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A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care

An Evidence-Based Practice

Description

Social workers perform counseling and case management as members of a multidisciplinary team to help improve patients’ self-efficacy, locus of control, and capacity for engagement. This includes evaluating patients for exposure to material disadvantage, violence,
and trauma and referring patients to community resources to address social needs including safe/affordable housing, food security, and social isolation.

The study included primary care patients with uncontrolled complex chronic conditions, high inpatient service use (4 or more admissions in 24 months), and at least 12 months of engagement in the program.

Goal / Mission

Patients with the highest medical and social vulnerability require a population-specific social work intervention in primary care to achieve positive medical outcomes and to decrease inefficient use of services, especially inpatient admissions and ED visits.

Impact

The study exhibits promise in decreasing inpatient visits and cost. The evidence also supports population-specific social work interventions integrated in primary care.

Results / Accomplishments

Program participants had a 49% reduction in inpatient encounters (from 98 to 50) and a 5% reduction in ED visits (from 66 to 63) from 12 months before to 12 months after the intervention, which was associated with a cost reduction of approximately $107,800 per year.

About this Promising Practice

Organization(s)
Maine Medical Partners Family Medicine
Topics
Health / Other Conditions
Health / Health Care Access & Quality
Organization(s)
Maine Medical Partners Family Medicine
Source
Health Soc Work
Date of publication
3/7/2016
Date of implementation
2014
Location
Portland, Maine
For more details
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC48880...

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An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.