Evaluating social work discharge planning services for elderly people: access, complexity, and outcome.

The discharge planning role of hospital social workers has become increasingly important in services to elderly people. This article examines three issues: (1) the extent to which elderly people most in need receive social work services, (2) the extent to which the discharge planning performed is a professional task, and (3) the effectiveness of discharge planning for those who return to their homes after hospitalization. The study focused on 1,100 elderly patients from five Baltimore hospitals. Data were gathered from their social workers, from the patients themselves (by phone after discharge), and from medical records. Results show that only a minority of elderly patients who return to the community after hospitalization receive social work services while in the hospital but that those who do are likely to have posthospital needs. In most cases, the discharge planning uses professional skills, but 28 percent of cases are fairly routine. Finally, social work services were effective in reducing the level of unmet needs in the areas of nursing, medication, and physical therapy.

Impact of hospital discharge planning on meeting patient needs after returning home.

This study examines the contribution of hospital discharge planning in meeting the needs of patients for care after their return home. A random sample of 919 admissions (age 60 and over) to five hospitals was studied to obtain information on characteristics of discharge planning during the patients' hospital stay. Specifically, information was obtained on the involvement of a designated professional for managing and coordinating the discharge plan, and the extent to which the planning was interdisciplinary. Patient interviews conducted two weeks after discharge provided information on needs for care related to: (1) treatment, (2) activity limitations, and (3) other self-sufficiency limitations. Patients were asked about their need for care in these three areas and about whether or not these needs were being met. Overall, 97 percent reported one or more needs for care and 33 percent reported that at least one of these needs was not being met. Findings show that the involvement of a discharge planning case manager is related to a significant reduction in unmet treatment needs, but not to reductions in activity limitation, other self-sufficiency needs, or overall needs. No significant effects of interdisciplinary planning were identified. These findings suggest that treatment-related benefits result when a case manager has specific responsibility for the discharge planning of elderly patients returning home after hospitalization. These results provide insights into what is being achieved through current discharge planning practices. The meeting of specific patient needs through enhanced discharge planning may save future costs by reducing the rates of complications and hospital readmissions in an era of prospective payment, thus potentially offsetting the increased costs involved in planning and coordinating postdischarge care for older adults.

Unusual volar dislocation of the lunate into the distal forearm: case report.

A case of a severe wrist injury (fractures of the scaphoid, capitate, hamate, and ulnar styloid process) with volar dislocation of the lunate into the soft tissues of the forearm is presented. This degree of displacement of the lunate is exceedingly rare, and we believe has not been previously reported. Possible mechanisms, hyperextension injury forcing the lunate forward out of the carpus, or contact between the volar wrist skin surface and another object or surface propelling the dislocated lunate into the forearm, are discussed.

Biochemical evidence for a relative lack of inhibition of thrombin formation by nonionic contrast media.

An in vitro study was done to investigate the thrombogenic potential of nonionic contrast media. Whole blood from 18 healthy volunteers was mixed with ionic contrast medium (diatrizoate, ioxaglate), a non-ionic contrast medium (iohexol), or saline (the control) and incubated in glass and plastic test tubes. Levels of prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III complex (TAT), and antithrombin III (AT III) were measured. Evidence showed increased thrombin formation in glass tubes compared with that in plastic tubes, a finding in concordance with the known association between contact with glass and increased activation of coagulation. F1 + 2 and TAT levels were significantly increased in the nonionic mixtures compared with such levels in ionic mixtures (P less than or equal to .05). Control mixtures showed little or no overall increased thrombin formation by F1 + 2 and TAT levels compared with nonionic mixtures. These findings suggest an inhibition of thrombin generation by ionic contrast media in vitro and a relative lack of such inhibition by iohexol.

Patient counseling by general practitioners: Republic of San Marino's experience.

General practitioners (GPs) can play a unique role in improving individual health behaviors. To maximize this role, it is important to know what health education activities GPs are performing and where improvements can be made. This article presents data covering a one-year period regarding the health education/counseling activities of GPs in the Republic of San Marino, which has a National Health Service. The overall rate of health education interventions is 8.8 per 100 GP contacts. The diagnosis having the highest rate of health education counseling is lipid metabolism disorders (50/100). Other diagnoses having high rates are: anxiety, depression, irritable bowel syndrome, and disorders of stomach dysfunctions/gastritis (42, 40, 36, and 33/100 respectively). The lowest rate within the top 17 diagnoses receiving health education is uncomplicated hypertension (11.4/100). The range of provider variation in performing health education interventions ranges from 1.2 to 24.1 per 100 patients contacts. Such analyses permit identification of the specific areas where GPs may need assistance for increasing the appropriate use of effective health education interventions so that further progress can be made in meeting the health needs of communities.

