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            Program Objectives

Define the role of the social worker.
• Increase knowledge of emotional support needs,
  interventions and resources.
• Increase awareness of financial assistance
• Understand the needs of patients with psychiatric
  mental health or substance use disorders.
   Program Objectives (Cont’d)

• Gain knowledge about advance directives,
  end of life care, grief and loss.
• Strengthen awareness regarding abuse,
  neglect, exploitation and domestic violence.
• Review maternal and pediatrics areas of
  risk, substance exposed newborns and
              Scope of Practice for
             Acute Care Social Work
“Social Work services are provided to patients and
their families to meet their medically related social
and emotional needs as they impinge on their
medical condition, treatment, recovery, and safe
transition from one care environment to another.”

NASW Clinical Indicators for Social Work & Psychosocial Services in the Acute Care
Medical Hospital.
        Role of the Social Worker
The Social Worker is a trained professional who

  •   Assessment for discharge needs.
  •   Emotional support to patients and families.
  •   Crisis intervention.
  •   Education to patients and families.
  •   Patient and family advocacy.
  •   Information and referral to community
     Common Reasons
for a Social Worker Consult

   • Emotional Support.
   • Financial Assistance.
   • Psychiatric Disorders.
   • Substance Use Disorders.
     Common Reasons
for a Social Worker Consult

  • Advance Directives.
  • End of Life Care, Grief and Loss.
  • Abuse and Neglect.
  • Maternal Child.
Emotional Support
           Emotional Support
Social workers provide counseling
interventions related to:

  •   Adjusting to a new diagnosis.
  •   Change in level of care.
  •   Family stressors.
  •   Chronic illnesses.
  •   Multiple admissions.
General Social Work Interventions

     • Active/Empathetic Listening.
     • Reflection of Feelings.
     • Identification of Coping Skills.
     • Problem Solving.
General Social Work Interventions

      • Crisis Intervention.
      • Mediation.
      • Advocacy.
      • Information and Referral.
    Emotional Support
Potential Referral Resources
     Inpatient Services
     • Behavioral Health
     • Palliative Care
     • Pastoral Care
          Emotional Support
Potential Referral Resources (Cont’d)
          Outpatient Services
          • Crisis Hotlines
          • Employee Assistance Programs
          • Mental Health Providers
          • Spiritual Programs
          • Support Groups
          • 12-Step Groups
     Hospital Palliative Care
Hospital based palliative care programs provide
systemic treatment of pain, distressing
symptoms, and patient stress for patients with
debilitating chronic disease and life-threatening
 • Interdisciplinary team to help physician
    coordinate care for chronic long term
 • Not the same as Hospice.
         When to consider a
        Palliative Care Consult?
• Team/patient/family needs help with complex
  decision making and determination of goals of
• Patient has unacceptable level of pain or other
  symptom distress.
• Patient has frequent visits to ER for same
       When to consider a
Palliative Care Consult? (Cont’d)

• Patient has prolonged LOS(>5days) without
  evident progress.
• Patient has prolonged stay in ICU.
• Patient in ICU setting with documented poor
Financial Assistance
          Financial Assistance

Patients and families may need information
regarding patient eligibility for financial assistance
for the cost of their medical care or other
 • Connect patients and families with federal, state
   and local governmental programs for financial
 • Utilize community charity organizations.
Financial Assistance Options
    • Emergency Medicaid
    • Medicaid
    • State funding
    • Local funding
    • Social Security
    • Worker’s
    • Hospital charity care
Financial Assistance Options
    • Community agencies
    • Schools
    • Churches
    • Victim’s assistance funding
    • Pharmaceutical Indigent
      Prescription Programs
Psychiatric Disorders
 Substance Abuse
Most Common Psychiatric Disorders
 •   Major Depression.
 •   Bipolar Disorder.
 •   Severe Anxiety/Panic Disorder.
 •   Schizophrenia.
 •   Schizoaffective Disorder.
 •   Refer to most current Diagnostic and Statistical
     Manual of Mental Disorders (DSM) for further
   Psychiatric Disorders

