DRGs and the social worker's role in discharge planning.

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DRGs and the Social Worker's Role in Discharge Planning Judith Dobrof MSW

a

a

Assistant Director, Medical/Surgical Services, Department of Social Work Svcs, Mt Sinai Medical Center; Teaching Assistant, Dept of Community Medicine (SW), Mt Sinai School of Medicine, New York, NY 10029 Published online: 26 Oct 2008.

To cite this article: Judith Dobrof MSW (1992) DRGs and the Social Worker's Role in Discharge Planning, Social Work in Health Care, 16:2, 37-54, DOI: 10.1300/ J010v16n02_04 To link to this article: http://dx.doi.org/10.1300/J010v16n02_04

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DRGs and the Social Worker's Role in Discharge Planning


Judith Dobrof, MSW

ABSTRACT. Cost containment measures have positive and negative consequences for the hospitali~cdpatient and the health care profcqsional. The impact of DRGs on the work environment and daily practice of the hospital-bilsed social worker is examined. Strategies to enhance social workers' ability to effectively providc comprchensive, coordinated psychosocial services to patients within a cost conlninmunt climate are suggested.

As part of the continuing effort to stem the tide of escalating health care costs, the fcderal government in 1983 implemented a prospective payment reimbursement system for costs accrued by hospitals in treating patients in acute-care settings. Prior to 1983 reimbursement had been retrospectively based on the actual cost of caring for the patient. The prospective payment system, through diagnostic-related groups (DRGs), was developed in an effort to provide an incentive to hospitals to become more efficient, thereby decreasing the overall cost of medical care. Efforts at cost-containmcnt were not new. In 1965, for example, undcr legislation which created the Medicare program, utilization review committees were mandated to monitor patient length of stay (LOS) and to educate physicians on the efficient use of medical resources. The 1980's, however, were characterized by a revolution Judith Dobrof is Assistant Director, MedicallSurgical Services, Department of Social Work Services, Mount Sinai Medical Center, Teaching Assistant, Department of Community Medicine (Social Work), Mount Sinai School of Medicine, One Gustave Levy Place, New Ynrk, NY 10029. The author wishes lo acknowledge the contribulions to lhis article of l w i n Epstein, PhD. Social Work in Health Care, Vnl. 16(2) 1991 O 1991 hy The Haworth Press, Inc. All rights reserved. 37


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SOCIAL WORK IN HEALTH CARE

in the way in which health care costs were reimbursed. Never before did incentives to increase efficiency have such a determining effect on the patient, the health care professional and the health care delivery system. Moreover, cost-containment measures are here to stay. And, in their goal of providing efficient medical care, these measures may positively affect patients by decreasing unnecessary treatments and/or preventing iatrogenic effects of lengthy hospitalizations. On the other hand, DRGs have several negative consequences for the health care of patients and for the professionals who must care for these patients. The purpose of this paper is to discuss the impact of DRGs on the role of the social worker as discharge planner. Discharge planning, one of many complex responsibilities of the medical social worker, is defined as the provision of services that help patients and families cope with the impact of illness and which link them with necessary supports for the patient's return to the community (Davidson, 1978). This paper begins by examining the literature which describes the problems faced by patients as a result of the implementation of a prospective reimbursement system. Pertinent questions to be addressed include: Are patients being denied access to the hospital? Once admitted, what is their experience in the hospital? Are they satisfied with the health care services they receive? Once discharged, is the social worker's discharge plan adequate to meet patient needs? The paper then moves to an examination of how the work environment has changed for the health care professional as a result of the new reimbursement system. The specific focus is on the positive and negative consequences for the social worker in practicing under a system which rewards the hospital primarily for timely and efficient discharge planning efforts. The paper concludes with a discussion of strategies for change which help the social worker cope with the pressures of DRGs while providing comprehensive, coordinated psychosocial services to the patient within the context of a costcontainment focused environment.

ARE DRGs AFFECTING PATIENTS' ACCESS


TO THE H O S K f A E ?

