How the social work profession can embrace case management assessments
Assessment tools in healthcare have evolved from handwritten, multi-page, narrative progress notes to electronic templates with succinct drop-down options that include most frequently used patient-level descriptors. Patient records have shifted from extensive and inclusive customized recordings to exception-based documentation that indicates only variances to standard care delivery or variations in standard responses to care. As the meaningful use campaign progresses, electronic medical records (EMR) and portals have challenged healthcare providers to record relevant and timely findings using compliant and acceptable terms and abbreviations, and in the most efficient manner
Historically, the social work profession resisted the change from manual documentation to template-based tools, especially as our opportunities to communicate professional perceptions and insights became less welcome and our summarized facts became more required. Regardless, assessments remain an evidence-based standard of professional documentation, and the goal of an assessment has not changed from conveying two essential indicators:
- The relevant and important details regarding the patient
- The action plan of the social worker
A social work assessment should include the following five elements that the clinical healthcare teams rely on social workers to communicate:
- Patient’s immediate life circumstances (e.g., caregiving structure, setting of the residence, services received, social factors)
- Expectations of the hospitalization (e.g., tests, decision-making, rehabilitation)
- Identification of patient resources (e.g., caregivers, support, financial)
- Potential barriers (e.g., medical impairment, financial, instrumental activities of daily living such as transportation, cultural barriers such as language and literacy)
- Post-hospital action plans and time frame (e.g., home versus skilled community services)
In recent years, with an emphasis on quality and reducing hospital readmissions, social workers have begun to include additional information related to risk for readmission in the assessments by many members of the healthcare and case management team.
The social work assessment of patients flagged for readmission may include answers to the following questions:
- Were medications explained in first hospitalization to a level of understanding?
- Was the caregiver included in the discharge planning of the first hospitalization?
- Does the patient feel confident in his or her ability to meet the care plan?
Risk for readmission queries are used to help guide the social work action plan and inform the clinical team of potential risks and barriers, and are they attested in the assessment tool.
For more information, see Social Work: Strength-Based Practice in Hospital Case Management.