Delayed discharge from mental health hospitals: results of an English postal survey.

This paper reports findings from a postal survey conducted by the UK's NHS Confederation to explore the rate and cause of delayed hospital discharges in mental health inpatient services. With delayed discharges the subject of considerable UK government activity in general hospital settings, there has been debate about extending recent financial penalties to mental health, fining social services departments for delayed discharges (a system known as reimbursement). Against this background, the NHS Confederation sent a postal survey to all 83 English mental health trusts and Primary Care Trusts with responsibility for providing mental health services. This asked respondents about delayed discharges from mental health inpatient beds in terms of number of delays, duration of delay, specialty and cause. Responses were then analysed quantitatively (in terms of number and extent of delays) and qualitatively (attitudes to reimbursement and other policies that might help resolve the issue). Overall, the survey reveals high levels of delayed discharges (with from 4% to 16% of beds affected and some 25 to 2,366 bed days lost depending on specialty). The causes of delayed discharge are varied, with a range of factors interacting. Although opinion was divided on the benefits of extending reimbursement, closer analysis revealed greater agreement than may at first be apparent. In particular, those favouring extension tended not to be 'pro-reimbursement' per se, but rather desperate to tackle delayed discharges and prepared to consider any policy that might help. This is an important addition to the current literature and debate, as it suggests that those seemingly in favour of reimbursement may actually be more motivated by a desire to try anything that might reduce delays rather than by commitment to this particular policy.

Cost-benefit analysis of social work services in the emergency department: a conceptual model.

OBJECTIVE: To describe an economic model for formal cost-benefit analysis of emergency department (ED)-based social services. METHODS: The varied monetary costs and benefits associated with ED-based social work services were projected for three hypothetical levels of ED volume (30,000, 60,000, and 90,000 patients/year). Primary benefits included the prevention of return ED visits, the prevention of "social" hospital admissions, and the protection of doctor and nurse time. The primary cost was salary support for full-time social work staffing. Sensitivity analysis was performed to account for varying estimates. RESULTS: For a small-volume ED, total benefits to offset costs ranged from $43,869 to $81,504, yielding a net cost of $99,936 up to $137,571 for full-time social work coverage. For a moderate-size ED, total benefits ranged from $87,660 to $162,930, yielding a net cost of only $18,510 on the high end of the sensitivity analysis, and $87,668 on the low end. For a large-volume ED, total benefits ranged from $131,529 to $247,434, yielding a net cost of $49,911 on the low end of the sensitivity analysis, but a net benefit of $65,994 on the high end. CONCLUSIONS: Dedicated social work staffing of EDs may yield net economic benefits, especially in large urban centers. Moderate-size EDs may almost "break even" in economic terms, and small EDs may realize a net cost, but in either case, the cost of social services can be significantly offset by decreased utilization of hospital and ED services, and by more efficient use of medical staff time.

Creating cost-efficient initiatives in social work practice in the cardiac program of an acute care hospital.

All three cost-saving initiatives--the creation of a one-page application form to streamline the rehabilitation application process, the use of the resource specialist to assist with applications, and the development of an information package on cardiac rehabilitation--reflect a process whereby a creative idea, generating planning, activities, and follow-up resulted in a measurable effective change in practice. This process truly translated strategy into action (Kaplan, 1996) and is vital to the current rethinking in health care of how best to do our work (Coan, 1994). Because of this process, social workers in the cardiovascular surgical division of the cardiac program are better equipped to respond to the psychosocial needs of a growing cardiac population in a fiscally restrained environment.

DRGs and hospital social work: when policy guides practice.

Since the early 1980s cost containment policies have changed the practice of hospital social work. Diagnosis Related Groups (DRGs), a cost containment mechanism, have increased the caseloads of hospital social workers, and placed a greater emphasis on discharge planning. In this article DRGs are described, and their function is discussed from a social work perspective. The literature surrounding DRGs and the role of the hospital social worker is addressed. Recommendations are made for social workers to evaluate the policies affecting their practice. It is proposed that if social workers understand policies, their origins, and how policies affect practice, then they can have greater influence as advocates and policy makers.

Rethinking social work service delivery.

Providence Centre is a 577-bed, multilevel, geriatric health facility located in Scarborough, Ontario. This article outlines the transition from a traditional model of social work service delivery to a specialized case referral system. It describes the review process, creation of the alternative service model, implementation strategies, evaluation measures and outcomes of the undertaking. Through these efforts, the centre succeeded in creatively redefining and restructuring its social work service delivery and resource utilization in today's tough economic climate.

Competitive allies: rural nurses' and social workers' perceptions of the social work role in the hospital setting.

The domain of social work in healthcare has not been clear, nor exclusive. Recently the social worker's role in hospital, particularly in rural hospitals, has been impacted by economic imperatives and legislative mandates. This article discusses the results of a study of rural hospital nurses' and social workers' perceptions of the domain of the medical social worker. Analyses of the profession identified as being best qualified to perform 15 generic hospital social service tasks revealed areas of clarity and collaboration. Implications include expanding the role and skills of medical social workers to include multi-systemic interventions and multi-disciplinary collaboration.

Transitions in psychiatric inpatient clinical social work.

As a group, psychiatric inpatient clinical social workers have been dramatically affected by the economic crisis in mental health. As they have attempted to cope with a myriad of changes, they also have become leaders in bringing change about. This article described the transition process as experienced by 27 social workers who were interviewed in a descriptive exploratory study. The study showed that inpatient social workers are struggling to create ways to meet increased workload demands and are questioning the effectiveness of short-term hospital treatment. Respondents reported personal and professional losses as well as challenges. They expressed considerable concern about the future of their profession because of pressure to compromise standards.

Social work services in the emergency department: a cost-benefit analysis of an extended coverage program.

Although issues relating to cost and cost containment have assumed an increasingly important role in the delivery of health care services, relatively few attempts have been made to assess the costs and benefits of social work services in a hospital setting. This article examines a program that provides social work services in a general hospital's emergency department on a 24-hour, seven-day-a-week basis. The cost of these services is assessed through the output value index, a form of cost-benefit analysis in which the estimated value of the program's output is contrasted with the estimated investment of resources to maintain the program. The results suggest that the program was operated at a marginal cost to the hospital and that cost may have been outweighed by tangible and intangible program benefits.

Discharge planning: professional perspectives versus organizational effects.

The rise in legitimacy and visibility of hospital discharge planning has been accompanied by competition between social work and nursing over control of this function. The author used a survey of 229 California hospitals to test the hypothesis that the discharge planning process is the same regardless of the discipline or department in which it is located. The only significant difference among the social work, nursing, and administrative departments was in the type of staff used. Social work departments were more likely to have both a social worker and a nurse on the discharge planning staff and on the discharge planning team. The needs of the organization, rather than professional perspectives, drove discharge planning. More collaborative bonds between social work and nursing could propel system innovation and change.

Enhancing patient participation: clinical strategies in the discharge planning process.

Social workers are in an excellent position to develop clinical interventions to enhance patient control over decision making about post hospital care. Participation in decision making has been identified in many studies as influencing well-being, health status and even mortality rates for elderly individuals facing relocation. Some of the practice patterns that support patient autonomy include: (1) involving the patient when working with families; (2) reaching for underlying conflict; (3) creating a sense of choice within existing parameters; (4) preparing patients for discharge; and (5) educating families and hospital caretakers to assist in this process.