Research findings and anecdotal accounts of patients, families and hcalth care professionals ~rovideevidencc of thc restricted access paticnts currently havc as the acute-care hospital attempts to avoid carc of the "unprofitable" patient. For example, a rcporr by the U.S. Scnate Special Committee on Aging (1985a) describes testimony of family members, physicians, and hospital administrators who discuss the denial of admission to paticnts who may require heavy resources. In one of the few studies in which patients and families are askcd about their experiences before and after implementation of the DRGs, Fischer and Eustis (1988) cite increased concern with accehs and detail thc experience of a family in which an elderly rncmber was denied hospital admission. Other investigators also document the limitcd access to hospitals of those patients who would rcquire costly serviccs (Mizrahi, 1988; Rcamer, 1985). In a study of 648 members of the American Society of Internal Medicine (ASIM, 1988), respondents' attitudes were survcycd concerning the positivc and negative effccts of DRGs on patient care. Half of the internists questioned noted the positive consequence of cost-containmcnt policies which rcduce unnecessary hospital admissions. However, 55% indicated that they had experienced pressure to delay admitting patients to the hospital until they were sick enough to meet Professional Review Organization (PRO) requirements. These requirements focus on acuity of care criteria as a basis for payment for admission. Similarly, Kotclchuck (1987) reports that the PROS encourage hospitals to deny admission even to patients who rcquire hospital-bascd treatment. Limited access to acute-carc settings has both positive and negative consequences for patients. On the one hand, the trend towards outpatient testing and surgcry (Peterson, 1987) can reduce the iatrogenic effects of hospitalization and reduce expenditures for unnecessary and costly inpatient treatments. On the other hand, for those patients who would benefit from admission but are denied access due to stringent admissions criteria, the effort to rcduce costs by treating only the sickest, can have serious negative consequences for patients.


WHAT IS THE IMPACT OF DRGs


O N PATIENTS' HOSPITAL EXPERIENCES?

There is growing evidence that patients are admitted in a sicker, more debilitated condition than prior to the implementation of the DRG system (ASIM, 1988; Blumenfield and Rosenberg, 1988; Kotelchuck, 1984; Peterson, 1987; U.S. House of Representatives Committee on Government Operations, 1989). Predictably, there is widespread agreement that length of stay for hospitalization has decreased since the implementation of the DRGs (Goldberg and Estes, 1990; Kotelchuck, 1986a; Rosko and Broyles, 1987; Sloan, Morissey, and Valvona, 1988). Opinions vary, however, as to whether health care services of sufficient quality can be provided to these sicker patients within a shorter time frame. Thus, the Senate Special Committee on Aging Report (1985a) cites testimony of health care professionals who describe specific examples of inadequate patient care which resulted from an effort to save money. More generally, a full two-thirds of the physicians of the ASIM study (1988) reported that the prospective payment system has "diminished" the quality of patient care. Close to one-quarter (24%) reported pressure to underutilize tests that were medically necessary. On the other hand, slightly more (27%) indicated that DRGs decreased the ordering of unnecessary tests and procedures. In other words, DRGs produce benefits for some patients who are spared costly and possibly painful procedures which are unnecessary; for others, the medical care received may be less than it should be as a result of cost-saving measures. Two studies of patient and family perceptions of care received during hospitalization provide conflicting evidence about how hospitals are performing. Fischer and Eustis (1988) compare the results of a study, completed in 1982, of the interaction among family caregivers, elderly patients and hospital staff in a midwestern hospital with a comparable study conducted in 1986, after the advent of the DRGs. In addition, the authors also considered whether and how DRGs affected patients' and families' impressions of medical care. Both the 1982 and 1986 studies relied on in-depth interviews utilizing the same questions but with two questions about the impact of DRGs added to the 1986 interview schedule. In 1982, 15 family


