EVALUATING SOCIAL WORK DISCHARGE PLANNING SERVICES FOR ELDERLY PEOPLE: ACCESS, COMPLEXITY, AND OUTCOME JULIANNE S. OKTAY, DONALD M. STEINWACHS, JOYCE MAMON, LEE R. BONE, and MAUREEN FAHEY The discharge planning role of hospita! social workers has become increasingly important in services to elderly people. This article examines three issues: (1) the extent to which elderly people most in need receive social work services, (2) the extent to which the discharge planning performed is a professional task, and (3) the effectiveness of discharge planning for those who return to their homes after hospitalization. The study focused on 1,100 elderly patients from five Baltimore hospitals. Data were gathered from their social workers, from the patients themselves (by phone after discharge), and from medical records. Results show that only a minority of elderly patients who return to the community after hospitalization receive social work services while in the hospita! but that those who do are likely to have posthospital needs. In most cases, the discharge planning uses professional skilis, but 28 percent of cases are fairly routine. Finally, social work services were effective in reducing the level of unmet needs in the areas of nursing, medication, and physical therapy.
Since Medicare introduced prospective pricing in 1983, the discharge planning role of hospita! social workers has received considerable attention. A number of important questions have been raised, but, unfortunately, little 290
research has been conducted that sheds light on these questions. In this article, the results of a survey on discharge planning for hospitalized elderly patients are examined. Data from the study pertinent to the following three questions
CCC Code: 0360-7283/92 $3.00 ©1992, National Association of Social Workers, Inc.
are examined: (1) To what extent are the elderly people most in need of social work services actually receiving them? (2) Is discharge planning a highly professional task, or can it be effectively performed by less skilled workers? (3) How effective is discharge planning for elderly patients who return home?
LITERATURE REVIEW Increasing emphasis has been placed on discharge planning in hospita! social work in the past decade from both within and outside of the hospita!. The adoption by Medicare of a reimbursement system based on prospective pricing in 1983 meant that for the first time, hospitals could benefit financially from early discharge of their elderly patients. This situation caused hospitals to emphasize social work's discharge planning role, a role that has been a part of hospital social work since its inception (Blumenfield, 1986; Peterson, 1987). Discharge planning has also been viewed as critical by those who are concerned that the Medicare pricing system is negatively affecting the elderly population. The average length of stay of Medicare patients dropped precipitously in 1984 (Guterman & Dobson, 1986), as elderly patients were being released from hospitals "quicker and sicker." Discharge planning is seen by some as the key to ensuring that community services, such as home health care, are provided as patients return home (Simmons, 1986). Unfortunately, communitybased services for elderly people are highly fragmented, inadequate, and inaccessible in many areas (Palley & Oktay, 1983). Surveys of elderly people show that families are the major providers of care (Brody, 1985) and that large numbers of elderly people with limitations in activities of daily living (ADL) continue to go without the help they need (Jones, Densen, & Brown, 1989). Although most agree that social work has an important role in ensuring that elderly hospital patients receive needed posthospital services, and although most hospitals indicate that they rely on social workers to coordinate discharge planning (Society for Hospita! Social
Work Directors [SHSWD], 1986), little research has been done in this area. Many social work leaders have urged social workers to take the leadership in discharge planning to ensure that the discharge planning process reflects social work values, such as the patient's right to self-determination and family involvement (Blumenfield, 1986; Kane, 1980; Rehr, 1986). Social work has also been argued to be the most suitable profession for the discharge planning responsibility because of its systems perspective, which is helpful in both in-hospital collaboration and work with complex community systems (Rehr, 1986). Very little, however, is actually known about the extent to which discharge planning is performed by social workers rather than other health care personnel. Discharge planning is theoretically a very complex and highly skilled task, involving screening, thorough psychosocial assessment, provision of counseling and education, coordination of an interdisciplinary team of providers, activation of community services in a highly complex and fragmented system, and follow-up and evaluation (Blumenfield, 1986; Kane, 1980; SHSWD, 1986). In reality, however, it is often perceived by social workers as a "demeaning, unprofessional chore" (Blumenfield, 1986, p. 52) that is done primarily because it is vital to the financial survival of hospitals. Reasons social workers do not like discharge planning have been analyzed by Kulys (1983) and Abramson (1981). As Rehr (1986) pointed out, "There is no widespread agreement on the level of skili and sophistication [discharge planning] requires" (p. 47). This remais true today. In fact, the need for quick discharge planning in the high-pressure atmosphere of today's hospita!, combined with shrinking resources available in the community, has recently been considered to be a factor in the high rates of burnout among hospita! social workers (Siefert, Jayaratne, & Chess, 1991). In spite of Rossen and Coulton's cal! in 1985 for empirical research to examine the social work community's assumptions about what methods of discharge planning are most effective, little research of this type has been done. Research in the discharge planning field has
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focused on the cost reductions gained for hospitals by early intervention (Boone, Coulton, & Keller, 1981; Cable & Mayers, 1983) and the effect of having patients and families participate in the decisions made in the discharge process (Arenth & Mamon, 1985; Dunkle, Coulton, Mackintosh, & Goode, 1982). Recent research has examined the discharge planning process, focusing on the common complications that social workers experience (Proctor & Morrow-Howell, 1990). More pertinent to the question of effectiveness, Morrow-Howell, Proctor, and Mui (1991) looked at how social workers rate the "adequacy" of the discharge plan—that is, how likely it is to meet the postdischarge needs of the patient. In their research, 73 percent of the plans were rated "more than adequate" to meet medical needs, and 77 percent were rated "more than adequate" to meet psychological needs. These assessments of adequacy are much higher than are those of studies of community-based populations, which show high rates of posthospital unmet needs (Jones, Densen, & Brown, 1989). In the summer of 1986, a large study of hospital discharge planning for elderly patients who returned to their homes was conducted in Baltimore under the sponsorship of the National Center for Health Services Research and Health Care Technology Assessment. This article addresses the results of this study that bear on the following three questions: (1) Are those elderly patients at greatest risk for posthospital problems being seen by social workers? (2) How complex and skilled is the discharge planning being provided? (3) How effective is the discharge planning provided by social workers in decreasing levels of posthospital unmet needs for patients who return home? STUDY DESCRIPTION Sample
