The Enhanced Role The Enhanced Role for for

Social Work in the Social Work in the Conditions for Conditions for

CoverageCoverage

Jim Hafner, MSW, LCSW, Jim Hafner, MSW, LCSW, LSCSWLSCSW

DaVita Healthcare NorthlandDaVita Healthcare Northland

What Social Workers Have What Social Workers Have Always Done to Evaluate Always Done to Evaluate

Psychosocial NeedsPsychosocial Needs• Cognitive status/capacity Cognitive status/capacity

to understandto understand• Ability to meet own Ability to meet own

needsneeds• Ability to follow Ability to follow

prescriptionprescription• Mental health historyMental health history• Substance abuse historySubstance abuse history• Coping ability/resilienceCoping ability/resilience• Expectations for futureExpectations for future• Education/employment Education/employment

status, concerns, goalsstatus, concerns, goals

• Home environmentHome environment• Legal issues (guardian, Legal issues (guardian,

advance directive advance directive status)status)

• Advocacy needs Advocacy needs • Financial capability & Financial capability &

resourcesresources• Access to community Access to community

resourcesresources• Eligibility for Federal, Eligibility for Federal,

state, or local state, or local resourcesresources

Current Social Work Role Current Social Work Role in Interdisciplinary in Interdisciplinary

AssessmentAssessment• Psychosocial needsPsychosocial needs• Family & support systemFamily & support system• Abilities, interests, Abilities, interests,

preferences, goals preferences, goals including participation in including participation in care, modality & setting, care, modality & setting, expectations for care expectations for care outcomesoutcomes

• Transplant suitability Transplant suitability • Physical activity levelPhysical activity level• Suitability for referral to Suitability for referral to

voc rehab & physical voc rehab & physical rehabrehab

• Current health statusCurrent health status• Dialysis prescriptionDialysis prescription• Blood pressure, fluid Blood pressure, fluid

mgmtmgmt• LabsLabs• Immunizations, medsImmunizations, meds• AnemiaAnemia• Renal bone diseaseRenal bone disease• Nutritional statusNutritional status• Dialysis accessDialysis access

Traditional Social Work Traditional Social Work Role in Long Term & Short Role in Long Term & Short

Term Care PlansTerm Care Plans• Long Term Care Long Term Care

Plan Plan – Long-term dialysis Long-term dialysis

status/intereststatus/interest– Long-term transplant Long-term transplant

status/intereststatus/interest– Functional statusFunctional status– Rehab status/interestRehab status/interest– Advance directive Advance directive

statusstatus

• Short Term Care Short Term Care PlanPlan– Health problemsHealth problems– Problems with labsProblems with labs– BP/fluid problemsBP/fluid problems– Dialysis problemsDialysis problems– Adequacy problemsAdequacy problems– Access problemsAccess problems– Psychosocial/mental Psychosocial/mental

health problemshealth problems

Expanded Social Work Role Expanded Social Work Role in Plan of Carein Plan of Care

• Achieve & sustain Achieve & sustain psychosocial statuspsychosocial status– Counsel and educateCounsel and educate– Community referralsCommunity referrals– Administer KDQOL-Administer KDQOL-

36 to measure 36 to measure functionfunction

• Rehab status & goalsRehab status & goals– EducationEducation– VocationalVocational– PhysicalPhysical– Age appropriate Age appropriate

activityactivity

• Dialysis doseDialysis dose• Nutritional statusNutritional status• Mineral Mineral

metabolismmetabolism• AnemiaAnemia• Vascular accessVascular access• Modality Modality

– Home dialysisHome dialysis– TransplantTransplant

Continuous Quality Continuous Quality Improvement Improvement

• Facility basedFacility based• Problem focusedProblem focused• Outcome drivenOutcome driven

– AccessAccess– AdequacyAdequacy– AnemiaAnemia– Mineral metabolism Mineral metabolism – NutritionNutrition– TransplantTransplant– Vocational Vocational

rehabilitationrehabilitation

• AdherenceAdherence– KnowledgeKnowledge– Creative motivationCreative motivation

• Resources & Resources & advocacyadvocacy– Transportation Transportation – Patient assistance Patient assistance – Insurance optionsInsurance options– Nutrition programsNutrition programs– Vocational Vocational

rehabilitation rehabilitation – Legislative Legislative

Quality Assessment & Quality Assessment & Performance ImprovementPerformance Improvement

• Effective, data drivenEffective, data driven• Facility based, not Facility based, not

patient specificpatient specific• Uses MAT to focus on Uses MAT to focus on

indicatorsindicators– Improved health Improved health

outcomesoutcomes– Prevention/reduction of Prevention/reduction of

medical errorsmedical errors

• Documentation of Documentation of QAPI activities QAPI activities

• IDT reviews nine IDT reviews nine areas in priority orderareas in priority order

• Systemic & proactive Systemic & proactive • Tracks & trendsTracks & trends• Seeks & welcomes Seeks & welcomes

patient feedback patient feedback

Optimizing Team Optimizing Team FunctioningFunctioning

• IssuesIssues– CensusCensus– Documentation Documentation

requirementsrequirements– Staff stressStaff stress– Patient concernsPatient concerns– Staffing/Staffing/

attentivenessattentiveness– Budget/financesBudget/finances

• PlanPlan– Effective time Effective time

managementmanagement– Review of patient Review of patient

inputinput– Acuity based Acuity based

staffing staffing – Competency-based Competency-based

assignmentsassignments– Ease of recordingEase of recording

It Takes A TeamIt Takes A Team