Judith Dobrof

41

caregivers and 11 patients were interviewed; in 1986, 16 family carcgivcrs and 9 patients were interviewed. All patients and families were middle-class. After comparing the findings in the two studies the authors conclude that, after implementation of the DRG systcm, patients and families were much more concerned with the poor quality of care received and could cite examples of inadequate provision of health care services. In addition, family caregivers in the 1986 study described experiences in which they felt a family member had difficulty gaining admission, was discharged prematurely and, during the hospital stay, did not receive adequate attcntion by hospital staff. They also reported that since the advent of DRGs, paticnts were also more likely to be discharged in a condition requiring home care serviccs. This is an expected finding because a goal of the DRG reimbursement system is to shorten LOS and discharge the patient to spend much of the recuperation period at homc (Fischcr and Eustis, 1988; Mizrahi, 1988; Wolock, Schlesinger, Dincrman, & Seaton, 1987). By comparison, in a study of the cxpcricnccs of 144 elderly paticnts from three New York City hospitals, Monk and Stuen (1988) find that the respondcnts are generally satisficd with the services they received in the hospital and with the discharge plan coordinated for them. The authors combine available data concerning LOS and readmission ratcs with patient interviews in order to examine the effects of a prospective paymcnt systcm on Medicare beneficiaries. Data were collcctcd about their current health status, the impact of DRGs on the patient's experience with hospitalization, and patient satisfaction with thc discharge planning services they received. In telephone interviews with the patients 4-5 wccks after discharge it was found that 78.7% of the respondents were ready to leave the hospital when they did and 89.9% were satisfied with their discharge plan. The authors conclude that despite DRGs, most patients were satisfied with the hospital services and post-hospital care they rcccived. Differences in the findings of the studies cited may reflect the differences in the health care settings from which the samples were drawn. Thus, Monk and Stuen interviewed patients in three different hospitals within a large urban area using both measurements of intervening variables such as LOS, readmission rates and need for


42

SOCML WORK IN HEALTH CARE

assistance with activities of daily living along with exploratory interviews of patients, whereas Fischer and Eustis interviewed patients and families from one midwestern hospital and relied only on their perceptions of their experience during and after hospitalization. In addition, Fischer and Eustis studied patients who were described as "economically secure" (p. 384) while Monk and Stuen's respondents reflected a mix of economic backgrounds. Patients who were otherwise economically secure may not have had sufficient funds to pay for the high costs of health care and home care services not covered by their insurance and therefore could have felt less satisfied with their hospital and post-hospital experience. However, the low-income paticnts included in Monk and Stuen's study may have felt more satisfied as they were able to receive comprehensive services paid for by their Medicaid insurance.

WHAT IS THE PATIENT'S EXPERIENCE W T H THE DISCHARGE PROCESS? The extent to which patients are prematurely discharged is an important factor to consider in assessing the consequences of the DRG system. The Senate Special Committee on Aging (1985b) reports that many seriously ill patients are being discharged "inappropriately and prematurely" (p. 1). The U.S. House of Representatives Committee on Government Operations, in a report entitled, "Quicker and Sicker: Substandard Treatment of Medicare Patients" (1989), cites a Rand Corporation study which concludes that the number of patients discharged with at least one "instability" (e.g., abnormal blood pressure, temperature greater than 101 degrees) had risen from 54% prior to DRGs to 82% after DRGs. The ASIM (1988) study finds that 63% of physician respondents report that patients are discharged prematurely due to fiscal pressures and others also describe the "quicker but sicker" syndrome (Coulton, 1988; Kotelchuck, 1986b; Mizrahi, 1988). Asking patients and families directly, Fischer and Eustis (1988) discover that premature discharges do occur, although at times ways are found to delay the discharge to conform to reimbursement policy. Monk and Stuen (1988) find, however, that 78.7% of the patients interviewed felt ready for discharge, while 15.6% did not feel ready and 5%


were unsure. I t is possible that, in gencral, patients may perceive themselves to be discharge-ready because they place their trust in the health care professionals who tell them this is so, when in reality the premature discharge may occur. It is intcresting to note that, of the I I% in Monk and Stuen's study who wcre dissatisfied with their discharge plans, 63.3% felt that they werc not ready to leave the hospital. Moreover, 45.5% of those who were dissatisfied needed the most help with activities of daily living. Paticnts who fccl that their discharge is occurring too soon may also be more debilitated and most needful of post-dischargc services. Further research needs to be conducted in order to ascertain what contributes to patients' dissatisfaction with their discharge plans.