Five medium to large hospitals in Baltimore, selected to be representative of the population in the area, participated in the study. Two were major teaching institutions, two had religious affiliations, and one was a community hospital with no religious affiliation. A stratified ran292
dom sample was taken such that each hospital had an equal number of cases in the study and such that half of the patients were 60 to 74 years old and half were 75 or more. All patients who were placed in nursirig homes or other institutions and all who stayed in the hospital less than three or more than 30 days were omitted. Patients were sampled randomly at admission, and informed consent was obtained. Eighty percent of those sampled ( n = 1,100) agreed to participate. Instruments
A questionnaire was completed by the social worker after each sampled patient's discharge. Social workers were not told that a patient was in the study until after discharge to minimize the chance of changes from normal services. The five-page questionnaire covered information on how the patient was identified, when service was begun, the worker's assessment of the patient's needs at discharge, the availability of informal support, patient and family involvement in the discharge plan, the specific services provided by the social worker, how much time was spent on discharge planning, and the social worker's assessment of the adequacy of both the discharge planning process and the discharge plan itself. The form was based on a series of meetings with the social workers at each of the five hospitals and went through numerous revisions. Social workers in the five hospitals completed questionnaires on 1,077 of the sampled elderly patients who were discharged to the community, representing a response rate of 98 percent. Data on posthospital needs were based on a postdischarge phone interview with the patient. All 1,100 study participants were approached at two weeks postdischarge for a telephone interview that averaged 45 minutes. Interviews were completed principally in the interval of two to four weeks postdischarge, with the average patient being interviewed 21 days postdischarge. For 2 percent of the participants, it was not possible to conduct the interview by telephone, and the interview was done in person. For 30 percent, the interview was
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done with a proxy only, usually a spouse or relative. Interviews were completed with 84 percent of the 1,100 patients in the study. The two-week structured interview was divided into several sections, including measures of the resources available to the patient, patient-reported need for care after discharge, and the extent to which these needs were met or unmet. Three types of need were identified: (1) specific treatment needs (for example, nursing, medications, physical therapy); (2) ADL needs; and (3) a variety of social needs (called "other self-sufficiency"), including transportation, housing, legal, and financial needs. FINDINGS Sample Characteristics
As dictated by the sampling design, half of the 1,100 patients were 60 to 74 years old, and half were 75 or older. Fifty-three percent were female, and 79 percent were white. Forty-seven percent lived with a spouse, 26 percent lived alone, and 27 percent lived with a relative or friend. Fully 51 percent relied on a caregiver at admission. Eighty-six percent had Medicare, and 66 percent of them supplemented it with private insurance and 7 percent with Medicaid. In terms of hospitalization characteristics, 23 percent of the 1,100 in the sample had elective admissions; the remainder were either emergency or emergent admissions. Forty-five percent were admitted by their usual physician. Thirty-five percent stayed in the hospital four to six days, 31 percent stayed seven to 10 days, and 34 percent stayed 11 to 30 days. Forty-eight percent had some type of surgery while in the hospital. For 89 percent, all of the hospital days were judged "appropriate"; 11 percent had one or more days judged "Mappropriate." Discharge planning involved the social work department in 33 percent of the 1,077 cases for which questionnaires were completed. Unmet needs as measured at two weeks postdischarge showed that 20 percent of the 924 patients interviewed had an unmet need in the area of treatment, 11 percent indicated an unmet need in ADLs, and 15 percent had
an unmet need in other self-sufficiency areas. Overall, 33 percent of the patients had some unmet need two weeks after hospital discharge. Are Elderly Patients at Greatest Risk for Posthospital Unmet Needs Receiving Social Work Services?
Eighteen percent of the 1,077 patients for whom questionnaires were completed received some social work service, and an additional 4 percent received a social work assessment with no service provided (Table 1). Eleven percent received a brief review (screen) with no faceto-face contact or service. Sixty-seven percent of the elderly patients discharged home were unknown to the social work departments. The patients in the study most likely to receive social work services were older, single women who lived alone; were poor; had ADL, instrumental activity of daily living (IADL), or mobility limitations at admission; had poor prognoses; and experienced longer lengths of stay. (Chi-square tests showed all of these factors were significant at p < .01.) These same factors were found to be predictive of posthospital unmet needs (Mamon et al., 1992). One factor that was predictive of unmet posthospital needs and that was not related to receipt of social work services was relying on a caregiver prior to admission. These data suggest that for the most part, the type of patient most likely to have posthospital needs is also most likely to receive social work services. Because social workers see a fairly small percentage of elderly patients in the hospital, it is
Table 1. Level of Social Work Involvement with Elderly Patients (n = 1,077) Level of Involvement Patient or family received social work service. Patient or family received a social work assessment only. Social work department reviewed or screened the case. No service or assessment was provided. No social work involvement.
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11 67
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important to examine the process by which patients are referred to social workers. In this study, 355 patients had some contact with the social work department, and the largest source of referral was direct referral from a health care professional (49 percent). Twenty-six percent were identified by a social worker screening an admission summary. An additional 20 percent were identified in rounds. Other sources of patient referral to social work departments were discharge planning conference (7 percent), outpatient caseload (5 percent), patient self-referral (4 percent), and family referral (4 percent). (These numbers add up to more than 100 percent because there was more than one source of referral in some cases.) There is some suggestion in the data that the source of referral was related to the nature of the service provided. The proportion of cases that received screening only (no service provided) was higher (42 percent) for cases that came to the social worker's attention by way of a screening device (administrative sheet review) than were those channeled to social workers by other methods (20 percent to 31 percent). Also, those coming to the social worker's attention through an administrative screen tended to require less of the social worker's time (42 percent took less than one hour). These results probably reflect the low specificity of the screening devices, which often rely on broad demographic characteristics like age and living arrangement. Referrals coming from health professionals, rounds, and discharge conferences were more likely to consider a large number of complex characteristics of the case. How Complex a Task Is Discharge Planning?