Development and implementation of an intervention to increase cervical cancer screening in inner-city women.

Community interventions are increasingly recognized as an effective method for reaching individuals in need of health behavior change. We present our experience in developing and implementing an intervention to increase Pap test screening in an inner-city community with a high rate of cervical cancer mortality. Results of a baseline needs assessment survey showed that: almost one-half of the population was inadequately screened; 66 percent of inadequately screened women reported belonging to a church; and, a significant proportion of those who tended to rely on the physician for screening did not receive adequate testing. These results formed the basis of our community intervention strategy: lay peer educators, recruited predominantly from churches, were trained to motivate inadequately screened women to actively seek testing. The implementation of the intervention was flexible and responsive to insights gained in the field and process evaluation data. Recommendations for future community-based interventions are offered.

Medication compliance and health education among outpatients with chronic mental disorders.

Medication noncompliance occurs among as many as one-third to one-half of all medical and psychiatric outpatients. Noncompliance has serious consequences for individuals diagnosed with schizophrenia, often resulting in higher rates of relapse and rehospitalization, and poorer community adjustment. Health education interventions have been shown to be effective in promoting compliance among patients with chronic medical illness such as hypertension or diabetes, but there have been few randomized trials of this approach among patients with chronic psychiatric disorders. This paper presents the results of an application of health education among a group of male psychiatric outpatients. Two interventions were developed which used health education techniques to 1) engage families or significant others as active participants in the aftercare process, and 2) train patients to become effective health care consumers. A total of 418 individuals participated in a six-month trial over a four-year study. Both interventions significantly improved medication compliance among those who received them. The results show that comparatively brief interventions can significantly alter medication compliance behavior and improve the quality of life for patients with chronic psychiatric disorders.

Inner-city women at risk for cervical cancer: behavioral and utilization factors related to inadequate screening.

This study investigated the relationships between health care utilization, knowledge, attitudes, sociodemographic characteristics, and adequacy of cervical cancer screening among a random sample of women from inner-city neighborhoods with high rates of cervical cancer mortality. Of 416 women interviewed, 30.3% reported hysterectomies; women with intact uteri (N = 290) are the subjects of this analysis. Over two-fifths (44.1%) reported not receiving adequate Pap testing during the previous 4 years. Compared with adequately screened women, they were more likely to be 45 years or older, have no medical insurance, report never having been to an obstetrician-gynecologist, recall never having been told by a medical provider how often to get a Pap test, rely on providers for adequate screening, report not seeking care as often as they think they should, have less knowledge of risk factors for cervical cancer, and believe that women should get Pap tests less than yearly. Separate models for younger and older women showed that these factors vary by age, demonstrating the need for interventions to be sensitive to age subgroups. These findings suggest that cancer control activities should place more emphasis on motivating women as well as influencing the health care delivery system to maximize reductions in cervical cancer.

Effectiveness of a hospital-based cooperative care model on patients' functional status and utilization.

The primary objective of this study was to test the hypothesis that inpatient care which emphasized structured, patient education, self-care and social support from a care partner (the Cooperative Care Program) is a cost-effective alternative to the more expensive staff-intensive, traditional hospital care; and that such care can be substituted without resulting in poorer outcomes with regard to subsequent health status or use of services. The effects of this program on patient and physician acceptance, patient knowledge and treatment and health status, were evaluated by means of an experimental design with comparable groups of patients assigned to experimental (cooperative care) or control (usual hospitalization) group status. Follow-up analyses of both groups of patients for a 12-month time period concluded that there were comparable and equally positive post-hospitalization experiences, with greater than 90% of both groups of patients functioning well with respect to a series of measures of functional status. There was no evidence that Cooperative Care patients were re-hospitalized more often or needed more emergency, home care or other types of services. There was, on the other hand, evidence of the positive effect on patient understanding, adherence to treatment, satisfaction, and self-management.