ARE HOME CARE SERVICES SUFFICIENT TO MEET PATIENTS9 PB§T-DP§CH4RGE NEEDS? Thc litcraturc strongly suggcsts an incrcased need for home care services because patients leave the hospital sooner under DRGs and rccuperatc at homc (Coulton, 1988; Fischer and Eustis, 1988; Goldbcrg and Estes, 1990; Long, Chesney, Ament, Desharnais, Fleming, Kobrinski, & Marshall, 1987; Mizrahi, 1988; Monk and Stuen, 1988; U.S. House of Representatives Committee on Government Operations, 1989; U.S. Senate Special Committee on Aging, 1985a & b; Stuen, 1957; Wolock, Schlesinger, Dinerman, & Seaton, 1987). The advantages cited by health care professionals of discharging thc paticnt home more quickly, even with increased home care needs, include increased involvement of families in planning for discharge, and an incrcased focus on sclf-care and independence (Bull, 1988). However, for those without family or friends who are available to assist in home care needs (Kotelchuck, 1984; Mizrahi, 1988; Stuen, 1987); for thosc family members or friends who become overburdened by the multiple needs of the patient (Bull, 1988; Coulton, 1988; Fischcr and Eustis, 1988; U.S. Senate Special Committee on Aging, 1985a & b; Wolock et al., 1987); or for patients who do not have the resources or the insurance to pay for services, or who have need for services which do not exist (Goldberg and Estes, 1990;


44


Goodwin, Zeitel, & Fox, 1989; U.S. House of Representatives Committee on Government Operations, 1989), hospital discharge is problematic. Focusing on community agencies providing post-hospita1 care, Goldberg and Estes (1990) studied the perception of staff regarding changes in the service needs of elderly patients since the advent of the DRGs. Agency personnel described barriers to accessible post-hospital care in the form of waiting lists for services or outright refusal to service some elderly clients. The House of Representatives Committee on Government Operations (1989) cites Health Care Financing Administration researchers who find that insufficient resources are available for Medicare beneficiaries to gain access to home care services. Monk and Stuen (1988) cite the need for hospitals to provide patients with linkages to community services, especially since these researchers found that many of the patients who were satisfied with the discharge plan were receiving home care services 4 to 5 weeks after hospitalization.

WHAT IS THE IMPACT OF DRGs ON SOCLAL WORK PRACTICE?

The foregoing studies suggest that the social worker providing services to hospitalized patients is faced with a patient population which may be receiving less comprehensive care as the hospital attempts to save money under a prospective reimbursement system. The worker also confronts difficulty in fully implementing discharge plans due to the unavailability of and/or limited reimbursement for home care services while patient need for these services is increasing. As they work with families who are facing increased burden, both financially and emotionally, social workers are struggling to assure adequate care for their patients. These themes are clearly evident in the social work literature which describes hospital-based social workers confronting larger caseloads of sicker patients with increased need for home care services or placement in nursing homes. Increasingly these community or institutional services are difficult or impossible to obtain. Although patients may recuperate better at home with a coordinated plan of in-home services, social workers are many times forced to develop makeshift discharge plans and hope for the best. After patients are discharged, social workers rarely have time to make a


Judith Dobwf

45

follow-up assessment on the adequacy of the discharge plan (Stuen, 1987). In addition, there is pressure to completc the task of discharge planning as quickly as possible in order to decrease LOS (Blumenfield and Rosenberg, 1988; Coulton, 1988; Dinerman, Seaton, & Schlcsingcr, 1986; Mizrahi, 1988; Pctcrson, 1987; Scmke, VanDcrWeele, & Weatherley, 1989). As a consequence the social worker is able to spend lcss timc pcr patient. The situation is exacerbated by the increased demand for discharge planning services (Coulton, 1988). Thcrc is also evidence that social workers have little control over the availability of resources which are required by the discharge plan such as adequate home care services or nursing home beds, sufficient family support, or a caregiver in the community who can provide hands-on assistancc (Scmkc ct al., 1089; Stuen, 1987). With the pressure to discharge patients as soon as possible and the comniitnicnt to quality care, health care professionals need to be working together to reach this complex goal. Bull (1988) finds that incrcascd coniniunication and collaboration are evident among the hospital workers she studied. Stuen (1987) also finds that social workers arc spending nlore timc collaborating in order to coordinate the discharge plan. However, conflicts are also evident in relation to which discipline is best suited to perform the discharge planning function (Stuen, 1987). In addition, conflicts arise because of differences in strategies to reach cost-containment goals (Powderly and Smith, 1989). Eighty-six percent of ASIM physicians do not believe that DRGs have improved relations among hospital staff (ASIM, 1988). Consequently, social workcrs must work in an environment in which pressure on themselves and their medical colleagues at times results in enhanced communication and at other times results in conflictual relationships. These conflicts are an added obstacle to the social worker's ability to coordinate thc discharge plan in a timely and efficient manner. Ethical Considerations