Table 2 shows the activities that social workers performed for 194 patients in completing the discharge planning task. After assessments, the most common service was referrals (52 percent had new referrals, and another 13 percent had old referrals reactivated). More than half (53 percent) of the patients received planning and coordinating services. Education was more common than was counseling (received 294
Table 2. Services Provided by Social Workers (n = 194) Service
%a
Assessment interview Referrals Planning and coordinating Family education Patient education Patient counseling Follow-up after discharge Family counseling Advocacy
89
65 53 40 37 26 22 20 8
'The figures add to more than 100 percent because most cases received more than one service.
by 26 percent of the patients). The least common service, advocacy, was received by only 8 percent of patients. Analysis of the 126 referrals received shows that most cases (85 percent) were referred to a home health agency. Twenty-seven percent received referral to a social services agency for such services as meals, transportation, and housing. Twenty-four percent received equipment referrals. Only 5 percent were referred for mental health services such as drug or alcohol treatment, counseling, or self-help groups. Social workers were also asked to estimate how complex it was to assess and arrange postdischarge care for each of the 194 cases served. The results show a broad range of complexity, somewhat skewed toward the "less complex" end of the continuum (Table 3). Sixteen percent were rated "not at all complex," and 5 percent were "very complex." Table 3 also shows how much time was spent asseSsing, planning, and arranging for each discharge. The results show a normal distribution, with 88 percent of cases falling between 30 minutes and five hours. About one-third (32 percent) of the cases took more than two hours. If social work activities, complexity of discharge planning, and time spent on discharge planning are considered in combination, 28 percent of the 194 social work cases were completely "routine": That is, discharge planning was rated as being of average complexity, not very complex, or not at all complex; the time spent was less than two hours; the activities
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Table 3. Complexity of and Time Spent on Discharge Planning (n = 194) Discharge Planning Variable Complexity Very complex Moderately complex Average Not very complex Not at all complex Time spenta Less than 30 minutes 30 minutes to 1 hour 1 to 2 hours More than 2 and less than 5 hours 5 or more hours
5 21 29 29 16 4 30 34 24 8
alncludes time assessing, planning, and arranging for the discharge.
involved no counseling, education, planning and coordinating, advocacy, follow-up, or other services; and referrals made were limited to home health care or medical equipment. Unfortunately, further analysis was unable to isolate characteristics that distinguish the complex or difficult cases from the more routine ones. This is consistent with the results of other work on screening (Berkman & Abrams, 1986; Berkman, Dumas, Gastfriend, Poplawski, & Southworthe, 1987), which has found it difficult to accurately predict cases with complications. Thus, although most of the 194 social work cases received professional services such as counseling, education, and advocacy, 28 percent of the cases received fairly brief and routine services. However, because of the unpredictability of those cases that were not complex, a professional assessment is still probably needed in all cases. How Effective Is Social Work Discharge Planning?
Two methods were used to assess the effectiveness of discharge planning with the 194 social work clients. First, the social worker assessed the adequacy of the discharge planning process and the discharge plan itself. The results show high levels of satisfactory ratings. The percentages of cases rated adequate or
very adequate were 73 percent for the planning process and 77 percent for the plan itself. In 46 percent of cases, the social workers indicated that nothing more could have been done to improve the discharge planning process. The major factors mentioned when they did feel the process could have been improved were factors external to the hospital such as greater availability of resources (32 percent), better cooperation of family (28 percent), and better cooperation of patient (20 percent). Factors related to hospital processes were seen as less likely to have impeded the discharge planning process. Social workers felt the discharge planning process would have been improved by more time to work on the case in 19 percent of cases and by earlier notification of referral in 16 percent. Concerns about interprofessional cooperation ranged from only 2 percent to 8 percent. The major reason social workers gave for why the discharge plan might fail was related to lack of flexibility: For 48 percent of the 194 patients, the social worker responded, "The plan won't withstand many changes in the patient's physical condition and/or treatment." Almost as common was concern that the family support system would prove inadequate (45 percent). In 32 percent of cases, social workers feared that the patient would be unable to manage the regimen because of cognitive or physical limitations. The most common concern Biven about formal services was that they would be cut off too soon (23 percent), although services were also sometimes seen as inadequate (9 percent) or not available soon enough (6 percent), or the patient was ineligible for them (6 percent). Thus, in the social workers' perceptions, reasons for anticipated failures in the discharge plan had more to do with patients and families than with problems in existing formal services. The effectiveness of social work services was also assessed by comparing the posthospital unmet needs of patients who received social work services with those of patients who did not. Because the patients most likely to receive social work services were also most likely to have unmet needs in the posthospital period,
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it was necessary to first control for patient and hospitalization characteristics. To do this, a regression analysis was conducted for each of the three unmet need measures (treatment, ADLs, and other self-sufficiency areas). The impact of social work services was examined after controlling for patient characteristics (such as age, sex, race, living arrangement, reliance on caregiver, and insurance), hospitalization characteristics (diagnosis, type of admission, surgery, length of stay, severity of illness, inappropriate days, and usual source of care), and need for posthospital care. The results showed that receiving social work services was significantly and negatively related to having an unmet treatment need at two weeks after discharge (Mamon et al., 1992). That is, those patients who received social work services were significantly less likely to have an unmet need for medications, nursing care, physical therapy, or other prescribed treatments or procedures than were patients with similar characteristics who did not receive social work services. However, in ADLs and other self-sufficiency areas, patients who received social work services were no less likely than were other patients to have unmet needs two weeks after discharge. This finding is not surprising considering the finding that a large portion of social work discharge planning is composed of home health agency referrals. Because of current Medicare practices, most home health service is focused on treatment needs. DISCUSSION
Before discussing the results, it is important to examine the study's limitations. The five hospitals studied were in the Baltimore area, an area that may differ significantly from other parts of the country. The project took place in the spring of 1986, a period that may not be representative of other time periods. Also, most of the measures used in this study were developed by the authors, and their reliability and validity cannot be estimated. Also, the outcome measure of "need" was measured by patient report only. Most important, the study limited
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itself to patients 60 years of age and older who returned home. Because social workers do discharge planning with many patients under 60 and arrange discharges for many elderly patients who do not return home, these results cannot be generalized to all discharge planning. The study showed that 18 percent (194 of 1,100) of the elderly hospital patients who returned to their homes received some social work services, and another 15 percent (161) were assessed or screened by the social work department but received no service. Of the 1,077 patients for whom forms were completed, 67 percent went home having received no social work services at all. Because social workers saw a minority of the elderly hospital patients who returned home, it is reassuring to know that the characteristics of the social work patients (older, female, poorer, sicker) were also the characteristics of the patients most likely to have unmet needs after discharge. This suggests that the screening systems (primarily referrals from health care providers and screens by instruments and rounds) are working to ensure that the patients most in need do see social workers. However, the relatively low coverage being provided by social work departments also raises serious questions. In this study, 98 percent of the 924 patients interviewed at two weeks postdischarge had some posthospital needs, and 33 percent had unmet needs. Thus, large numbers of patients with posthospital needs and unmet needs are not seeing social workers. These results show many more patients receiving no social work services than has been found in previous studies (Wolock, Schlesinger, Dinerman, & Seaton, 1987). If social work is truly the most appropriate profession to handle the discharge planning function, as much of the literature suggests, then social workers are clearly not providing nearly enough service to meet the need. Major expansion of social work departments would be needed to provide social work services to the entire population with posthospital needs. This article also explored the question of the level of complexity of discharge planning by hospital social workers. There is evidence