• Assist with the timely identification of
  patients with psychiatric issues that must be
• Collaborate with physician, patient, family
  and community service providers to obtain
  needed care for the patient.
Psychiatric Disorders (Cont’d)
• Refer patients to the appropriate level of
  care including inpatient, outpatient, and
  involuntary admissions.
• Know federal, state and organization
  guidelines regarding the care of patients
  with psychiatric diagnosis.
          Examples of Outpatient
           Psychiatric Treatment
•   Psychological evaluation.
•   Counseling (individual, family, and group).
•   Partial hospitalization day treatment programs.
•   Medication management.
•   Support groups.
•   Refer to local community providers.
     Inpatient Psychiatric Treatment
• Inpatient psychiatric treatment can be done on a
  voluntary or involuntary basis.
• Insurance must authorize inpatient treatment
  (unless admitted as self-pay) and will dictate
  facility placement options.
 Inpatient Psychiatric Treatment
        Referrals (Cont’d)

• Insurance covers limited inpatient treatment
  for crisis stabilization only.
• Long term treatment is generally provided in
  an outpatient setting or as self-pay.
  Referrals for Inpatient Psychiatric
      Treatment - Involuntary

• State laws dictate process for management and
  referral of patient’s under an involuntary
  commitment order.
• Ensure that legal documentation as per state law
  has been completed.
• Payer source and psychiatric facility bed
  availability factor into final disposition.
Referrals for Inpatient Psychiatric
Treatment - Involuntary (Cont’d)

   (Insert hospital/state process)
         Examples of Voluntary
         Psychiatric Treatment
• Patient presents with request for voluntary
  admission to a psychiatric treatment center.
• Involuntary commitment order is rescinded or
  expired and patient is agreeable to transfer to a
  psychiatric center for further treatment.
    Examples of Voluntary
 Psychiatric Treatment (Cont’d)
• Any adult patient can voluntarily sign
  themselves directly into a psychiatric
  facility. For a child, the parent must sign
  the consent for treatment.
          Substance Abuse
Alcohol and Drug Use
• Provide education regarding the negative
  effects of substance abuse.
• Provide information regarding community
  resources for treatment programs, i.e., AA,
  NA, Al-Anon.
• Connect patients with treatment services as
   Substance Abuse Key Points

• Detox is the immediate withdrawal of alcohol
  or drug use with medical management.
      • Detox can take place in the acute hospital
        setting or at a detox center.
• Patient’s willingness to accept treatment.
      Substance Abuse Key Points

• Availability of treatment centers for in-patient and
      • Lack of beds in community treatment
      • Many treatment programs require 3 days of
        drug/ETOH free.
Substance Abuse Key Points

• Urine drug screen or ETOH results are
  typically required for in-patient treatment.
• Insurance coverage and self pay.
Advance Directives
  Patient Self Determination Act 1990

Advance Directive: Written instructions relating to
the provision of health care when the individual is
      • Living Will
      • Durable Power of Attorney

Federal Regulation- Sec 489.100 and 489.102
Patient Self Determination Act 1990 (Cont’d)
Health Care Providers must:
     • Provide info on health care decision-making
       rights on admission.
     • Provide info on own facility policies
       regarding advance directives on admission.
     • Inquire about and document in the patient’s
       medical record whether or not the patient
       has completed an advance directive on
     Federal Regulation- Sec 489.100 and 489.102
Patient Self Determination Act 1990
• Not discriminate against a patient based on
  whether or not they have completed an
  advance directive.
• Ensure compliance with federal and state
• Educate staff and community regarding
  advance directives.

Federal Regulation- Sec 489.100 and 489.102
 Advance Directive Living Will
A living will is a document in which you can
stipulate the kind of life-prolonging medical
care you want if you become terminally ill,
permanently unconscious, or in a vegetative
state and unable to make your own decisions.
Advance Directive Durable Power of

   A medical power of attorney is a document that
  lets you appoint someone you trust to make
  decisions about your medical care. This type of
  advance directive may be called a health care
  proxy, appointment of health care agent or a
  durable power of attorney for health care.
Advance Directive Durable Power of
        Attorney (Cont’d)

• State guidelines indicate when a POA for
  healthcare goes into effect.
• Some states may provide guidelines about who
  can make healthcare decisions for you if you do
  not already have a POA for healthcare.
  Advance Directives Key Points

• Social Workers serve as a resource for
  information about advance directives for
  patients, families and other healthcare team
• Know Federal, State and your
  organizational guidelines regarding Advance
End-of-Life Care
 Grief and Loss
                End-of-Life Care
  “End-Of-Life care refers to the care of a
  person during the last part of their life,
  from the point at which it has become
  clear that the person is in a progressive
  state of decline.”

