Dani Hackner MD, Robert I. Goodman MD, Carlie Galloway LC - PowerPoint Presentation

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Dani Hackner MD, Robert I. Goodman MD, Carlie Galloway LCSW, Judy Mei Ng LCSW, La Kisha Hooker LCSW, Shelly Mason RN MBA, David Esquith LCSW MPH, and Sharon Mass LCSW PhD

Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social Worker dyads have suggested improvements in team-based collaborative care through organizational change. We undertook to study the assignment of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, and readmissions. Would reorganization of social work staff to focus on improvement of progression of care among hospitalists improve efficiency and utilization?Could we control for population and cohort differences over time to identify efficiency related to the role of the social worker on a hospitalist team?

Study Overview (Introduction)

Background

SummaryIn a large community, teaching hospital with faculty caring for indigent, Medicaid and unassigned patients, we undertook to study reorganization of case management services to "support" collaborative faculty care. During two consecutive years, from April through October, we compared cohorts of patients under the care of faculty hospitalists and control hospitalist groupsCohort 1 – Faculty HospitalistsIn one cohort during 2011, patients were admitted to faculty and residents with 'geographic' unit-based social workers and case managers. In July 2012, patients were admitted to faculty and residents rounding daily with team-based social workers. In the team-based approach, Social Workers served as the main conduit to unit-based RN case managers.Cohort 2 – Control HospitalistsIn a second cohort during 2012, patients were admitted to hospitalist physicians with 'geographic' unit-based social workers and case managers. In July 2012, patients were admitted to faculty and residents rounding daily with team-based social workers. In the team-based approach, Social Workers served as the main conduit to unit-based RN case managers.All statistics were performed using Minitab® 16.2.3, 2012. Multivariate analysis was applied to adjust for severity, time and interactions using log-transformed LOS. Mann-Whitney tests were applied to compare median LOS (2 sample Wilcoxon rank-sum). Chi-Square tests were applied to compare proportions.

Materials and Methods

After the reorganization from geographic staffing in 2012 to team-based staffing, over the course of two months we observed a reduction of median length of stay from 6 days (in the 3 months prior, 528 cases) compared to 4 days (in the two months following, 486 cases, p<0.01). We also observed a significant reduction in median length of stay compared to a matched period in 2012 (p<0.01). We did not observe significant changes in LOS between the corresponding periods in 2011 (475 and 518 cases, respectively, p=NS) or among cases of a control hospitalist service (434, 384 cases in 2012, p=NS). No statistically significant increases in readmission rates were observed for the intervention group.

Results

Discussion

With the addition of service-based social workers, faculty hospitalists and new residents appear to show improvements in LOS while preserving low readmission rates and mortality. Similar findings were not observed during a six month period (3 pre-intervention months and 3 post intervention months) among non-faculty hospitalist cases. The findings for faculty hospitalist populations raises questions about which populations are best suited to dedicated service-based social work staffing. Do indigent and difficult to place patients benefit more from embedded social workers on hospitalist teams?This report adds to the medical literature that explores determinants of efficiency in hospitalist care-- including the role of faculty, the value of team-based coordinators, the impact of lower physician-patient ratios, and yield of difficult patient teams. In the face of regional staffing shortages and the reductions in support for teaching services by Federal and State payers, the "solution" of adding nursing staff or physicians to academic hospitalist teams may not be feasible or achievable.

Conclusions

In this study, accounting for potential confounding variables, we report that faculty may show preserved or improved efficiency with the addition of team-based social workers--a less costly resource when added versus alternative staffing models. With reallocation from unit-based models to service-based teams, faculty social work staffing offers a lean, zero net staffing cost opportunity--one that may produce large savings of hospital costs and improved patient flow. Whether further gains can be made in general populations of patients versus particular social and demographic subpopulations remains to be seen.Does team-based social work staffing improve length of stay in a hospitalist cohort? Preliminary data suggests yes.Does team-based inpatient social work staffing affect hospital readmissions? We have insufficient power to conclude.What can a hospitalist service do to improve coordination of care with the help of case managers and social workers? Possibly in appropriate populations with physician alignment.

Acknowledgements

The Case Management Staff including Social Workers and Case Managers (RNs). Special thanks to Carolyn Sharp RN and Sarah Morrison LCSW who helped to conceptually develop the clinical project.The General Internal Medicine Medical Staff and Faculty: Robert Goodman MD, William Stanford MD, Leon Henderson-McLennan MD, Anish Desai MD, Joya Favreau MD, Peggy Miles MD, Karl Wittnebel MD, Doran Kim MD, Claude Killu MD, Genise Fraiman MD, Tricia Len MD, Julia Wegge MD, Anna Stewart MD, Amanda Ewing MD, Mark Noah MD, and Brian Kan MD.Our leadership team including Linda Procci PhD,Glenn Braunstein, MD, Zab Mosenifar MD, and Paul Noble, MD.

ChallengeAt many centers, indigent and complex patient with many difficulties in access to care or transitions of care were under the care of faculty hospitalist teams. Faculty had demonstrated their ability to improve efficiency in the care of this patient population in comparison to non-faculty physicians. What additional measures could be taken to further improve faculty hospitalist efficiency without additional staff?Innovation?Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social Worker dyads have suggested improvements in team-based collaborative care through organizational change.Would reorganization of social work staff to focus on improvement of progression of care among faculty hospitalist patients improve efficiency and utilization?Study QuestionWe undertook to study the reorganization of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, mortality and readmissions.

Cedars-Sinai, Los Angeles, CA

Team-based Social Work Staffing: Efficiency and Savings for Appropriate Populations

Demographics2011SD2012SDP valueAge47.8216.9047.6817.50p=0.11Racep=0.47Asian4.31%2.76% Black25.84%22.38% Pacific Islander0.48%0.28% Native American0.00%0.28% White/Other69.38%73.76% Unavailable0.00% 0.55%  Sex    p=0.24Female45%44% Male55% 56%  

SEVERITY OF ILLNESS2011 2012  P valueAPRDRG p=0.29122.25%28.73%241.63%42.27% 328.47%24.86% 47.66% 4.14%  

2011 – pre

2012 - pre

2012 – post reorganization

DISPOSITION

2011 2012  Against Medical Advice3.83%5.25%p=0.24Expired1.91%1.66% Home77.03%79.01% Home with Home Health6.70%6.35% Home with Hospice1.91%0.28% Acute Hospital Transfer1.67%2.76% Psychiatric Facility0.72%0.83% Inpatient Rehabilitation2.15%1.10% Long Term Acute Care0.24%0.00% Nursing Facility3.11%1.93% Other Facility0.72%0.83% Expired or Hospice3.83% 1.93%  

Faculty Faculty Controls Controls

2011 (pre) 2012 (post) 2011 (pre) 2012 (post)

2011 – pre

2012 - pre

2012 – post reorganization

Box Plot of LOS

Learning Objectives