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here that the social work services provided are not always very time consuming or complex. In 28 percent of the 194 social work cases, the service provided was fairly routine. The interpretation of this finding depends on the extent to which the routine services were appropriate to the patient needs. The fact that the social workers feit these plans were generally adequate and did not indicate that they needed more time suggests that they may well have been appropriate. If so, the data suggest that some of the discharges now being handled by social workers could be done by less skilled personnel. However, at this point adequate knowledge of measures that would predict which patients are most likely to need more professional services is not available. Research to develop more precise instruments should be a high priority in the field, as should experimental research to test the effects of providing lower cost services for those who need only routine services. Finally, the results show that social work service is effective in reducing the level of unmet needs in the treatment area. This finding is especially encouraging because other analyses of this data set show that unmet treatment needs are predictive of complications such as readmission or posthospital emergency room visits (Mamon et al., 1992). The analysis also shows that the social workers generally rated the adequacy of both the discharge planning process and the plan itself fairly high. They attribute the reasons why the plans might fail to patient and family characteristics and, to a lesser extent, to problems in the availability and quality of community-based services. Only a small percentage of the problems are attributed to problems in the discharge planning process itself, such as late timing or lack of interdisciplinary cooperation. The lack of social work effectiveness in preventing unmet needs in activities of daily living or other self-sufficiency areas probably reflects the lack of adequate community-based services for elderly people rather than the inability of social workers themselves. The combination of an expanding elderly population, spiraling
health care costs, a budget deficit, and policy that supports institutional instead of community-based care for elderly people has resulted in a crisis in the availability of in-home services. The best social worker in the world cannot arrange for adequate posthospital care where needed services do not exist. Perhaps attention needs to shift from discharge planning to community-based services (Coulton, 1988). Also, the frequency of social workers' concern that the plans would not withstand changes in the patient's condition or treatment and that family support would not hold up suggests that some ongoing assessment and planning is needed after the patient returns home. It is unrealistic to expect the hospital social worker to provide long-term care from an acute care setting. About the Authors Julianne S. Oktay, PhD, is Professor, University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201. Donald M. Steinwachs, PhD, is Professor, Health Policy and Management, and Director, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD. Joyce Mamon is AdjunctAssociate Professor in Health Policy and Management and Senior Research Associate, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, and Visiting Professor, School of Medicine, Center of Epidemiology and Community Medicine, University ofPadchva, Treviso, Italy. Lee R. Bone, MPH, is Instructor, and Maureen Fahey, MLA, is Senior Research Program Coordinator, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD. This study was supported under grant HS 054190 from the National Center for Health Services Research. This study would not have been possible without the cooperation of the following participating hospitals: Francis Scott Key, Sinai, St. Agnes, Union Memorial, and University of Maryland.
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References Abramson, M. (1981). Ethica' dilemmas for social workers in discharge planning. Social Work in Health Care, 6(4), 33-42. Arenth, L. M., & Mamon, J. A. (1985). Determini ng patient needs after discharge. Nursing Management, 16(9), 20-24. Berkman, B., & Abrams, R. D. (1986). Factors related to readmission of elderly cardiac patients. Social Work, 31, 99-103. Berkman, B., Dumas, S., Gastfriend, J., Poplawski, J., & Southworthe, M. (1987). Predicting hospita' readmission of elderly cardiac patients. Health and Social Work, 12, 221-228. Blumenfield, S. (1986). Discharge planning: Changes for hospita' social work in a new health care climate. Quality Review Bulletin, 10, 51-54. Boone, C., Coulton, C., & Keller, S. (1981). The impact of early and comprehensive social work services on length of stay. Social Work in Health Care, 7(1), 1-9. Brody, E. (1985). Parent care as a normative family stress. Gerontologist, 25, 19-29. Cable, E. P., & Mayers, S. P. (1983). Discharge planning effect on length of hospita' stay. Archives of Physical Medicine and Rehabilitation, 64(2), 57-60.
Coulton, C. J. (1988). Prospective payment requires increased attention to quality of post hospital care. Social Work in Health Care, 13(4), 19-30. Dunkte, R., Coulton, C., Mackintosh, J., & Goode, R. (1982). Factors affecting the post-hospital care planning of elderly patients in an acute care setting. Journa/ of Gerontological Social Work, 4, 95-106. Guterman, S., & Dobson, A. (1986). Impact of the Medicare prospective payment system for hospitals. Health Care Financing Review, 7,97— 114. Jones, E. W., Densen, P. M., & Brown, S. D. (1989). Posthospita) needs of elderly people at home: Findings from an eight-month follow-up study. Health Services Research, 24, 645-664. Kane, R. (1980). Discharge planning: An undischarged responsibility? Health and Social Work, 5,2-3.
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Kulys, R. (1983). Future crisis for the very old: Implications for discharge planning. Health and Social Work, 8, 182-195. Mamon, J., Steinwachs, D. M., Fahey, M., Bone, L., Oktay, J., & Klein, L. (1992). Impact of hospital discharge planning on meeting patient needs after returning home. Health Services Review, 27, 155-175. Morrow-Howell, N., Proctor, E. K., & Mui, A. C. (1991). The adequacy of discharge plans for elderly patients. Social Work Research & Abstracts, 27(1), 6-13. Palley, H. A., & Oktay, J. S. (1983). The chronically limited elderly: The case for a national policy for inhome and supportive community-based services. New
York: Haworth. Peterson, K. J. (1987). Changing needs of patients and families in the acute care hospital: Implications for social work practice. Social Work in Health Care, 13(2), 1-14. Proctor, E. K, & Morrow-Howell, N. (1990). Complications in discharge planning with Medicare patients. Health and Social Work, 15, 45-54. Rehr, H. (1986). Discharge planning: An ongoing function of quality care. Quality Review Bulletin, 12, 47-50 Rossen, S., & Coulton, C. (1985). Research agenda for discharge planning. Social Work in Health Care, 10(4), 55-61. Siefert, K., Jayaratne, S., & Chess, W. A. (1991). Job satisfaction, burnout, and turnover in health care social workers. Health and Social Work, 16, 193-202. Simmons, W. S. (1986). Planning for discharge with the elderly. Quality Review Bulletin, 10, 68-71. Society for Hospita) Social Work Directors. (1986). The role of the social worker in discharge planning. Quality Review Bulletin, 10, 76. Wolock, I., Schlesinger, E., Dinerman, M., & Seaton, R. (1987). The post hospital needs and care of patients: Implications for discharge planning. Social Work in Health Care, 12(4), 61-76. Accepted February 25, 1992
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Since Medicare introduced prospective pricing in 1983, the discharge planning role of hospita! social workers has received considerable attention. A number of important questions have been raised, but, unfortunately, little 290
research has been conducted that sheds light on these questions. In this article, the results of a survey on discharge planning for hospitalized elderly patients are examined. Data from the study pertinent to the following three questions
CCC Code: 0360-7283/92 $3.00 ©1992, National Association of Social Workers, Inc.