   Grieving begins prior to death.
Oxford Handbook of Palliative Care
 Stages of Grief and Loss

      • Denial
      • Anger
      • Bargaining
      • Depression
      • Acceptance

Elizabeth Kubler-Ross “On Death and Dying”
End-of-Life Care Grief and Loss
 • Provide patients and their loved-ones with
   support and referral to community or in-
   hospital services.
 • Provide coping techniques related to death
   and dying.
 • Provide bereavement counseling – Refer to
  End-of-Life Care Grief and Loss
• Refer to Pastoral Care as needed.
• Offer information regarding practical matters such
  as listings of local funeral homes and cremation
  services including options for indigent burial.
    Victims of Abuse
Identifying and Reporting
 The Federal Child Abuse Prevention
     and Treatment Act (CAPT)
• Federal legislation provides a foundation for states
  by identifying a minimum set of acts or behaviors
  that define child abuse and neglect.
• Each state provides its own definitions of child
  abuse and neglect.
    The Federal Child Abuse Prevention
    and Treatment Act (CAPT) (Cont’d)

•    Legislatures in all 50 states have passed some
     form of child and elder abuse prevention laws.
•    All states have a reporting system.

        (Insert your state statue and telephone
                 number for reporting.)
  Main Types of Abuse

• Physical
• Emotional
• Neglect
• Exploitation
• Sexual
• Domestic Violence
               Identifying Abuse
Report any of the following regarding a child or
  vulnerable adult:

• Any suspected abuse i.e. physical, sexual, or
• Neglect.
• Exploitation.
• Contact your state’s Department of Children and
  Families Welfare System that provides
  investigations and follow up services.
       Definition of Physical Abuse

  “Physical injury as a result of punching, beating,
  kicking, biting, shaking, throwing, stabbing, choking,
  hitting (with a hand, stick, strap, or other object),
  burning, or otherwise harming a child.”
Examples of Physical Abuse
    • Fracture – pay special attention to
      spiral fractures.
    • Bruises, welts, burns.
    • Lack of medical care, untreated
      injuries, no follow up or follow
    • Any intentional injury that causes
      purposeful harm.
Examples of Physical Abuse (Cont’d)

         • Evidence of overall poor care.
         • Lack of medical care or non-
         • Sexual assault and exploitation.
         • Locking an individual in a room,
           closet, shed, etc.
               Definition of
      Emotional/Mental/Verbal Abuse
  “A pattern of behavior that impairs a child’s
  emotional development or sense of self-worth. This
  may include constant criticism, threats, or
  rejections, as well as withholding love, support, or
                 Definition of Neglect

Failure to provide for a child’s basic needs.
Neglect may include:
   • Failure to provide necessary food, shelter, or lack
     of appropriate supervision.
   • Failure to provide necessary medical or mental
     health treatment.
       Definition of Neglect (Cont’d)

   • Failure to educate a child or attend to special
     educational needs.
   • Inattention to a child’s emotional needs, failure
     to provide psychological care, or permitting the
     child to use alcohol or other drugs.
                     Elder Abuse

  “An umbrella term referring to any knowing,
  intentional, or negligent act by a caregiver or any
  other person that causes harm or a serious risk of
  harm to a vulnerable adult.”
  Older Americans Act: Title VII
Vulnerable Elder Rights Protection
For nearly forty years, the Older Americans Act has
expressed the nation's commitment to protecting vulnerable
older Americans at risk.
When the Act was reauthorized in 1992, Congress created
and funded a new Title VII, Chapter 3 for prevention of
abuse, neglect and exploitation. Title VII Vulnerable Elder
Rights Protection also includes provisions for long term care
ombudsman programs and state legal assistance
          Elder Abuse (Cont’d)
Legislators in all 50 states have passed some form
of elder abuse prevention laws. Laws and
definitions of terms vary considerably from one state
to another. Every state has a reporting system.

