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RESEARCH POSTER PRESENTATION DESIGN © 2012 www.PosterPresentations.com Dani Hackner MD, Robert I. Goodman MD, Carlie Galloway LCSW, Judy Mei Ng LCSW, La Kisha Hooker LCSW, Shelly Mason RN MBA, David Esquith LCSW MPH, and Sharon Mass LCSW PhD Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social Worker dyads have suggested improvements in team-based collaborative care through organizational change. We undertook to study the assignment of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, and readmissions. Would reorganization of social work staff to focus on improvement of progression of care among hospitalists improve efficiency and utilization? Could we control for population and cohort differences over time to identify efficiency related to the role of the social worker on a hospitalist team? Our challenge At many centers, indigent and complex patient with many difficulties in access to care or transitions of care were under the care of faculty hospitalist teams. Faculty had demonstrated their ability to improve efficiency in the care of this patient population in comparison to non-faculty physicians. What additional measures could be taken to further improve faculty hospitalist efficiency without additional staff? Our innovation? Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social Worker dyads have suggested improvements in team-based collaborative care through organizational change. Would reorganization of social work staff to focus on improvement of progression of care among faculty hospitalist patients improve efficiency and utilization? Study Question We undertook to study the reorganization of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, mortality and readmissions. Study Overview In a large community, teaching hospital with faculty caring for indigent, Medicaid and unassigned patients, we undertook to study reorganization of case management services to "support" collaborative faculty care. During two consecutive years, from April through October, we compared cohorts of patients under the care of faculty hospitalists and control hospitalist groups Cohort 1 – Faculty Hospitalists In one cohort during 2011, patients were admitted to faculty and residents with 'geographic' unit- based social workers and case managers. Cohort 2 – Control Hospitalists In July 2012, patients were admitted to faculty and residents rounding daily with team-based social workers. In the team-based approach, Social Workers served as the main conduit to unit-based RN case managers. All statistics were performed using Minitab® 16.2.3, 2012. Multivariate analysis was applied to adjust for severity, time and interactions using log- transformed LOS. Mann-Whitney tests were applied to compare median LOS (2 sample Wilcoxon rank-sum). Chi-Square tests were applied to compare proportions. Materials and Methods Major Outcomes Patient Characteristics Conclusions In this study, accounting for potential confounding variables, we report that faculty may show preserved or improved efficiency with the addition of team-based social workers--a less costly resource when added versus alternative staffing models. With reallocation from unit-based models to service-based teams, faculty social work staffing offers a lean, zero net staffing cost opportunity--one that may produce large savings of hospital costs and improved patient flow. Whether further gains can be made in general populations of patients versus particular social and demographic subpopulations remains to be seen. Acknowledgments The Case Management Staff including Social Workers and Case Managers (RNs). Special thanks to Carolyn Sharp RN and Sarah Morrison LCSW who helped to conceptually develop the clinical project. The General Internal Medicine Medical Staff and Faculty: Robert Goodman MD, William Stanford MD, Leon Henderson-McLennan MD, Anish Desai MD, Joya Favreau MD, Peggy Miles MD, Karl Wittnebel MD, Doran Kim MD, Claude Killu MD, Genise Fraiman MD, Tricia Len MD, Julia Wegge MD, Anna Stewart MD, Amanda Ewing MD, Mark Noah MD, and Brian Kan MD. Our leadership team including Linda Procci PhD,Glenn Braunstein, MD, Zab Mosenifar MD, and Paul Noble, MD. Cedars-Sinai, Los Angeles, CA Team-based Social Work Staffing: Efficiency and Savings for Appropriate Populations Demographics 2011 SD 2012 SD P value Age 47.82 16.90 47.68 17.5 0 p=0.11 Race p=0.47 Asian 4.31% 2.76% Black 25.84% 22.38% Pacific Islander 0.48% 0.28% Native American 0.00% 0.28% White/Other 69.38% 73.76% Unavailable 0.00% 0.55% Sex p=0.24 Female 45% 44% DISPOSITION 2011 2012 Against Medical Advice 3.83% 5.25% p=0.24 Expired 1.91% 1.66% Home 77.03% 79.01% Home with Home Health 6.70% 6.35% Home with Hospice 1.91% 0.28% Acute Hospital Transfer 1.67% 2.76% Psychiatric Facility 0.72% 0.83% Inpatient Rehabilitation 2.15% 1.10% Long Term Acute Care 0.24% 0.00% Nursing Facility 3.11% 1.93% Other Facility 0.72% 0.83% Expired or Hospice 3.83% 1.93% Faculty Faculty Controls Controls 2011 (pre) 2012 (post) 2011 (pre) 2012 (post) Box Plot of LOS Learning Objectives 2011 – pre 2012 - pre 2012 – post reorganization Does team-based social work staffing improve length of stay in a hospitalist