and Distressing”: Understanding and Improving the Experience of Transferring Palliative Care Inpatients to Residential Care

The survival of patients with advanced cancer, coupled with the increased presence of end-stage chronic illnesses in an aging population, is leading to a demand in palliative care. Due to the ongoing need for acute-pain and symptom control in hospice/palliative care units, few are able to offer long-stay admission for those whose symptoms have stabilized. When a patient no longer requires specialist palliative care services, transfer from an inpatient palliative care facility may then be necessary. A core component of the role of palliative-care social workers involves working with patients and their families/carers when the care pathway shifts and the option of residential aged care facility (RACF) needs to be considered. This research explored several issues, including the impact of this transition on the patient and their families and on the interdisciplinary health care team treating the patient. An investigation was undertaken to identify concerns and barriers regarding the transition from hospice care to RACF and opportunities were highlighted to improve clinical practice in this area. A tripartite approach was adopted conducting face-to-face interviews with patients, their families/carers, and health care professionals. Members of the interdisciplinary team were interviewed and social workers working in similar inpatient palliative-care facilities undertook telephone interviews to gauge their experiences. A thematic analysis discerned a number of themes highlighting the impact of this transition on key stakeholders and incorporated recommendations to improve or best manage this process. The research has highlighted the difficulties that patients/families encounter in this transition, as well as the emphases of protecting the integrity of the patient and family. This is achieved by holding open and ongoing dialogue, particularly through family meetings and working in collaboration with the patient, the family, and the team. Understanding the experience and impact of this transition on key stakeholders is helpful in building up a knowledge base and to ensure a more effective relationship occurs. This research incorporated the voices of terminally ill patients, families, and members of the health care team in order to understand their views and recommendations for best managing the transition from a hospice/inpatient palliative-care facility to a RACF. This enables their input to have some real impetus in clinical practice and service delivery.     

Integrating Health and Social Care at the Micro Level: Health Care Professionals as Care Managers for Older People

A common problem in the provision of coordinated long‐term care is the separation of health and social care. The present government has been increasingly concerned with promoting convenient, user‐centred services and improving integration of health and social care. One arrangement that could contribute to this for some older service users is for health care staff to act as care managers, coordinating the provision of both health and social care. This paper presents the findings of a survey of arrangements in place in local authorities for health staff to work as care managers for older people. This was designed to provide details about the range and scope of care management activities undertaken by health care professionals. Key areas of enquiry included: which kinds of health care staff undertook care management and in what settings; how long the arrangements had been in place and how widely available they were; whether there was a distinction between the types of cases and care management processes undertaken by health care staff compared with their social service department counterparts; and what management and training arrangements were in place for the health care staff.     

Development,Feasibility, and Piloting of a Novel Natural Mentoring Intervention for Older Youth in Foster Care

Aging out of foster care is associated with deleterious emerging adulthood outcomes. The enduring presence of a caring adult, such as a natural mentor, can improve outcomes for emancipating foster youth. Caring Adults ‘R’ Everywhere (C.A.R.E.) is a novel, child welfare-based intervention designed to facilitate natural mentor relationships among aging-out youth. Our aims were to test the feasibility of implementing C.A.R.E. and the feasibility of conducting a randomized controlled study with older foster youth. Twenty-four foster youth aged 18–20.5 years were recruited and randomly assigned to the intervention (n = 12) or control groups (n = 12). Ten natural mentors were identified and contacted for participation in the intervention and study. Process-oriented qualitative data and quantitative pre- and postintervention outcome data were collected and analyzed. Utilizing a controlled rigorous design, the findings highlight the positive experience of both the intervention youth and their natural mentors with C.A.R.E. Overall, results support the continued refinement, delivery, and rigorous testing of C.A.R.E. with great promise for programmatically supporting natural mentor relationships among youth aging out of foster care.     

Does Volunteering Experience Influence Advance Care Planning in Old Age?