(Insert your state statute and telephone number
                    for reporting)

    “Illegal taking, misuse, or concealment of funds,
         property, or assets of a vulnerable elder.”
         Exploitation (Cont’d)
  • Sudden changes in financial situations, large
    withdrawals from the bank or ATM.
  • Additional names added to an elder’s bank
    signature card.
  • Abrupt changes in a will or other financial
  • Disappearance of valuable possessions without
  2004 Survey from Administration on
    Aging of State Adult Protective
• 19.7% increase from 2000-2004 in the combined
  total number of elder reports and vulnerable adult
  abuse and neglect.
• 15% increase from 2000-2004 in substantiated
  2004 Survey from Administration on
    Aging of State Adult Protective
          Services (Cont’d)
• In 20 of the states, more than two in five victims
  (42.8%) were age 80 or older.
• Most alleged perpetrators in 2003 were adult
  children (32.6%) or other family members (21.5%)
  and spouses/intimate partners accounted for
  11.3% of the total (11 states responding).
            Social Worker’s Role

• Discussion with the parent, caregiver and physician
  will better assist in deciding if the injury coincides
  with the parent’s or caregiver’s description of
• Be very careful in asking questions to the
  child/vulnerable adult as to not confuse or give
  words that may cause distortion of events/injuries
 Social Worker’s Role (Cont’d)

• Once it is determined an abuse report is
  being initiated avoid asking any additional
  questions so as not to influence further
• The investigator is trained in abuse and
  neglect interviewing and will determine
  validity, events, and status.

Abuse crosses all boundaries
     Patients trust us !
• Every Health Care worker has a legal
  responsibility to report cases of alleged or
  suspected abuse.
• Refer to your state statue and hospital specific
  policy and procedure for identifying and reporting

  ***Failure to report alleged or suspected
  abuse can be a misdemeanor or felony. Refer
  to your state statue.****

If a report is required, it must contain:

• Name, age, race, sex and description of events.
• Names, addresses and phone numbers of victim’s
  family, caregiver and alleged perpetrator.
        Reporting (Cont’d)

• Names, address and phone number of
  the person reporting the alleged abuse.
• Document in medical record name of
  person accepting report, identification
  number and date/time.
     Victims of Domestic Violence

Domestic violence:

•May take the form of emotional, psychological, physical,
sexual, or economic abuse and is defined as one person in
an intimate relationship using any means to control the
Victims of Domestic Violence (Cont’d)
• Maltreatment that takes place in the context of
  any romantic relationship is abuse as
  described by the above specific terms.
• Also called intimate partner abuse or intimate
  partner violence. It therefore involves men,
  women, or teen girls and boys, whether in a
  heterosexual or homosexual relationship.
             How to Intervene

• Provide a confidential, respectful, and
  encouraging environment.
• Ask questions in a non-judgmental manner.
• Use encouraging, kind words.
      How to Intervene (Cont’d)
• Say you care about their well being, they are
  important and help is available.
• Provide community contacts for safe housing,
  counseling, and safety plan.
• Only report to police if the patient wishes to
  file charges.
   Victims of Domestic Violence
Signs and Symptoms and Examples

•   Fearful
•   Ashamed
•   Embarrassed
•   Low self-esteem
•   Reluctant to speak or make eye contact.
•   Minimizes extent of injuries.
   Victims of Domestic Violence
Signs and Symptoms and Examples
• Suspected abuser refuses to leave the patient
  and/or answers all of the questions.
• Bruises in various stages of healing.
• Injuries to the trunk of the body and head.
• Repeated or chronic injuries.
   Victims of Domestic Violence
Signs and Symptoms and Examples
 • Injuries inconsistent with the explanation.
 • Timid, afraid to answer questions, looks to
   the abuser for response inappropriately.
 • Injuries during pregnancy.
            How to Document

• Chief complaint and description of event.
• Use the patient’s own words.
• Complete and relevant medical history.
• Factual, detailed description of injuries (photos
  are helpful).
• Chart only what you see and hear.
         Alleged Sexual Assault

• Provide medical care and emotional support.
• Refer to your state statue for community partners,
  sexual assault victim advocates, SAVE examination
  teams, etc.

