The Enhanced Role for Social Work in the Conditions for Coverage The Enhanced Role for Social Work in the Conditions for Coverage Jim Hafner, MSW, LCSW, LSCSW DaVita Healthcare Northland

What Social Workers Have Always Done to Evaluate Psychosocial Needs Cognitive status/capacity to understandCognitive status/capacity to understand Ability to meet own needsAbility to meet own needs Ability to follow prescriptionAbility to follow prescription Mental health historyMental health history Substance abuse historySubstance abuse history Coping ability/resilienceCoping ability/resilience Expectations for futureExpectations for future Education/employment status, concerns, goalsEducation/employment status, concerns, goals Home environmentHome environment Legal issues (guardian, advance directive status)Legal issues (guardian, advance directive status) Advocacy needsAdvocacy needs Financial capability & resourcesFinancial capability & resources Access to community resourcesAccess to community resources Eligibility for Federal, state, or local resourcesEligibility for Federal, state, or local resources

Current Social Work Role in Interdisciplinary Assessment Psychosocial needsPsychosocial needs Family & support systemFamily & support system Abilities, interests, preferences, goals including participation in care, modality & setting, expectations for care outcomesAbilities, interests, preferences, goals including participation in care, modality & setting, expectations for care outcomes Transplant suitabilityTransplant suitability Physical activity levelPhysical activity level Suitability for referral to voc rehab & physical rehabSuitability for referral to voc rehab & physical rehab Current health status Dialysis prescription Blood pressure, fluid mgmt Labs Immunizations, meds Anemia Renal bone disease Nutritional status Dialysis access

Traditional Social Work Role in Long Term & Short Term Care Plans Long Term Care PlanLong Term Care Plan –Long-term dialysis status/interest –Long-term transplant status/interest –Functional status –Rehab status/interest –Advance directive status Short Term Care Plan –Health problems –Problems with labs –BP/fluid problems –Dialysis problems –Adequacy problems –Access problems –Psychosocial/mental health problems

Expanded Social Work Role in Plan of Care Achieve & sustain psychosocial statusAchieve & sustain psychosocial status –Counsel and educate –Community referrals –Administer KDQOL-36 to measure function Rehab status & goalsRehab status & goals –Education –Vocational –Physical –Age appropriate activity Dialysis dose Nutritional status Mineral metabolism Anemia Vascular access Modality –Home dialysis –Transplant

Continuous Quality Improvement Facility basedFacility based Problem focusedProblem focused Outcome drivenOutcome driven –Access –Adequacy –Anemia –Mineral metabolism –Nutrition –Transplant –Vocational rehabilitation Adherence –Knowledge –Creative motivation Resources & advocacy –Transportation –Patient assistance –Insurance options –Nutrition programs –Vocational rehabilitation –Legislative

Quality Assessment & Performance Improvement Effective, data drivenEffective, data driven Facility based, not patient specificFacility based, not patient specific Uses MAT to focus on indicatorsUses MAT to focus on indicators –Improved health outcomes –Prevention/reduction of medical errors Documentation of QAPI activitiesDocumentation of QAPI activities IDT reviews nine areas in priority order Systemic & proactive Tracks & trends Seeks & welcomes patient feedback

Optimizing Team Functioning IssuesIssues –Census –Documentation requirements –Staff stress –Patient concerns –Staffing/attentiveness –Budget/finances Plan –Effective time management –Review of patient input –Acuity based staffing –Competency-based assignments –Ease of recording

It Takes A Team