Advance care planning (ACP) increases the likelihood patients will receive end-of-life care that is congruent with their preferences and lowers stress among both patients and caregivers. Previous efforts to increase ACP have mainly focused on information provision in the very late stage of life. This study examines whether a relationship exists between volunteering and ACP, and whether this relationship is associated with social support. The sample comprises 877 individuals who were aged 55+ in 2008, and were deceased before 2010. The sample is derived from seven waves (1998–2010) of data from the Health and Retirement Study. Logistic regression results showed that overall ACP and durable power of attorney for health care (DPAHC) were both higher (OR = 1.61 and 1.71, respectively) for older adults with volunteering experience in the past 10 years than those without such experience. Available social support (relatives and friends living nearby) was not associated with the relationship between volunteering and ACP. Other factors related to ACP included poorer health, death being expected, death due to cancer, older age, and being a racial minority. Involving older people in volunteer work may help to increase ACP. Future research is encouraged to identify reasons for the association between volunteering and ACP.     

The Attitudes of Social Work Students Toward End-of-Life Care Planning

This study examined the attitudes of social work students toward end-of-life care planning, as well as their degree of willingness to engage in this area of social work practice. Factors associated with their attitudes were measured through structured surveys completed by 102 social work students (N = 102) at a school of social work in the southeast. Results indicated that these social work students tended to have positive attitudes toward end-of-life care planning in general. Moreover, these attitudes were positively associated with preference for pain relief treatment, higher levels of comfort when discussing death, more emphasis on self-determination, and apprehension of conflicts of self-determination. The results of this study underscored the increased societal need for recognition of personal preferences in end-of-life care, higher levels of comfort when discussing death, and an increased commitment of social workers' to maintaining the ethical principle of the client's right to self-determination in end-of-life planning. While this is not surprising, it points to a continuing need to re-assess where the field stands in its preparation of social work professionals who will work closely with people who are dying and their families.     

The Influence of Sociodemographic and Psychosocial Factors on Advance Care Planning

This study investigated sociodemographic and psychosocial factors that enhance or impede the completion of advance care planning, analyzing data from the Health and Retirement Study. The analytic subsample included the panel participants who died between 2006 and 2010 and who had answered the psychosocial and lifestyle questionnaire when they were alive. Multinomial logistic regression was executed to answer the research question (N = 1,056). The study found that persons who were older, who were women, who identified themselves as White, and who had higher levels of income and education were more likely to be motivated to complete advance care planning. Having greater sense of control was found to weaken the adverse relationship between being African American and the completion of advance directives. Having cancer, suffering from the illnesses for longer periods of time, and having experience of nursing home institutionalization also predicted the completion of advance care planning. Implications include incorporating a culturally tailored approach for racial/ethnic minorities and using advance directives that are clear and easily understood. In addition, future research needs to include a larger minority population and examine the extent to which variations between racial/ethnic groups exist in relation to advance care planning.     

Lesbian Health Care: Women's Experiences and the Role for Social Work

ABSTRACT

Lesbian patients and their families may be exposed to discriminatory practices in the health care system. This qualitative study of 57 Midwestern lesbian parents used open- and closed-ended questions to examine the experiences the respondents had with their primary and secondary health care providers. Four themes emerged from the data: systemic barriers to health care, coming out to providers, seeking lesbian, gay, bisexual, and transgender-friendly health care providers, and concern about mistreatment and prejudice within the health care system. Implications for service delivery, health care education, and directions in policy and research are explored.     

Indigenous Elder Insights About Conventional Care Services in Alaska: Culturally Charged Spaces

Indigenous peoples around the world endure health and social disparities. In the United States, such disparities are typically ameliorated through conventional care services and organizations. Purpose: To examine points of tension that characterize culturally pluralistic care services in the United States, specifically Alaska, within context of Indigenous colonial histories. Design and Methods: The research design is ethnographic and multisited, comprising 12 months of fieldwork across urban, rural and remote village sites in Alaska. A conceptual lens that accounts for culturally diverse social spaces where relations of power are at stake frames research presented here. This work incorporates relational and participatory action research principles with Alaska Native Elders. Ethnographic evidence was collected through multiple methods, including field notes, documents, and interviews, with ethnographic analysis involving atlas.ti. Findings: Alaska Native Elders describe salient points of tension characterizing Alaska’s conventional care services through the following insights: generational curses-—a pain, prejudice on both sides—wounded, and value-systems clash—fighting. Conclusion: This article concludes with discussion about collective anxieties and implications for care services.     

