Enhancing Collaborative Leadership in Palliative Social Work in Oncology

The Institute of Medicine (IOM) Report—Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs—provided recommendations for meeting the palliative care needs of our growing population of older Americans. The IOM report highlights the demand for social work leadership across all aspects of the health care delivery system. Social workers are core interdisciplinary members of the health care team and it is important for them to be well prepared for collaborative leadership roles across health care settings. The ExCEL in Social Work: Excellence in Cancer Education &; Leadership education project was created as a direct response to the 2008 Institute of Medicine. (2008). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: National Academies Press. [Google Scholar] IOM Report. This article highlights a sampling of palliative care projects initiated by outstanding oncology social work participants in the ExCEL program. These projects demonstrate the leadership of social workers in palliative care oncology.     

Managing in the Trenches of Consumer Care: The Challenges of Understanding and Initiating the Advance Care Planning Process

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.     

Social Workers' Use of Spiritual Practices in Palliative Care

Abstract

Numerous studies have examined client use of spiritual and/or religious practices to cope with illness and adversity. This study explores social workers' use of spiritual practices as reflected in their work with palliative care clients. Survey results (n = 327) indicated significant relationships of spiritual practices such as yoga, prayer and meditation to working with palliative care clients. The total number of these approaches is predicted by factors such as theoretical orientation and the social workers' own struggles with palliative care and other issues. Our study supports the need for additional investigation of spiritual issues in practice.     

Comfort and Confidence Levels of Health Care Professionals Providing Pediatric Palliative Care in the Intensive Care Unit

ABSTRACT

Most childhood deaths that occur in the hospital happen in the pediatric intensive care unit. Providing pediatric palliative care in the intensive care unit comes with unique challenges due to the acute care, curative and often medically aggressive focus of these settings. In this study, 190 PICU health care professionals reported on their comfort and confidence in providing palliative care. Findings indicate that professionals report only a moderate level of comfort and confidence in this type of care in the pediatric ICU. For physicians and nurses, comfort and confidence was significantly higher for those who had practiced 8 years or more. Practitioners reported less comfort in providing psychosocial care. Implications for the social work role on the interdisciplinary team and suggestions for future research are discussed.     

An Ecological Understanding of Caregiver Experiences in Palliative Care

Palliative care is specialized health care to improve quality of life for patients with serious illness and their families through prevention and relief of suffering. A Palliative Care Institute was held in western Washington to capture community voices about diverse needs, strengths, and opportunities for improvement of palliative care. Researchers employed qualitative methods to obtain thematic data, provide real-time analysis, and engage in a multivoting technique to reflect stakeholder interest in individual themes and prioritize larger group interests. Bronfenbrenner’s ecological systems framework was used to explore caregiver experiences. Within the microsystem, caregivers reported difficulties in interactions with medical providers as a key challenge. Within the mesosysytem, interactions between patients and medical providers and the impact on caregivers were explored. Within the exosystem, caregivers reported lack of control over the schedules of personal care staff. Macrosystem influences included impact of local culture on the development of palliative care services. Chronosystem influences include de-medicalization of childbirth and its impact on perceptions of palliative care. Implications include the need for social workers to be proactive in fostering trust and effective communication between care providers and caregivers, and the demand for health care provider training in communication with patients and families.     

End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home

Education about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N?=?300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.     

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.     

Welfare Rights Advocacy in a Specialist Health and Social Care Setting: A Service Audit

Is a specialized welfare rights service, thought important insocial services departments, a valid element of social careservices in multi-professional settings in which social workis increasingly incorporated, where social workers often helpservice users with benefits? An audit of a specialized welfarerights advocacy service, part of social work provision in alarge UK hospice, demonstrated inconsistent referral by nursingstaff, the main referrers, a large workload including frequentcomplex cases and achievement of benefits and grants for patients,carers and families substantially in excess of the cost of theservice. Annual workload for a forty-eight-bed hospice with1,600 home care patients was estimated at 976 typical caseswith nearly 2,928 contacts; about sixty complex cases annuallygenerated a similar workload in themselves. Provision of specializedwelfare benefits advocacy for palliative care patients is foundlikely to meet a substantial need and to require specialistprovision. This may be true of other multi-professional servicesincorporating social workers.     

