 | The 131st Annual Meeting (November 15-19, 2003) of APHA |
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| The 131st Annual Meeting (November 15-19, 2003) of APHA |
Nancy Claiborne, PhD, ACSW, School of Social Welfare, University at Albany, SUNY, 135 Western Avenue, Albany, NY 12222, 518 442-5349, nc@albany.edu
Objectives: This study investigated the effectiveness of a social work care coordination model for elderly stroke patients. Care coordination addresses patient care and resources across the healthcare system to reduce risk and improve outcomes. Empirical clinical guidelines for stroke patients identify the period immediately following hospitalization as a high-risk one. Postdischarge monitoring and support for patient emotional and physical adaptation to independent living, caregiver support, and adherence to medical and rehabilitation regimens are necessary. Stroke requires proactive coordinated care to address the diverse needs of the patient, maximizing effectiveness and efficiency.
Methods: A randomly assigned, pre-post design measured 28 participants' (16 Intervention; 12 Control) changes over three months. A social worker proactively contacted intervention subjects, including one home assessment visit and weekly telephone contacts. The social worker provided assessment, problem solving, advocacy, crisis counseling, educational reinforcement, and referral. They did not provide psychological counseling. Measures were: SF-36 (quality of life), geriatric depression scale, Functional Independence Measure (FIM), Medical Utilization, Adherence to Self-Care, and Service Needs.
Results: Paired Samples t-test revealed significant improvement for intervention group in SF-36 physical domain, 12 of 19 FIM measures, decreased emergency room and inpatient hospitalization, increased physician visits, and increase in services that were met.
Conclusions: Stroke patients whose care was coordinated by social workers enjoyed significant improvements in independence and appropriate use of medical services. Improvements required problem solving around barriers to needed services and adherence to self-care regimens, educational re-enforcement to patients and caregivers, and monitoring care and patient progress.
Learning Objectives:
Keywords: Elderly, Health Care Delivery
Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.