are examined: (1) To what extent are the elderly people most in need of social work services actually receiving them? (2) Is discharge planning a highly professional task, or can it be effectively performed by less skilled workers? (3) How effective is discharge planning for elderly patients who return home?
LITERATURE REVIEW Increasing emphasis has been placed on discharge planning in hospita! social work in the past decade from both within and outside of the hospita!. The adoption by Medicare of a reimbursement system based on prospective pricing in 1983 meant that for the first time, hospitals could benefit financially from early discharge of their elderly patients. This situation caused hospitals to emphasize social work's discharge planning role, a role that has been a part of hospital social work since its inception (Blumenfield, 1986; Peterson, 1987). Discharge planning has also been viewed as critical by those who are concerned that the Medicare pricing system is negatively affecting the elderly population. The average length of stay of Medicare patients dropped precipitously in 1984 (Guterman & Dobson, 1986), as elderly patients were being released from hospitals "quicker and sicker." Discharge planning is seen by some as the key to ensuring that community services, such as home health care, are provided as patients return home (Simmons, 1986). Unfortunately, communitybased services for elderly people are highly fragmented, inadequate, and inaccessible in many areas (Palley & Oktay, 1983). Surveys of elderly people show that families are the major providers of care (Brody, 1985) and that large numbers of elderly people with limitations in activities of daily living (ADL) continue to go without the help they need (Jones, Densen, & Brown, 1989). Although most agree that social work has an important role in ensuring that elderly hospital patients receive needed posthospital services, and although most hospitals indicate that they rely on social workers to coordinate discharge planning (Society for Hospita! Social
Work Directors [SHSWD], 1986), little research has been done in this area. Many social work leaders have urged social workers to take the leadership in discharge planning to ensure that the discharge planning process reflects social work values, such as the patient's right to self-determination and family involvement (Blumenfield, 1986; Kane, 1980; Rehr, 1986). Social work has also been argued to be the most suitable profession for the discharge planning responsibility because of its systems perspective, which is helpful in both in-hospital collaboration and work with complex community systems (Rehr, 1986). Very little, however, is actually known about the extent to which discharge planning is performed by social workers rather than other health care personnel. Discharge planning is theoretically a very complex and highly skilled task, involving screening, thorough psychosocial assessment, provision of counseling and education, coordination of an interdisciplinary team of providers, activation of community services in a highly complex and fragmented system, and follow-up and evaluation (Blumenfield, 1986; Kane, 1980; SHSWD, 1986). In reality, however, it is often perceived by social workers as a "demeaning, unprofessional chore" (Blumenfield, 1986, p. 52) that is done primarily because it is vital to the financial survival of hospitals. Reasons social workers do not like discharge planning have been analyzed by Kulys (1983) and Abramson (1981). As Rehr (1986) pointed out, "There is no widespread agreement on the level of skili and sophistication [discharge planning] requires" (p. 47). This remais true today. In fact, the need for quick discharge planning in the high-pressure atmosphere of today's hospita!, combined with shrinking resources available in the community, has recently been considered to be a factor in the high rates of burnout among hospita! social workers (Siefert, Jayaratne, & Chess, 1991). In spite of Rossen and Coulton's cal! in 1985 for empirical research to examine the social work community's assumptions about what methods of discharge planning are most effective, little research of this type has been done. Research in the discharge planning field has
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focused on the cost reductions gained for hospitals by early intervention (Boone, Coulton, & Keller, 1981; Cable & Mayers, 1983) and the effect of having patients and families participate in the decisions made in the discharge process (Arenth & Mamon, 1985; Dunkle, Coulton, Mackintosh, & Goode, 1982). Recent research has examined the discharge planning process, focusing on the common complications that social workers experience (Proctor & Morrow-Howell, 1990). More pertinent to the question of effectiveness, Morrow-Howell, Proctor, and Mui (1991) looked at how social workers rate the "adequacy" of the discharge plan—that is, how likely it is to meet the postdischarge needs of the patient. In their research, 73 percent of the plans were rated "more than adequate" to meet medical needs, and 77 percent were rated "more than adequate" to meet psychological needs. These assessments of adequacy are much higher than are those of studies of community-based populations, which show high rates of posthospital unmet needs (Jones, Densen, & Brown, 1989). In the summer of 1986, a large study of hospital discharge planning for elderly patients who returned to their homes was conducted in Baltimore under the sponsorship of the National Center for Health Services Research and Health Care Technology Assessment. This article addresses the results of this study that bear on the following three questions: (1) Are those elderly patients at greatest risk for posthospital problems being seen by social workers? (2) How complex and skilled is the discharge planning being provided? (3) How effective is the discharge planning provided by social workers in decreasing levels of posthospital unmet needs for patients who return home? STUDY DESCRIPTION Sample
Five medium to large hospitals in Baltimore, selected to be representative of the population in the area, participated in the study. Two were major teaching institutions, two had religious affiliations, and one was a community hospital with no religious affiliation. A stratified ran292
dom sample was taken such that each hospital had an equal number of cases in the study and such that half of the patients were 60 to 74 years old and half were 75 or more. All patients who were placed in nursirig homes or other institutions and all who stayed in the hospital less than three or more than 30 days were omitted. Patients were sampled randomly at admission, and informed consent was obtained. Eighty percent of those sampled ( n = 1,100) agreed to participate. Instruments