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.     

Advance Care Planning in the Delivery of Adult Protective Services

ABSTRACT

In ensuring the safety and protection of older adults from abuse and exploitation, adult protective services (APS) workers face a variety of situations involving serious illness and end-of-life conditions. Many older adults encountered in APS will present with one or more chronic conditions that may warrant discussion of advance care planning with clients and their families. This study surveyed APS workers (n = 508) in 21 states regarding encounters with end-of-life situations and the practice of future care planning. Results revealed that three-fourths of APS workers encounter clients with serious illnesses and about two-thirds do discuss planning in advance for care. More than one-half of the respondents indicated client incapacity and refusal to address future care needs as barriers to discussing planning in advance for care. Recommendations to enhance advance care planning among APS workers are discussed.     

Barriers Associated with the Implementation of an Advance Care Planning Program in a Prison Setting

Advance care planning is considered a best practice within health care. However, the extent to which planning occurs within prison settings is unknown. Through the course of implementing an advance care planning (ACP) program for aging and dying offenders at a medical classification center, multiple barriers were identified that need to be addressed systemically to ensure the medical wishes of offenders were known and honored. This article will outline the barriers and the steps that were taken to create systems change to promote and sustain advance care planning.     

Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life

Although evidence-based therapies for Posttraumatic Stress Disorder (PTSD) exist for physically healthy populations, these often do not adequately address PTSD in dying patients. Particularly because these interventions require 8–16 weekly sessions, and the median stay in U.S. hospices is 17.5 days (National Hospice and Palliative Care Organization [NHPCO], 2015 National Hospice &; Palliative Care Organization (NHPCO). (2015). NHPCO Facts and figures: Hospice care in America. Retrieved from http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf. [Google Scholar]), there is a potentially serious timing mismatch. Moreover, these treatments may temporarily increase trauma symptoms (Nishith, Resick, &; Griffin, 2002 Nishith, P., Resick, P. A., &; Griffin, M. G. (2002). Pattern of change in prolonged exposure and cognitive-processing therapy for female rape victims with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 70, 880–886. doi:10.1037//0022-006x.70.4.880[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]), resulting in some patients dying in greater distress than had they not received care. The Stepwise Psychosocial Palliative Care (SPPC) model presented in this article compensates for these difficulties by embracing a palliative care approach to PTSD. Although it utilizes techniques drawn from existing PTSD interventions, these are re-ordered and utilized in a time-responsive, patient-centered manner that takes into account prognosis, fatigue, and logistical concerns. The SPPC approach is further considered with respect to existing social work palliative care competencies (Gwyther et al., 2005 Gwyther, L. P., Altilio, T., Blacker, S., Christ, G., Csikai, E. L., Hooyman, N., … Howe, J. (2005). Social work competencies in palliative and end-of-life care. Journal of Social Work in End-of-Life &; Palliative Care, 1, 87–120. doi:10.1300/j457v01n01_06[Taylor &; Francis Online] , [Google Scholar]) and a case study is used to demonstrate its application.     

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.     

A Time and Place: The Role of Social Workers in Improving End-of-Life Care

Americans are living longer, but dying after a prolonged period of management of multiple chronic illnesses and functional disabilities. Despite waves of public and professional activity targeted toward improving care for the dying and supporting the families, gaps in care and challenges in end-of-life care persist. Contentious issues such as the so-called “death panels” or physician payment for discussion of advance directives and care wishes at the end of life; aid in dying; and regarding individuals who actively choose death (case of Brittney Maynard) are continually debated in the public media. Progress toward improvement in the experience of dying remains incremental and change has been slow. With the release of a second Institute of Medicine (2014 Institute of Medicine (IOM). (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: National Academy Press. [Google Scholar]) report devoted to what it means to die in America in the 21st century, momentum and opportunity for change may increase. If this is to happen, social workers will need to deliver the range of biopsychosocial care that patients and families so desperately need. However, holistic care of the individual will only improve, if the nation also addresses ongoing systemic problems in financing, policy, and service delivery in end-of-life care.     