The stress placed on the social worker who believes that patients are not recei;ing adequate medical carc and home care services (Powderly and Smith, 1989; Reamer, 1985) yet who feels incapable of remedying this situation, creates feelings of frustration and inept-


46


ness. It is readily apparent that the emphasis on provision of costeffcctive health care services has increased the practice and ethical dilemmas which social workers and other health care professionals face (Bull, 1988; Dougherty, 1989; Morreim, 1985, 1988; Reamer, 1985). For example, the social work value of client self-determination has the potential to be compromised (Abramson, 1988; Reamer, 1985) as the medical social worker may not always have the time to discuss the complete range of discharge options with the patient. Participation in the discharge planning process, essential to the success of the discharge plan (Abramson, 1988), may have become more limited as the pressures of cost-containment policies influence the practice of the social worker. Another area of conflict involves the social worker's allegiance to the patient vs. the health care institution. The conflict has been characterized as the ". . . pressure to contain costs and still maintain . . . professional ethics and standards . . ." (Vourlekis, 1989, p. 25). Staff members may face a dilemma when they believe that quality of care is being compromised by the rush to discharge (Reamer, 1985). In addition, all patients are provided with notification of their rights regarding discharge as a matter of hospital policy. Despite this procedural guarantee, when a patient disagrees with a discharge order, staff must decide whether to encourage the patient to assert hislher right to appeal the discharge (a right mandated by Congress to protect patients against premature discharge [Mizrahi, 19881). Such an appeal of course might delay the discharge and mean loss of revenue for the hospital. The conflict between responsibility to the client vs. the agency is not a new one for the social worker (Billingsky, 1964; Epstein, 1970). Even prior to implementation of DRGs, Davidson (1978) describes the pressure for early discharge because of the need of hospitals to comply with regulations and warns the medical social worker of the danger of viewing ". . . discharge planning as a role in service of the institution rather than of the individual client" (p. 51). With the advent of DRGs, the ethical and practice dilemmas that health care professionals face today are pronounced since provision of cost-effective health care can determine the survival of the acute-care hospital. The challenge for social workers is to con-

tinue to hold onto social work values while providing cfficicnt and quality scrvices.


DRGs: An Opportunity for Social Work

Apart from the negative view of the impact of the DRGs on the patient, the hospital, and the social worker held by many social work writers, a consistent theme which is also evident is that implementation of a prospective reimbursement system crcatcs opportunities for social work dcpartmcnts to strengthen their role through discharge planning. There is little evidence that social work staff havc hecn cut as a result of cost-cutting strategies in hospitals. Instead, social work dcpartments havc bccn able to increase in size (Coulton, 1988; Dincrman ct al., 1986; Patchner and Wattenberg, 1985; Stucn, 1987). Dinerman et al.'s (1986) study of the conscqucnccs of DKGs on 82 hospital social dcpartments in New Jersey reveals that most directors bclicvc that the new system enhances social work's role and influence and that other health care professionals have greater appreciation of social work's expertise. Other writers tlescribe the crcativc programniatic changes that social workers have introduced into the increasingly important function of discharge planning. Examples include implementation of high risk screening programs (Fisher, 1987; Wolock and Schlcsinger, 1986), development of management information systems to enhance and document social work effectiveness (Coulton, 1984; Patchner and Wattenberg, J985), hospital-bascd social work consultation services for physicians, case management services for the elderly and disabled, and health education and promotion programs (Blumenfield and Rosenberg, 1988). Implcmcntation of the DRG system can also present the opportunity to expand the role of the discharge planner. Mizrahi (1988) calls for the discharge planner to view thc hospitalized patient along a continuum of care and to educate patients about the regulations and the discharge appeal process along with attending to thc prcand post-hospitalization nccds of the patient. Blumenfield and Rosenberg (1988) redefine the discharge planner as a "social health care manager" (p. 32) and present a similar model in which the role

SOCL4L WORK IN HEALTH CARE

.