A questionnaire was completed by the social worker after each sampled patient's discharge. Social workers were not told that a patient was in the study until after discharge to minimize the chance of changes from normal services. The five-page questionnaire covered information on how the patient was identified, when service was begun, the worker's assessment of the patient's needs at discharge, the availability of informal support, patient and family involvement in the discharge plan, the specific services provided by the social worker, how much time was spent on discharge planning, and the social worker's assessment of the adequacy of both the discharge planning process and the discharge plan itself. The form was based on a series of meetings with the social workers at each of the five hospitals and went through numerous revisions. Social workers in the five hospitals completed questionnaires on 1,077 of the sampled elderly patients who were discharged to the community, representing a response rate of 98 percent. Data on posthospital needs were based on a postdischarge phone interview with the patient. All 1,100 study participants were approached at two weeks postdischarge for a telephone interview that averaged 45 minutes. Interviews were completed principally in the interval of two to four weeks postdischarge, with the average patient being interviewed 21 days postdischarge. For 2 percent of the participants, it was not possible to conduct the interview by telephone, and the interview was done in person. For 30 percent, the interview was
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done with a proxy only, usually a spouse or relative. Interviews were completed with 84 percent of the 1,100 patients in the study. The two-week structured interview was divided into several sections, including measures of the resources available to the patient, patient-reported need for care after discharge, and the extent to which these needs were met or unmet. Three types of need were identified: (1) specific treatment needs (for example, nursing, medications, physical therapy); (2) ADL needs; and (3) a variety of social needs (called "other self-sufficiency"), including transportation, housing, legal, and financial needs. FINDINGS Sample Characteristics
As dictated by the sampling design, half of the 1,100 patients were 60 to 74 years old, and half were 75 or older. Fifty-three percent were female, and 79 percent were white. Forty-seven percent lived with a spouse, 26 percent lived alone, and 27 percent lived with a relative or friend. Fully 51 percent relied on a caregiver at admission. Eighty-six percent had Medicare, and 66 percent of them supplemented it with private insurance and 7 percent with Medicaid. In terms of hospitalization characteristics, 23 percent of the 1,100 in the sample had elective admissions; the remainder were either emergency or emergent admissions. Forty-five percent were admitted by their usual physician. Thirty-five percent stayed in the hospital four to six days, 31 percent stayed seven to 10 days, and 34 percent stayed 11 to 30 days. Forty-eight percent had some type of surgery while in the hospital. For 89 percent, all of the hospital days were judged "appropriate"; 11 percent had one or more days judged "Mappropriate." Discharge planning involved the social work department in 33 percent of the 1,077 cases for which questionnaires were completed. Unmet needs as measured at two weeks postdischarge showed that 20 percent of the 924 patients interviewed had an unmet need in the area of treatment, 11 percent indicated an unmet need in ADLs, and 15 percent had
an unmet need in other self-sufficiency areas. Overall, 33 percent of the patients had some unmet need two weeks after hospital discharge. Are Elderly Patients at Greatest Risk for Posthospital Unmet Needs Receiving Social Work Services?
Eighteen percent of the 1,077 patients for whom questionnaires were completed received some social work service, and an additional 4 percent received a social work assessment with no service provided (Table 1). Eleven percent received a brief review (screen) with no faceto-face contact or service. Sixty-seven percent of the elderly patients discharged home were unknown to the social work departments. The patients in the study most likely to receive social work services were older, single women who lived alone; were poor; had ADL, instrumental activity of daily living (IADL), or mobility limitations at admission; had poor prognoses; and experienced longer lengths of stay. (Chi-square tests showed all of these factors were significant at p < .01.) These same factors were found to be predictive of posthospital unmet needs (Mamon et al., 1992). One factor that was predictive of unmet posthospital needs and that was not related to receipt of social work services was relying on a caregiver prior to admission. These data suggest that for the most part, the type of patient most likely to have posthospital needs is also most likely to receive social work services. Because social workers see a fairly small percentage of elderly patients in the hospital, it is
Table 1. Level of Social Work Involvement with Elderly Patients (n = 1,077) Level of Involvement Patient or family received social work service. Patient or family received a social work assessment only. Social work department reviewed or screened the case. No service or assessment was provided. No social work involvement.
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18 4
11 67
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important to examine the process by which patients are referred to social workers. In this study, 355 patients had some contact with the social work department, and the largest source of referral was direct referral from a health care professional (49 percent). Twenty-six percent were identified by a social worker screening an admission summary. An additional 20 percent were identified in rounds. Other sources of patient referral to social work departments were discharge planning conference (7 percent), outpatient caseload (5 percent), patient self-referral (4 percent), and family referral (4 percent). (These numbers add up to more than 100 percent because there was more than one source of referral in some cases.) There is some suggestion in the data that the source of referral was related to the nature of the service provided. The proportion of cases that received screening only (no service provided) was higher (42 percent) for cases that came to the social worker's attention by way of a screening device (administrative sheet review) than were those channeled to social workers by other methods (20 percent to 31 percent). Also, those coming to the social worker's attention through an administrative screen tended to require less of the social worker's time (42 percent took less than one hour). These results probably reflect the low specificity of the screening devices, which often rely on broad demographic characteristics like age and living arrangement. Referrals coming from health professionals, rounds, and discharge conferences were more likely to consider a large number of complex characteristics of the case. How Complex a Task Is Discharge Planning?
Table 2 shows the activities that social workers performed for 194 patients in completing the discharge planning task. After assessments, the most common service was referrals (52 percent had new referrals, and another 13 percent had old referrals reactivated). More than half (53 percent) of the patients received planning and coordinating services. Education was more common than was counseling (received 294
Table 2. Services Provided by Social Workers (n = 194) Service
%a
Assessment interview Referrals Planning and coordinating Family education Patient education Patient counseling Follow-up after discharge Family counseling Advocacy
89
65 53 40 37 26 22 20 8
'The figures add to more than 100 percent because most cases received more than one service.