Practitioners' Documentation of Assessment and Care Planning in Social Care: The Opportunities for Organizational Learning

This paper analyses practitioners’ documentation of socialcare assessments and care plans for disabled adults of workingage. The data were collected in the course of an innovativeproject that introduced new outcome-focused documentation intoroutine social care assessment, care management and review processes.The project aimed to encourage practitioners to focus duringthese processes on the full range of outcomes that individualdisabled adults might seek to achieve; and identify the appropriateservices for realizing those outcomes. Analysis of the new documentationprovides insights into the diverse range of priorities and outcomesthat service users aspire to achieve as a result of receivingservices, and the service inputs that were agreed between practitionersand service users. However, despite the new documentation, themajority of both outcomes and services that were recorded tendedto cluster around a fairly narrow range of conventional socialcare service functions. Moreover, the emphasis of both outcomesand service inputs differed between different groups of socialcare professionals. In the context of current policies to makesocial care services more individualized and outcome-focused,each of these findings has major organizational implications.The opportunities for using routine practitioner documentationto identify areas of organizational and professional changeand learning are discussed.     

NHS Purchaser–Provider Relationships in England and Wales: The View from Primary Care

Primary care organizations (PCOs) in the National Health Service in England and Wales are required to purchase most hospital-based health care for their populations. This 'quasi-market' in health care can be seen as 'relational', characterized by an emphasis on cooperative long-term relationships rather than on true competition. The English government has recently introduced new market mechanisms as a response to the perceived weakness of the relational market. This article draws on three qualitative case studies of PCOs to investigate whether PCO personnel interviewed in 2005/6 concurred with that perception of weakness. Overall, relationships between PCOs and hospital services providers were regarded as unbalanced in favour of the latter, despite a shared framework of central government policy. Commissioners were seen as generally weak, and providers were judged to be generally unresponsive to PCOs' wishes. Top–down pressure by governments on PCOs and providers of hospital services was more important than commissioning power in shaping hospital services. It remains to be seen whether the remarketization strategy succeeds in strengthening the commissioning function in primary care.     

Eldercare Service Redesign in Finland: Deinstitutionalization of Long-Term Care

ABSTRACT

Deinstitutionalization is an important trend in the redesign of long-term eldercare in Finland. It refers to a process where traditional institutional care is partly replaced by home care services and the creation of homelike housing units. The first part of this article provides an overview of eldercare service redesign by using national statistics. The second part consists of qualitative analysis of the deinstitutionalization of eldercare. The data consist of 27 interviews conducted among municipal care administrators and is analyzed using thematic and discourse analysis. Main findings show a deep policy change taking place in eldercare deinstitutionalization discourse lying at its center. A distinction between explicit and implicit deinstitutionalization discourse is made. The former clearly states that institutional care needs to be cut back making it possible for all older people to live at home or in homelike housing facilities. Implicit deinstitutionalization discourse is underpinned by comments of a different type, more critical and problem-centered. Within intensive service housing, for instance, fee policy is reformed. The main results include the observation that explicit deinstitutionalization discourse is in line with the national policy aims of putting home first, while implicit discourse deals with hidden or unexpected consequences. The article discusses future research in the conclusion.     

The State of Care Management in Learning Disability and Mental Health Services 12 Years into Community Care

This paper reports on the organization of care management froma longitudinal study of community care for people resettledfrom long-stay learning disability and psychiatric hospitals.The findings from a 12-year follow-up of care management arrangementsin 12 learning disability and eight mental health study siteservices are described. The diversity of care management arrangementsfound at earlier points in the evaluation remained evident.Also, many of the former ‘care in the community’service users were excluded from mainstream care managementarrangements in their localities. The difficulty of developingperson-centred arrangements in learning disability and the lackof integration of the Care Programme Approach and care managementwere evident. The findings and observations are placed in thewider policy and practice context, with suggestions for takingcare management forward nationally and locally.