Knowledge, attitudes, and reported practices of medical students and house staff regarding the diagnosis and treatment of alcoholism.

Although alcoholism is prevalent in both general and inpatient populations, barriers to its timely diagnosis and effective treatment exist. These are often attributed to physicians' inadequate understanding and skill development and negative attitudes toward the disease. All Johns Hopkins' medical students and house staff, during 1986 through 1987, received a self-administered survey of their attitudes, skills, perceived role responsibility, knowledge, and reported practices with regard to alcoholism. Results indicate a strong relationship between perceived role responsibility, confidence in skills, and reported screening and referral practices among students and house staff. Knowledge levels strengthened the association between skills and practices for medical students. House staff perceived less of a responsibility for screening than medical students. There was a trend toward lower confidence and more negative attitudes among house staff than medical students. The results point to areas where educational interventions can be improved to enhance quality of care and outcomes for this major chronic disease.

Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers.

This study introduced trained paraprofessionals, community health workers (CHWs), into the emergency department (ED) to supplement providers' routine efforts in high blood pressure (HBP) detection, treatment, and follow-up among high-risk black men. In a demonstration project over a 2-year period, CHWs provided (1) BP and pulse measurements, and educational counseling regarding HBP and cardiovascular risk factors; (2) telephone preappointment reminders to improve ED follow-up visit rates; and (3) recontact of patients failing to show for their ED follow-up visits to improve return rates even after missed BP appointments. Results of preappointment reminders by CHWs showed a 19% improvement in appointment keeping (P less than .001). With a sample of patients who had failed to return for a follow-up visit, CHW contact was also effective, showing an overall improvement rate of 7% (P less than .001). The results reported support the idea that individuals from the community, trained as paraprofessionals, can improve appointment keeping as well as be useful in assisting in screening and counseling for chronic conditions within the ED. These CHWs are seen as having the additional advantage of enhancing the integration of the ED, the community, and continuing care sites. The approaches used in this study should be applicable and may serve as a model for the approach to other chronic conditions experienced in urban high-risk communities.

Prevalence, detection, and treatment of alcoholism in hospitalized patients.

As part of an institution-wide program to enhance the education of physicians in diagnosing and treating alcohol dependence and abuse, a comprehensive survey was conducted in which all new admissions to the adult inpatient services of The Johns Hopkins Hospital were screened for alcoholism. The prevalence of screen-positive alcoholism, by department, was as follows: medicine (25%), psychiatry (30%), neurology (19%), obstetrics-gynecology (12.5%), and surgery (23%). Detection rates by the house staff and faculty physicians caring for those patients who screened positively were less than 25% in surgery and obstetrics-gynecology, between 25% and 50% in neurology and medicine, and greater than 50% in psychiatry. However, physicians were less likely to identify as alcoholic those patients with higher incomes, higher education, or private medical insurance; women; and those who denied heavy alcohol intake. Physician-instituted treatment rates for those patients diagnosed by the physician as having nonrecovered alcoholism were less than 50% in surgery and obstetrics-gynecology, between 50% and 75% in medicine and neurology, and 100% in psychiatry. The extent to which the physicians intervened while the patient was hospitalized correlated with the patient's reported change in alcohol use after discharge. Recommendations based on these data are being incorporated into the medical education curriculum.

Using the emergency department as a screening site for high blood pressure. A method for improving hypertension detection and appropriate referral.

This study describes the development and testing of a high blood pressure protocol for use in emergency departments (ED) to enhance detection of those patients appropriate for subsequent referral. The protocol involves two serial blood pressure measurements and a patient interview to determine: 1) previous history of high blood pressure (HBP), 2) treatment in past year for HBP, and 3) usual source of medical care. The accuracy of patient reporting was validated by comparison with the patients' hospital record (reflecting outpatient and inpatient visits). Results indicate that these self-reports have high levels of sensitivity (range 90-100%) and specificity (range 79-96%). Use of the additional patient information increased the sensitivity of the screening protocol in identifying when and where a patient should be referred. Use of this methodology indicates that the protocol is a simple and effective method for HBP screening. The findings also suggest that the ED is an ideal site for screening the "hard-to-reach" hypertensive population.

Identifying coronary-prone behavior in adolescents using the Bortner Self-Rating Scale.

