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The Big Squeeze
Social workers face a one-two punch: dwindling community resources, shorter hospital stays


Social Workers like Renee Eubanks, above, must often scramble to line up post-hospital care.
Last winter, a 35-year-old man from Pennsylvania—we’ll call him Jason—was admitted to a neurology unit. He was having muscle spasms and was unresponsive to all commands. Strangely enough, Jason had been a healthy, robust young man only the month before when he became increasingly confused. He had been rabbit and deer hunting in the mountains, and doctors ultimately concluded he must have hunted and eaten a diseased deer that likely had caused his brain injury.

Therapists worked with Jason every day, and soon he began to occasionally respond to commands and open his eyes to his name. The neurology team felt strongly that he could benefit from an acute rehab program, but Jason’s insurer insisted on custodial care in a nursing home. Social worker Renee Eubanks made two unsuccessful appeals, then resorted to applying for Medical Assistance and searched for an appropriate rehab facility. Very few, she quickly discovered, were available. Meanwhile, Jason waited on the unit while other, new patients needed his bed.

Eubanks’ struggle is typical of the challenges social workers face today. Insurance cut-backs and dwindling community resources are impediments to post-discharge planning. This situation, coupled with hospitals’ renewed emphasis on shortened patient stays, is putting the squeeze on what social workers can accomplish. The medical team has a mandate to free up the beds; the social worker must scramble to nail down the post-hospital care the patient requires and wants.

How hard is that? Just try to find dialysis for an alien, shelter for a substance-abusing victim of domestic violence, a bed for an adult patient, like Jason, on a vent. Want to get a patient into a state mental institution? Good luck. Area psychiatric facilities have either closed or shrunk to meet the size of their own long-term, chronic patient population. “A few years ago, we used to move two or three patients a month into places like Springfield and Spring Grove,” says Jan Hedblom, director of psychiatry social work. “But in the last year, if we moved five patients there, I’d be surprised.”

Also closing their doors are extended-care facilities like nursing homes and group homes. Shelters for the homeless, particularly for women, are in short supply. Some state entitlement programs are no longer in existence. The state’s pharmacy assistance programs have changed radically. One now requires more documentation and longer periods for processing applications. Another, for children, has reduced the amount it will pay for “rare and expensive” medicines.

Against this backdrop is Hopkins’ ongoing, aggressive campaign to shorten patients’ hospital stays. Social workers participate in all the length-of-stay initiatives, explains Carol Stansbury, director of Med/Surg social work, and thus their concerns and needs are well understood. But frequently, she says, “the medical team comes up with wonderful discharge plans that often can’t be met. We get pulled in to make it happen anyway, and we have to do it within a tight time frame.”

Take the case of an elderly woman who came in through the ED with chest pain. She lived alone in her house, but her granddaughter had the keys and was selling drugs there. The chest pain turned out to be simple anxiety, and the medical staff wanted to send her home. “On the one hand,” says Hedblom, summarizing this classic situation, “the doctors are dying to have the bed. On the other, we can’t send the patient home. Often, social workers are very much in the middle, and we have to tell the docs: Cool your jets; this patient is not moving.”

In the end, the social worker was able to get Adult Protective Services (APS) to handle the woman’s case, which according to Susan Rucker, director of social work for the AIDS service, was nothing short of a miracle. Rucker can’t remember the last time she was able to get APS, the state program that protects vulnerable adults, to accept a referral. She recalls a schizophrenic patient who couldn’t get the checks he was entitled to. To buy food, he was selling furniture out of his house and prostituting himself. Rucker called APS for help. “They looked into the matter and found that if they did get him his check, his check was not enough to cover his expenses. Therefore, they decided that they would not provide any assistance. That was that. The end.”

Such frustrating battles with under-staffed state agencies are part of life for a social worker. Making arrangements, keeping abreast of changing rules, regulations and policies, finding money—all are challenges they routinely face. They must deal continually with an array of external groups.

How do they do it? “We build relationships,” says Hedblom. Social workers make it a point to get to know staff in the Maryland Medical Assistance Program, which has an office on Osler 1, for example. Twice a year, they send over food. “We send the workers out beyond the walls when they have identified the places where they are going to make referrals,” says Stansbury. They might check out dialysis programs, Bayview’s Care Center (geriatrics) or chemical dependency unit, or shelters in Baltimore City. Adds Hedblom: “We tell the truth about patients. If the patient does not do well in a facility, we promise to take him back. And we will try to tune him up again. If we don’t tell the truth, and they have to face care they can’t provide, they won’t take our next patient.”

It is not easy to measure the benefits of social work in terms of clinical outcomes and contributions to the bottom line. In Psych, however, Hedblom and others showed that when there were staff vacancies or new social workers in training, length of stay increased dramatically. Eventually, studies in the other units will likely bear out similar conclusions. For now, the proof, as they say, is in the pudding.

-Anne Bennett Swingle

Council of Five

JHH's social work directors, left to right, Loretta Wall, Pediatrics/Gyn-Ob; Jan Hedblem, Psychiatry; Susan Rucker, AIDS Service; Louise Knight, Oncology; Carol Stansbury, Med/Surg.

The social work program at The Johns Hopkins Hospital is one of the oldest in the country. It was established in 1907, just two years after the first program was launched at Massachusetts General Hospital. Today, about 20 percent of the nation’s social workers practice in hospitals.

At Hopkins Hospital, approximately 80 social workers practice within their respective functional units (Medicine/

Surgery, AIDS Service, Oncology, Pediatrics/Gyn-Ob, and Psychiatry). A council consisting of the five directors meets twice a month. Social workers play a role in setting institution-wide policy, serving, for example, on hospital committees such as those dealing with ethics, palliative care, clinical performance improvement and length-of-stay reduction.

Social workers provide services to the entire spectrum of hospitalized and ambulatory patients, from neonates to the elderly. The cases typically are unusual and complex; the needs, great. So in addition to linking patients with appropriate community agencies and resources, social workers counsel patients and families and help them resolve problems related to illness, health care and rehabilitation.

An integral part of the health care team, social workers are well supported by their functional units, says Carol Stansbury, director of Med/Surg social work. “The chairmen are very aware of the current state of social work resources. They advocate as best they can for us to get the help patients need.”

 

 

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