. . encompasses the coordination of chronic care, the development of health promotion programs and the negotiation of the aftermath of chronic care. It includes the provision of psychosocial services along a continuum of primary, secondary, and tertiary care with assistance to individuals at any point in the health care system. (p. 38) The implementation of DRGs is also seen as an opportunity for those who are knowledgeable about the negative consequences to take leadership positions to modify the system. Coulton (1988) calls for social workers to take a leadership role in developing quality assurance mechanisms in relation to home care. Others call for the social worker to become a leader in advocacy for changes in the DRG system which would benefit the patient and family (Caputi and Heiss, 1984; Reamer, 1985; Vourlekis, 1989; Walsh, 1987). Mizrahi (1988) describes specific "arenas for action" (p. 9) for the social worker in the hospital, in the community and at the governmental level to enhance the system's responsiveness to patients and families. The View From the Front Lines

Stuen's (1987) study indicates that discharge planners have a different view of the possible strengthening effect DRGs can have on the social worker's position in the hospital. This study of both social workers and nurses who are responsible for the coordination of the patient's discharge plan is unique in its systematic and comprehensive exploration of thc experience of these professionals. The questionnaire used for the study of social workers (who make up 85% of respondents) and nurses who are responsible for discharge planning, focuses on changes in discharge planning tasks which have resulted since the introduction of DRGs. In addition, the study cxamines social workers' and nurses' impressions of the status of the discharge planner among other health care professionals. Stuen remarks that, as pressure has increased to discharge the patient as quickly as possible, there has been a reallocation of time spent on discharge planning activities. Social workers and nurses responsible for discharge planning report that they arc spending more time on "concrete services," that is, screening patients for discharge and


discussing the discharge plan, than on the counseling of patients and families regarding issues of impact of il!ness. Ovcr half (54%) of social work-discharge planners believe that the number of patients in their caseload who require discharge planning services has increased. Documentation of dischargc planning efforts has become essential for reimbursement (Blumenfield and Rosenbcrg, 1988) and Stuen finds that the amount of time spent on this activity has also increased. In addition, if onc combines the responses of nurse and social work discharge planners in the study, the conclusion is drawn that the DRGs have only somewhat enhanced their role among other hcalth care professionals. In this study, social workers wcrc less optimistic about the opportunities which DRGs can create. Instead, many feel unprepared to carry out discharge planning responsibilities. In fact, as many as one-third respond that their professional education did not adcquatcly train them for the responsibilities of the role. Many also feel that counseling skills are underutilized as coordination of "concrete" tasks dominates their practice. It is quite conceivable that for the social worker on the front lines, the greater responsibilities and tasks associated with the discharge planning function are not valued. Consequently, their view of the DRGs may not be as positive as that of administrators and academicians who are writing on the impact of DRGs on social work practice. Hence, thc positivc view of discharge planning by those who are not discharge planners may be less pcrsuasive to the line worker.

FUTURE RESEARCH AND A CALL FOR ACTION Since social workers responsible for discharge planning arc not viewing positively the impact of DRGs on daily practice, further research is needcd on the way in which DRGs and other cost-containmcnt policics arc affecting the work experience of the hospitalbased social worker. Do line social workcrs see any positive effects of the DRGs in moving patienls out of the acute-care setting more quickly? Do thcy fccl that the new system has resulted in increasing overall efficiency or in enhancing the discharge planning function among health care professionals? How do they feel about working in a hospital setting, and about the quality of their work?