cohort? Preliminary data suggests yes. Does team-based inpatient social work staffing affect hospital readmissions? We have insufficient power to conclude. What can a hospitalist service do to improve coordination of care with the help of case managers and social workers? Possibly in appropriate populations with physician alignment. Results After the reorganization from geographic staffing in 2012 to team-based staffing, over the course of two months we observed a reduction of median length of stay from 6 days (in the 3 months prior, 528 cases) compared to 4 days (in the two months following, 486 cases, p<0.01). We also observed a significant reduction in median length of stay compared to a matched period in 2012 (p<0.01). We did not observe significant changes in LOS between the corresponding periods in 2011 (475 and 518 cases, respectively, p=NS) or among cases of a control hospitalist service (434, 384 cases in 2012, p=NS). No statistically significant increases in readmission rates were observed for the intervention group. Discussion With the addition of service-based social workers, faculty hospitalists and new residents appear to show improvements in LOS while preserving low readmission rates and mortality. Similar findings were not observed during a six month period (3 pre-intervention months and 3 post intervention months) among non-faculty hospitalist cases. The findings for faculty hospitalist populations raises questions about which populations are best suited to dedicated service-based social work staffing. Do indigent and difficult to place patients benefit more from embedded social workers on hospitalist teams? This report adds to the medical literature that explores determinants of efficiency in hospitalist care-- including the role of faculty, the value of team-based coordinators, the impact of lower physician-patient ratios, and yield of difficult patient teams. In the face of regional staffing shortages and the reductions in support for teaching services by Federal and State payers, the "solution" of adding nursing staff or physicians to academic hospitalist teams may not be feasible or achievable.
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Transcript of THIS SECTION WILL NOT PRINT 5. Bring your completed poster to the designated poster session location...
RESEARCH POSTER PRESENTATION DESIGN © 2012
www.PosterPresentations.com
Dani Hackner MD, Robert I. Goodman MD, Carlie Galloway LCSW, Judy Mei Ng LCSW, La Kisha Hooker LCSW, Shelly Mason RN MBA, David Esquith LCSW MPH, and Sharon Mass LCSW PhD
Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social Worker dyads have suggested improvements in team-based collaborative care through organizational change.
We undertook to study the assignment of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, and readmissions.
Would reorganization of social work staff to focus on improvement of progression of care among hospitalists improve efficiency and utilization?
Could we control for population and cohort differences over time to identify efficiency related to the role of the social worker on a hospitalist team?
Our challenge At many centers, indigent and complex patient with many difficulties in access to care or transitions of
care were under the care of faculty hospitalist teams. Faculty had demonstrated their ability to improve efficiency in the care of this patient population in
comparison to non-faculty physicians. What additional measures could be taken to further improve faculty hospitalist efficiency without
additional staff?
Our innovation? Within the Case Management literature, qualitative studies of RN-case manager and Clinical Social
Worker dyads have suggested improvements in team-based collaborative care through organizational change.
Would reorganization of social work staff to focus on improvement of progression of care among faculty hospitalist patients improve efficiency and utilization?
Study Question
We undertook to study the reorganization of a dedicated Social Worker to a clinical hospitalist team and its impact on length of stay, mortality and readmissions.
Study Overview In a large community, teaching hospital
with faculty caring for indigent, Medicaid and unassigned patients, we undertook to study reorganization of case management services to "support" collaborative faculty care.
During two consecutive years, from April through October, we compared cohorts of patients under the care of faculty hospitalists and control hospitalist groups
Cohort 1 – Faculty Hospitalists In one cohort during 2011, patients were
admitted to faculty and residents with 'geographic' unit-based social workers and case managers.
Cohort 2 – Control Hospitalists In July 2012, patients were admitted to
faculty and residents rounding daily with team-based social workers. In the team-based approach, Social Workers served as the main conduit to unit-based RN case managers.
All statistics were performed using Minitab® 16.2.3, 2012. Multivariate analysis was applied to adjust for severity, time and interactions using log-transformed LOS. Mann-Whitney tests were applied to compare median LOS (2 sample Wilcoxon rank-sum). Chi-Square tests were applied to compare proportions.