Organizational Restructuring in European Health Systems: The Role of Primary Care

The main goal of this paper is to review the strategies developed across European health care systems during the 1990s to improve coordination among health care providers. A second goal is to provide some analytical insights in two fields. On the one hand, we attempt to clarify the relationships between pro‐coordination strategies and organizational change in health care. Our main conclusion is that the specific features of health care impede the operation of either market or hierarchical coordination mechanisms. These can, however, be selectively successful if applied as levers to promote the role and impact of the pro‐cooperative coordination strategies which are ultimately required to foster adequate inter‐professional and inter‐organizational coordination. On the other hand, we try to cast some light on the ongoing debate on convergence versus path dependency within the broader field of welfare state reform. Evidence on pro‐coordination reforms in health care apparently supports some insights from previous work on the centrality of the socio‐political structure to account for varying patterns of selective path dependency across countries. In particular, the informal power resources of specialist physicians vis‐à‐vis primary care professionals and the state are critical to explain the different rhythm and fate of pro‐coordination reforms across Europe. Against received wisdom, the evidence examined suggests that selective path dependency might apparently be compatible with a general trend towards convergence understood as hybridization.     

Health Care Fraud and Industry Structure in the United States

The cost of health care fraud and abuse is enormous. Not only is it costing us a lot of money but one wonders how many more people could afford and receive medical insurance if fraud and abuse were significantly lower. This paper will show that the problem is embedded in the way America does health business. The problem needs to be better addressed by both the criminal justice community and the health care industry. Most importantly, those making the health care industry policy decisions need to make a paradigm shift. The system is out of balance because of past policies and decisions that have given excessive power and liberty to the medical services community and insurance providers. Using O’Toole's Compass Card of the four major ideas that have influenced political decision‐making as a guide, this paper recommends that current decision‐making needs to strengthen the equality and community poles and restrict the liberty and efficiency poles so that more balance might exist within the American health care system. Talcott Parsons saw the dangers of commercializing health care over half a century ago. The health care scene of today shows that he was correct in his appraisal.     

Client Experiences of Trauma-Informed Care in Social Service Agencies

This paper describes a qualitative study of individual client interviews (n?=?26) from four social service agencies to understand how clients experience trauma-informed care services and implementation challenges. We used the Fallot and Harris framework to explore client experiences of the five core concepts of trauma-informed care (safety, trustworthiness, choice, collaboration, and empowerment) using semi-structured interview questions with each client. The four agencies consisted of: refugees (n?=?4), substance abuse (n?=?8), older adults (n?=?12), and maternal/child health (n?=?2), and the agencies varied in size, service goals, and clientele. The results of the study suggest that clients’ experience of these concepts was shaped by the actions of other clients, and these experiences were either mitigated or hindered by actions of the agency employees. Agency policies either supported or enhanced their experiences as well. The results also suggest that it was challenging for agencies to provide for all of the trauma-informed care (TIC) concepts at the same time. We discuss the implications of these findings for social service delivery in a range of agency types. Future research should examine the effects of trauma-informed policies on client experiences of each TIC domain.     

Developing the NICE/SCIE Guidelines for Dementia Care: The Challenges of Enhancing the Evidence Base for Social and Health Care

Internationally, interest is developing in the challenges ofdeveloping evidence-based guidelines for social work practice.The paper reports on the process of establishing the UK’sfirst joint health and social care evidence-based practice guideline,which is in dementia care. The paper addresses the methodologicaland procedural challenges of reviewing, meta-analysing and synthesizingknowledge for health and social care given the contrasting historiesof the two sectors in relation to the emergence of evidence-basedpractice. Dementia care is a complex domain within which socialand clinical perspectives intersect, reinforcing the desirabilityof producing ‘joined up’ health and social carepractice guidelines that are relevant to integrated services.It is suggested that the exemplar of producing a joint healthand social care guideline for dementia may be a model for futuredevelopment of practice guidelines. Some of the main recommendationsare presented to illustrate the character of the joint guideline,lessons are drawn for future guideline development, and implicationsfor policy and practice implementation are considered.     