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SOClAL

WORK IN HEALTH CARE

Research into the way in which the social work profession has viewed other cost-containment policies that were instituted in the past may also be useful in pointing towards a direction beneficial to both patient and professional. What was the response of the profession and daily practitioner and what strategies for managing these policies were successful or unsuccessful? Historically, the lack of adequate home care services and the lack of reimbursement mechanisms for these services has been a major problem. It is only exacerbated by the DRG system. Further empirical studies are therefore needed on the experience of the patients once they leave the hospital: how do they fare at home when a discharge plan is arranged? How are they coping with the increased responsibility, both financially and otherwise, to care for themselves with, and sometimes without, the help of community services? How are families coping with increased responsibility for hands-on care of the family member? What are the gaps in services which must be filled if patients are to return safely to the community? It is imperative that the social work profession use its expert advocacy skills to promote both an increase in post-hospital health care resources and to develop mechanisms for financing this care. Case management services must be provided both in the hospital and community in order to follow the patient along the continuum of the health care delivery system and to ensure that patients are receiving necessary medical treatment and home care services. It is also imperative that the social work profession recognize the way in which a prospective reimbursement system has changed the working environment of the hospital social worker and has resulted in increased and, many times contradictory, demands which are placed on himlher in the effort to discharge the patient as quickly as possible. As the work has become even more short-term and crisisoriented, the social worker is less likely to be rewarded with a patient who makes noticeable gains. Similarly, the social worker has less time to deal with the emotional impact of illness with patients and families while practice and ethical dilemmas increase. It follows that recruitment and retention of hospital-based social workers will become more and more difficult (O'Cleireacain, 1989). Bendor


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(1987) recognizes the conncction between the advent of DRGs and the "lost status and appeal'' (p. 25) of hospital-based social work. This is one possible explanation for the difficulty which hospital social work departmcnts are currently facing in filling vacancies. Graduate schools of social work must prepare students for the field of health care by teaching better use of clinical skills to assist patients and families in coping with the impact of illness while, at the same time, irnplemcnting discharge plans. Students must be informed about policies and regulations that are affecting the health care delivery system and also must be taught the necessary advocacy skills to work towards health care policics that balance quality and cost-effectiveness. Social work students and graduates alike must understand how to maintain a clinical focus even in the pressurcd atmosphere created by cost-containment policies. Hospital-based social work departmcnts must attend to the needs of workers through supervision, creative programming, and policies which support thc social worker who has responsibility for the discharge planning function. The supervisor must bc aware of the pressure on the social worker who is constantly confronted with practice and ethical dilcmmas and who experiences multiple demands in the role of discharge planner. Supervision oriented towards discharge planning in a clinical context helps workers preserve the values of thc profession in their changing practice. Resource manuals and information systcms made available to workers facilitate quick access to information on community rcsources. Visits to community agencies by social workers afford the opportunity to establish linkages with those agencies utilized frequently in the discharge plan. Support/education groups for newly hired workers facilitate their transition into the world of medical social work. Social policy committees which function for both educational and advocacy purposes, and ongoing social work ethics committees and legal clinics which provide a forum for considering ethical dilemmas and legal issues, arc a few examples of programmatic supports which can assist the social worker in daily practice. Finally, strearnlined and centralizcd discharge planning tasks and procedures ease the burden of performing the multiplc duties required of the social worker on the front lines.



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The social work role in hospital discharge planning: an administrative case history.

Discharge planning.

Discharge planning.

The anatomy of discharge planning.

Reinforcing discharge education and planning.

The role of part-time social workers in general practice.

Evaluating social work discharge planning services for elderly people: access, complexity, and outcome.

Planning for effective hospital discharge.

Comprehensive discharge planning for the elderly.

Evolving social work roles in health care:The case of discharge planning.

Discharge planning and home care in the United States.

The Social Workers' Viewpoint.

Increasing family planning in Myanmar: the role of the private sector and social franchise programs.

Social workers' involvement in advance care planning: a systematic narrative review.

Impediments to the course and effectiveness of discharge planning.

Social Workers in Contact.

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

Implementing a multidisciplinary approach to discharge planning.

DRGs and the "negative" trauma workup.

Social workers' role in tempering inequality in healthcare in hospitals and clinics: a study in Israel.

Development of a discharge readiness report within the electronic health record-A discharge planning tool.

Investigating hyponatremia, exit-site management and discharge planning.

Cultivating secondary traumatic growth among healthcare workers: the role of social support and self-efficacy.

New Social Workers Group.