Brief measures to identify coronary-prone (Type-A) behavior in young persons are greatly needed for longitudinal epidemiologic study of cardiovascular diseases. We examined the suitability of a modified 14-item Bortner Self-rating Scale (ABS) for use in an adolescent population. Responses of 549 racially mixed, low to middle income urban high school students were analyzed to see if ABS measurement properties matched those of the parent version. Construct validity was explored by correlating ABS scores with measures of anger expression, social support, life satisfaction, academic achievement and blood pressure. Results disclosed that the distribution and factor structure of adolescent ABS responses closely resembled findings obtained with adults. Scale validity was supported by significant associations of ABS scores with degree of overt anger expression, lack of social support, and dissatisfaction with school and life in and life in general. Academic achievement and blood pressure were found not to correlate with adolescent ABS scores. Possible race and sex differences are considered.

Utility of the health belief model in examining medication compliance among psychiatric outpatients.

This study investigates the relationship between health beliefs and medication compliance among a group of psychiatric outpatients who were prescribed antipsychotic drug regimens. The method of study was an interview with 107 outpatients discharged from two Veterans Administration Medical Centers. The health belief model (HBM) served as an organizing framework to explore the relationships among perceptions of illness severity, susceptibility, benefits and barriers of treatment, cues to action, and medication compliance. The results provide a systematic description of health beliefs reported by psychiatric outpatients. Analyses examine the ability of beliefs to predict compliance and affirm the model's theoretical cogency and appropriateness for use with psychiatric outpatients. Regression analysis showed that 20% of the total variance in compliance could be explained when all components of the HBM were examined together. The study supported the concepts that psychiatric outpatients hold identifiable patterns of health beliefs and attitudes and that the health belief framework functions best when utilized as an integrated model to examine compliance.

Breast self-examination by young women: I. Characteristics associated with frequency.

We surveyed a stratified random sample of college women (n = 869) to investigate correlates of the frequency of breast self-examination (BSE) in two young, relatively low risk populations, undergraduate and graduate women. The findings from this study compared to those from studies on older women suggest that certain factors are associated with BSE frequency for women of all ages (i.e., confidence in one's ability to perform the exam and exposure to information on breast cancer). There also appear to be distinct factors associated with the frequency of BSE performances among women within specific age-groups. For the younger, undergraduate women, attitudinal barriers; medical services use; skill knowledge; perception of personal control in detecting lumps; reinforcement through clinical breast exam; and the discussion of BSE with others were important factors in accounting for the variation in frequency of BSE performance. For the graduate women, in addition to confidence in one's ability to perform the test and exposure to breast cancer messages, one's perceived susceptibility, knowledge of risk factors, and perception of personal control in detecting lumps were important. The independent variables examined within each age-group accounted for a substantial amount of the variance in the dependent measure (34 percent and 42 percent, respectively, for undergraduate and graduate women), as compared to previous research, which has explained only 7-15 percent of the variance in BSE performance. This tends to validate our approach of using a multidimensional conceptual framework drawn from existing theoretical orientations.(ABSTRACT TRUNCATED AT 250 WORDS)

Breast self-examination by young women: II. Characteristics associated with proficiency.

Studying a stratified random sample of university women (n = 869) we investigated the correlates of proficiency (i.e., the correctness or competence) of breast self-examination (BSE). A 19-item BSE quality index score was developed based on the recommended steps a woman should perform when doing the exam in the three BSE positions. A comprehensive set of independent variables including knowledge, attitudes and perceptions, personal characteristics, and environmental factors were studied. While proficiency scores for both undergraduates and graduates were relatively low, the mean score for graduates was significantly higher than for undergraduates. This study corroborates the few recent studies that indicate that frequency of performance is not highly correlated with proficiency (relationships were r = .14 and .04, respectively, for undergraduate and graduate women). Bivariate and multivariate regression analyses demonstrate that the relevance of such factors varies by age (undergraduate and graduate). Results of the regression model indicate that the skill knowledge variable regarding time of month BSE should be performed, awareness of BSE, perceived effect of cancer detection, and perceived benefit of BSE were predictors of more proficient practice for undergraduates. Knowledge of time of month to do BSE and mammogram as a detection technology and discussion of BSE with others were important for graduate women. The independent variables examined accounted for 22 percent and 30 percent of the variance, respectively, for undergraduate and graduate women.(ABSTRACT TRUNCATED AT 250 WORDS)