Analysis and Advocacy in Home- and Community-Based Care: An Approach in Three Parts

A new chapter in health policy presents both challenges and opportunities for aging policy analysts and advocates concerned with long-term care. Millions of long-term care recipients and providers live today in a pubic policy netherworld, one principally associated with Medicaid. I suggest here that moving policy forward will entail three key steps: (a) to overcome structural lag in key home and community-based care (HCBC) policy arenas; (b) to reverse a contemporary pattern of risk-shifting from institutions to individuals; and (c) to inform and empower caregivers to have their own pressing needs recognized. Recent developments in Washington provide new optimism on these fronts. Voluntary long-term care and community-based care (LTC/HCBC) proposals are on the table within the broad context of health care reform. Whether they remain will be, in large, part a function of how far we have moved along the fronts described: modernizing policies, recognizing risks, and activating neglected policy constituencies.     

The impact of familism on future care planning for Korean parents caring for their children living with disabilities

ABSTRACT

Future care provision is a pervasive concern of parents with children living with disabilities. This article aims to provide an overview of the impact of familism on future care planning for Korean parents. For this qualitative study, data were collected using semi-structured interviews with parents (n = 9) and professionals (n = 9). Using conventional analysis, the study revealed there is strong emphasis on familial care with minimal governmental service provision and intervention; ultimately, this has a negative impact on the planning process. In support of the planning process taking its place as a standard phase of caring, a number of recommendations are made.     

The Integration of Health and Social Care: The Lessons from Northern Ireland

Mechanisms for the integration of social services with health have come to dominate the debate on providing a more seamless provision of health and social care. Working together at the health and social care interface has been strongly promoted and endorsed in government documents since the late 1990s. Moves towards integration have been treated with suspicion and scepticism in the academic literature, with many authors highlighting the many barriers and challenges presented by this method of working. Yet these proposals do not represent a paradigm shift in culture in all parts of the United Kingdom, as Northern Ireland has had an integrated health and social care system for over thirty years. Based on an empirical study of senior health care professionals in Northern Ireland, this study identifies and discusses the key issues associated with integration. It concludes that the experiences in Northern Ireland have to date been overlooked or misrepresented and could prove extremely valuable in gaining an understanding of the challenges and benefits of integrated arrangements.     

Implementing and sustaining evidence-based practice in health care: The Bridge Model experience

This qualitative study analyzed the experience of community-based organizations (CBOs) implementing and sustaining the Bridge Model of Transitional Care, a social work-based health service intervention for reducing hospital readmissions. We conducted semi-structured interviews with clinical supervisors from 13 CBOs that received Bridge Model training between 2012 and 2015. CBOs faced significant challenges implementing and sustaining transitional care programs, particularly related to building effective and sustainable partnerships with hospitals. Additional barriers to program implementation and sustainability included financial barriers and staff turnover. Facilitators to implementation and sustainability included organizational champions, organizational culture, and value of evidence. Recommendations for CBOs to implement health service interventions include gaining early buy-in from hospital partners, creating a contractual arrangement with the hospital partner, understanding changes in health-care payment models, diversifying funding sources, developing an evaluation plan, and nurturing organizational champions.     

Supporting familial and community care for children: legislative reform and implementation challenges in South Africa

This article critically evaluates important legislative reforms in South Africa, which, at the height of the AIDS pandemic, are intended to reduce the need for removing children from their families or communities. In a textual analysis of the 2005 Children's Act and the 2006 Children's Act Amendment Bill, the shift in focus from individual interventions to a developmental approach incorporating prevention and early intervention is explained. New family service and alternative care orders such as partial care, shared care, cluster care and support for child-headed households are described. Although these creative solutions have considerable potential, there are gaps in the legislation that require supplementary wording. Drawing on the work of researchers and commentators, it is also shown that an inappropriate approach towards implementation has commenced, which harms rather than assists children. Recommendations are made for improving implementation that may be of relevance to other countries faced with similar challenges.