by 26 percent of the patients). The least common service, advocacy, was received by only 8 percent of patients. Analysis of the 126 referrals received shows that most cases (85 percent) were referred to a home health agency. Twenty-seven percent received referral to a social services agency for such services as meals, transportation, and housing. Twenty-four percent received equipment referrals. Only 5 percent were referred for mental health services such as drug or alcohol treatment, counseling, or self-help groups. Social workers were also asked to estimate how complex it was to assess and arrange postdischarge care for each of the 194 cases served. The results show a broad range of complexity, somewhat skewed toward the "less complex" end of the continuum (Table 3). Sixteen percent were rated "not at all complex," and 5 percent were "very complex." Table 3 also shows how much time was spent asseSsing, planning, and arranging for each discharge. The results show a normal distribution, with 88 percent of cases falling between 30 minutes and five hours. About one-third (32 percent) of the cases took more than two hours. If social work activities, complexity of discharge planning, and time spent on discharge planning are considered in combination, 28 percent of the 194 social work cases were completely "routine": That is, discharge planning was rated as being of average complexity, not very complex, or not at all complex; the time spent was less than two hours; the activities
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Table 3. Complexity of and Time Spent on Discharge Planning (n = 194) Discharge Planning Variable Complexity Very complex Moderately complex Average Not very complex Not at all complex Time spenta Less than 30 minutes 30 minutes to 1 hour 1 to 2 hours More than 2 and less than 5 hours 5 or more hours
5 21 29 29 16 4 30 34 24 8
alncludes time assessing, planning, and arranging for the discharge.
involved no counseling, education, planning and coordinating, advocacy, follow-up, or other services; and referrals made were limited to home health care or medical equipment. Unfortunately, further analysis was unable to isolate characteristics that distinguish the complex or difficult cases from the more routine ones. This is consistent with the results of other work on screening (Berkman & Abrams, 1986; Berkman, Dumas, Gastfriend, Poplawski, & Southworthe, 1987), which has found it difficult to accurately predict cases with complications. Thus, although most of the 194 social work cases received professional services such as counseling, education, and advocacy, 28 percent of the cases received fairly brief and routine services. However, because of the unpredictability of those cases that were not complex, a professional assessment is still probably needed in all cases. How Effective Is Social Work Discharge Planning?
Two methods were used to assess the effectiveness of discharge planning with the 194 social work clients. First, the social worker assessed the adequacy of the discharge planning process and the discharge plan itself. The results show high levels of satisfactory ratings. The percentages of cases rated adequate or
very adequate were 73 percent for the planning process and 77 percent for the plan itself. In 46 percent of cases, the social workers indicated that nothing more could have been done to improve the discharge planning process. The major factors mentioned when they did feel the process could have been improved were factors external to the hospital such as greater availability of resources (32 percent), better cooperation of family (28 percent), and better cooperation of patient (20 percent). Factors related to hospital processes were seen as less likely to have impeded the discharge planning process. Social workers felt the discharge planning process would have been improved by more time to work on the case in 19 percent of cases and by earlier notification of referral in 16 percent. Concerns about interprofessional cooperation ranged from only 2 percent to 8 percent. The major reason social workers gave for why the discharge plan might fail was related to lack of flexibility: For 48 percent of the 194 patients, the social worker responded, "The plan won't withstand many changes in the patient's physical condition and/or treatment." Almost as common was concern that the family support system would prove inadequate (45 percent). In 32 percent of cases, social workers feared that the patient would be unable to manage the regimen because of cognitive or physical limitations. The most common concern Biven about formal services was that they would be cut off too soon (23 percent), although services were also sometimes seen as inadequate (9 percent) or not available soon enough (6 percent), or the patient was ineligible for them (6 percent). Thus, in the social workers' perceptions, reasons for anticipated failures in the discharge plan had more to do with patients and families than with problems in existing formal services. The effectiveness of social work services was also assessed by comparing the posthospital unmet needs of patients who received social work services with those of patients who did not. Because the patients most likely to receive social work services were also most likely to have unmet needs in the posthospital period,
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it was necessary to first control for patient and hospitalization characteristics. To do this, a regression analysis was conducted for each of the three unmet need measures (treatment, ADLs, and other self-sufficiency areas). The impact of social work services was examined after controlling for patient characteristics (such as age, sex, race, living arrangement, reliance on caregiver, and insurance), hospitalization characteristics (diagnosis, type of admission, surgery, length of stay, severity of illness, inappropriate days, and usual source of care), and need for posthospital care. The results showed that receiving social work services was significantly and negatively related to having an unmet treatment need at two weeks after discharge (Mamon et al., 1992). That is, those patients who received social work services were significantly less likely to have an unmet need for medications, nursing care, physical therapy, or other prescribed treatments or procedures than were patients with similar characteristics who did not receive social work services. However, in ADLs and other self-sufficiency areas, patients who received social work services were no less likely than were other patients to have unmet needs two weeks after discharge. This finding is not surprising considering the finding that a large portion of social work discharge planning is composed of home health agency referrals. Because of current Medicare practices, most home health service is focused on treatment needs. DISCUSSION
Before discussing the results, it is important to examine the study's limitations. The five hospitals studied were in the Baltimore area, an area that may differ significantly from other parts of the country. The project took place in the spring of 1986, a period that may not be representative of other time periods. Also, most of the measures used in this study were developed by the authors, and their reliability and validity cannot be estimated. Also, the outcome measure of "need" was measured by patient report only. Most important, the study limited
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itself to patients 60 years of age and older who returned home. Because social workers do discharge planning with many patients under 60 and arrange discharges for many elderly patients who do not return home, these results cannot be generalized to all discharge planning. The study showed that 18 percent (194 of 1,100) of the elderly hospital patients who returned to their homes received some social work services, and another 15 percent (161) were assessed or screened by the social work department but received no service. Of the 1,077 patients for whom forms were completed, 67 percent went home having received no social work services at all. Because social workers saw a minority of the elderly hospital patients who returned home, it is reassuring to know that the characteristics of the social work patients (older, female, poorer, sicker) were also the characteristics of the patients most likely to have unmet needs after discharge. This suggests that the screening systems (primarily referrals from health care providers and screens by instruments and rounds) are working to ensure that the patients most in need do see social workers. However, the relatively low coverage being provided by social work departments also raises serious questions. In this study, 98 percent of the 924 patients interviewed at two weeks postdischarge had some posthospital needs, and 33 percent had unmet needs. Thus, large numbers of patients with posthospital needs and unmet needs are not seeing social workers. These results show many more patients receiving no social work services than has been found in previous studies (Wolock, Schlesinger, Dinerman, & Seaton, 1987). If social work is truly the most appropriate profession to handle the discharge planning function, as much of the literature suggests, then social workers are clearly not providing nearly enough service to meet the need. Major expansion of social work departments would be needed to provide social work services to the entire population with posthospital needs. This article also explored the question of the level of complexity of discharge planning by hospital social workers. There is evidence