Materials and Methods
Major Outcomes
Patient Characteristics
Conclusions In this study, accounting for potential confounding
variables, we report that faculty may show preserved or improved efficiency with the addition of team-based social workers--a less costly resource when added versus alternative staffing models.
With reallocation from unit-based models to service-based teams, faculty social work staffing offers a lean, zero net staffing cost opportunity--one that may produce large savings of hospital costs and improved patient flow.
Whether further gains can be made in general populations of patients versus particular social and demographic subpopulations remains to be seen.
AcknowledgmentsThe Case Management Staff including Social Workers and Case Managers (RNs). Special thanks to Carolyn Sharp RN and Sarah Morrison LCSW who helped to conceptually develop the clinical project.The General Internal Medicine Medical Staff and Faculty: Robert Goodman MD, William Stanford MD, Leon Henderson-McLennan MD, Anish Desai MD, Joya Favreau MD, Peggy Miles MD, Karl Wittnebel MD, Doran Kim MD, Claude Killu MD, Genise Fraiman MD, Tricia Len MD, Julia Wegge MD, Anna Stewart MD, Amanda Ewing MD, Mark Noah MD, and Brian Kan MD.Our leadership team including Linda Procci PhD,Glenn Braunstein, MD, Zab Mosenifar MD, and Paul Noble, MD.
Cedars-Sinai, Los Angeles, CA
Team-based Social Work Staffing: Efficiency and Savings for Appropriate Populations
Demographics 2011 SD 2012 SD P valueAge 47.82 16.90 47.68 17.50 p=0.11
Race p=0.47Asian 4.31% 2.76% Black 25.84% 22.38%
Pacific Islander 0.48% 0.28% Native American 0.00% 0.28%
White/Other 69.38% 73.76% Unavailable 0.00% 0.55%
Sex p=0.24Female 45% 44%
Male 55% 56%
DISPOSITION 2011 2012 Against Medical Advice 3.83% 5.25% p=0.24Expired 1.91% 1.66% Home 77.03% 79.01% Home with Home Health 6.70% 6.35% Home with Hospice 1.91% 0.28% Acute Hospital Transfer 1.67% 2.76% Psychiatric Facility 0.72% 0.83% Inpatient Rehabilitation 2.15% 1.10% Long Term Acute Care 0.24% 0.00% Nursing Facility 3.11% 1.93% Other Facility 0.72% 0.83% Expired or Hospice 3.83% 1.93%
Faculty Faculty ControlsControls2011 (pre) 2012 (post) 2011 (pre)2012 (post)
Box Plot of LOS
Learning Objectives
2011 – pre
2012 - pre
2012 – post reorganization
Does team-based social work staffing improve length of stay in a hospitalist cohort? Preliminary data suggests yes.
Does team-based inpatient social work staffing affect hospital readmissions? We have insufficient power to conclude.
What can a hospitalist service do to improve coordination of care with the help of case managers and social workers? Possibly in appropriate populations with physician alignment.
Results After the reorganization from geographic staffing in 2012 to team-based staffing, over the course of two
months we observed a reduction of median length of stay from 6 days (in the 3 months prior, 528 cases) compared to 4 days (in the two months following, 486 cases, p<0.01).
We also observed a significant reduction in median length of stay compared to a matched period in 2012 (p<0.01).
We did not observe significant changes in LOS between the corresponding periods in 2011 (475 and 518 cases, respectively, p=NS) or among cases of a control hospitalist service (434, 384 cases in 2012, p=NS).
No statistically significant increases in readmission rates were observed for the intervention group.
Discussion
With the addition of service-based social workers, faculty hospitalists and new residents appear to show improvements in LOS while preserving low readmission rates and mortality. Similar findings were not observed during a six month period (3 pre-intervention months and 3 post intervention months) among non-faculty hospitalist cases. The findings for faculty hospitalist populations raises questions about which populations are best suited to dedicated service-based social work staffing. Do indigent and difficult to place patients benefit more from embedded social workers on hospitalist teams?
This report adds to the medical literature that explores determinants of efficiency in hospitalist care-- including the role of faculty, the value of team-based coordinators, the impact of lower physician-patient ratios, and yield of difficult patient teams. In the face of regional staffing shortages and the reductions in support for teaching services by Federal and State payers, the "solution" of adding nursing staff or physicians to academic hospitalist teams may not be feasible or achievable.
