Team-based Social Work Staffing: Efficiency and Savings for

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

Cedars-Sinai, Los Angeles, CA

Study Overview (Introduction)

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?

Background
Challenge

At 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?

Materials and Methods
Summary

In 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 groups
Cohort 1 Faculty Hospitalists

In 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 Hospitalists

In 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.

RESEARCH POSTER PRESENTATION DESIGN 2012

www.PosterPresentations.com

Results

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. Box Plot of LOS Faculty 2011 (pre) Faculty 2012 (post) Controls 2011 (pre) DISPOSITION Against Medical Advice Expired Home Home with Home Health Home with Hospice Acute Hospital Transfer Psychiatric Facility Inpatient Rehabilitation Long Term Acute Care Nursing Facility Other Facility Expired or Hospice 2011 3.83% 1.91% 77.03% 6.70% 1.91% 1.67% 0.72% 2.15% 0.24% 3.11% 0.72% 3.83% 2012 5.25% 1.66% 79.01% 6.35% 0.28% 2.76% 0.83% 1.10% 0.00% 1.93% 0.83% 1.93% 2011 pre 2012 - pre Demographics Age Race 2011 SD 47.82 16.90 Asian 4.31% Black 25.84% Pacific Islander 0.48% Native American 0.00% White/Other 69.38% Unavailable 0.00% 2012 post reorganization Sex Female Male 45% 55% 2012 post reorganization SEVERITY OF ILLNESS 2011 2012 SD P value 47.68 17.50 p=0.11 p=0.47 2.76% 22.38% 0.28% 0.28% 73.76% 0.55% p=0.24 44% 56% 2012 APRDRG P value p=0.29 1 22.25% 28.73% 2 41.63% 42.27% 3 28.47% 24.86% 4 7.66% 4.14% 2011 pre 2012 - pre p=0.24 Controls 2012 (post) Study Question We 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. 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. Learning Objectives 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. 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 HendersonMcLennan 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. Acknowledgements

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