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here that the social work services provided are not always very time consuming or complex. In 28 percent of the 194 social work cases, the service provided was fairly routine. The interpretation of this finding depends on the extent to which the routine services were appropriate to the patient needs. The fact that the social workers feit these plans were generally adequate and did not indicate that they needed more time suggests that they may well have been appropriate. If so, the data suggest that some of the discharges now being handled by social workers could be done by less skilled personnel. However, at this point adequate knowledge of measures that would predict which patients are most likely to need more professional services is not available. Research to develop more precise instruments should be a high priority in the field, as should experimental research to test the effects of providing lower cost services for those who need only routine services. Finally, the results show that social work service is effective in reducing the level of unmet needs in the treatment area. This finding is especially encouraging because other analyses of this data set show that unmet treatment needs are predictive of complications such as readmission or posthospital emergency room visits (Mamon et al., 1992). The analysis also shows that the social workers generally rated the adequacy of both the discharge planning process and the plan itself fairly high. They attribute the reasons why the plans might fail to patient and family characteristics and, to a lesser extent, to problems in the availability and quality of community-based services. Only a small percentage of the problems are attributed to problems in the discharge planning process itself, such as late timing or lack of interdisciplinary cooperation. The lack of social work effectiveness in preventing unmet needs in activities of daily living or other self-sufficiency areas probably reflects the lack of adequate community-based services for elderly people rather than the inability of social workers themselves. The combination of an expanding elderly population, spiraling
health care costs, a budget deficit, and policy that supports institutional instead of community-based care for elderly people has resulted in a crisis in the availability of in-home services. The best social worker in the world cannot arrange for adequate posthospital care where needed services do not exist. Perhaps attention needs to shift from discharge planning to community-based services (Coulton, 1988). Also, the frequency of social workers' concern that the plans would not withstand changes in the patient's condition or treatment and that family support would not hold up suggests that some ongoing assessment and planning is needed after the patient returns home. It is unrealistic to expect the hospital social worker to provide long-term care from an acute care setting. About the Authors Julianne S. Oktay, PhD, is Professor, University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201. Donald M. Steinwachs, PhD, is Professor, Health Policy and Management, and Director, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD. Joyce Mamon is AdjunctAssociate Professor in Health Policy and Management and Senior Research Associate, Health Services Research and Development Center, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, and Visiting Professor, School of Medicine, Center of Epidemiology and Community Medicine, University ofPadchva, Treviso, Italy. Lee R. Bone, MPH, is Instructor, and Maureen Fahey, MLA, is Senior Research Program Coordinator, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD. This study was supported under grant HS 054190 from the National Center for Health Services Research. This study would not have been possible without the cooperation of the following participating hospitals: Francis Scott Key, Sinai, St. Agnes, Union Memorial, and University of Maryland.
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References Abramson, M. (1981). Ethica' dilemmas for social workers in discharge planning. Social Work in Health Care, 6(4), 33-42. Arenth, L. M., & Mamon, J. A. (1985). Determini ng patient needs after discharge. Nursing Management, 16(9), 20-24. Berkman, B., & Abrams, R. D. (1986). Factors related to readmission of elderly cardiac patients. Social Work, 31, 99-103. Berkman, B., Dumas, S., Gastfriend, J., Poplawski, J., & Southworthe, M. (1987). Predicting hospita' readmission of elderly cardiac patients. Health and Social Work, 12, 221-228. Blumenfield, S. (1986). Discharge planning: Changes for hospita' social work in a new health care climate. Quality Review Bulletin, 10, 51-54. Boone, C., Coulton, C., & Keller, S. (1981). The impact of early and comprehensive social work services on length of stay. Social Work in Health Care, 7(1), 1-9. Brody, E. (1985). Parent care as a normative family stress. Gerontologist, 25, 19-29. Cable, E. P., & Mayers, S. P. (1983). Discharge planning effect on length of hospita' stay. Archives of Physical Medicine and Rehabilitation, 64(2), 57-60.
Coulton, C. J. (1988). Prospective payment requires increased attention to quality of post hospital care. Social Work in Health Care, 13(4), 19-30. Dunkte, R., Coulton, C., Mackintosh, J., & Goode, R. (1982). Factors affecting the post-hospital care planning of elderly patients in an acute care setting. Journa/ of Gerontological Social Work, 4, 95-106. Guterman, S., & Dobson, A. (1986). Impact of the Medicare prospective payment system for hospitals. Health Care Financing Review, 7,97— 114. Jones, E. W., Densen, P. M., & Brown, S. D. (1989). Posthospita) needs of elderly people at home: Findings from an eight-month follow-up study. Health Services Research, 24, 645-664. Kane, R. (1980). Discharge planning: An undischarged responsibility? Health and Social Work, 5,2-3.
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Kulys, R. (1983). Future crisis for the very old: Implications for discharge planning. Health and Social Work, 8, 182-195. Mamon, J., Steinwachs, D. M., Fahey, M., Bone, L., Oktay, J., & Klein, L. (1992). Impact of hospital discharge planning on meeting patient needs after returning home. Health Services Review, 27, 155-175. Morrow-Howell, N., Proctor, E. K., & Mui, A. C. (1991). The adequacy of discharge plans for elderly patients. Social Work Research & Abstracts, 27(1), 6-13. Palley, H. A., & Oktay, J. S. (1983). The chronically limited elderly: The case for a national policy for inhome and supportive community-based services. New
York: Haworth. Peterson, K. J. (1987). Changing needs of patients and families in the acute care hospital: Implications for social work practice. Social Work in Health Care, 13(2), 1-14. Proctor, E. K, & Morrow-Howell, N. (1990). Complications in discharge planning with Medicare patients. Health and Social Work, 15, 45-54. Rehr, H. (1986). Discharge planning: An ongoing function of quality care. Quality Review Bulletin, 12, 47-50 Rossen, S., & Coulton, C. (1985). Research agenda for discharge planning. Social Work in Health Care, 10(4), 55-61. Siefert, K., Jayaratne, S., & Chess, W. A. (1991). Job satisfaction, burnout, and turnover in health care social workers. Health and Social Work, 16, 193-202. Simmons, W. S. (1986). Planning for discharge with the elderly. Quality Review Bulletin, 10, 68-71. Society for Hospita) Social Work Directors. (1986). The role of the social worker in discharge planning. Quality Review Bulletin, 10, 76. Wolock, I., Schlesinger, E., Dinerman, M., & Seaton, R. (1987). The post hospital needs and care of patients: Implications for discharge planning. Social Work in Health Care, 12(4), 61-76. Accepted February 25, 1992
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