   (Insert your facility’s policy and procedure)
Specialized Areas of Care
     in Social Work

• Maternal Child
• Pediatrics
• Substance exposed newborns
• Adoption
        Maternal Child Health
         High-Risk Factors

• Young mothers < 18-years old
• Mothers with several small children, single,
  limited family support.
• No prenatal, late prenatal care or poor
• Adoption.
• Multiple admissions or readmissions within 30
     Maternal Child Health
   High-Risk Factors (Cont’d)
• Suspected drug abuse and/or positive drug
• High-risk pregnancy.
• Mental health dysfunction.
• Suspected child abuse.
• General lack of knowledge of resources, lack of
  caring for child.
     Maternal Child Health
   High-Risk Factors (Cont’d)

• NICU length of stay anticipated to be
  greater than 3 days.
• Infant with medical problems or special
• Apnea monitors, home O2, or any other
  special needs.
• Self pay patients that may need financial

•   No Primary Care Pediatrician/Physician.
•   Parental/guardian custody concerns or issues.
•   Multiple admissions or re-admit within 30 days.
•   Parental financial difficulties.
•   Department of Child Welfare Involvement.
     Substance Exposed Newborns

• Know your state statue regarding the requirement
  of reporting maternal illegal substance use during
• Provide educational information on effects of
  substance abuse during pregnancy.
• Limited availability for inpatient treatment
  programs for pregnant women.
          Adoption of a Newborn

Every state statute is different in defining guidelines
for adoption. Some key areas to pay close
attention to are:
•   State approved agencies, and licensed
•   The time a birth parent can legally sign after
    giving birth.
Adoption of a Newborn (Cont’d)

• Speak with the birth mother alone, review
  her wishes, options and plans.
• Revocation period.
• Health care system policy and procedure
  for adoptive parents’ visitation.
    Resources and Key Contacts
• National Mental Health information center
• National Domestic Violence Hotline
• Suicide Hotline
  1-800-SUICIDE or 1-800-273-TALK
• Medicare
• Social Security Administration
Resources and Key Contacts (Cont’d)

 • State Department of Children and Family Welfare
 • Local Public Health Department.
 • Drug and ETOH Treatment Programs.
 • Listing of local homeless shelters.
 • County School Board.
Resources and Key Contacts (Cont’d)

  •   Local Mental Health providers
  •   Free clinics/Prescription assistance
  •   Bereavement Services
  •   Hospice
  •   Home visiting services
   Policies and Procedures
     You Need To Know
• Abuse reporting
• Domestic violence and sexual assault
• Drug exposed newborn
• Car seat
• Signing out Against Medical Advice
• Adoption
 Policies and Procedures
You Need To Know (Cont’d)
•   Visitation guidelines
•   Discharge planning
•   Involuntary commitment orders
•   Advance directives
•   Financial assistance
              Review Questions
1. Give an example of a social worker role.
2. Provide an example of a type of outpatient
   psychiatric treatment.
3. What is the name of the federal law regarding
   providing patients with information about advance
4. Name a common stage of grief and loss.
        Review Questions (Cont’d)

5. A one year old child is admitted with multiple
   fractures and parents are vague in their
   explanation. What do you do?
6. Give three examples of abuse.
7. What are two maternal child high-risk health
1. Crisis intervention.
2. Medication management.
3. Patient Self Determination Act 1990.
4. Denial.
5. Discuss case with physician, make report to your
   state child welfare designated agency.
6. Physical, neglect and exploitation.
7. No pre-natal care, adoption.

• Elizabeth Kubler-Ross - On Death and Dying June
  1997 Collier Books Publishing
• Federal Regulation-Sec 489.100 and 489.102
• NASW Clinical Indicators for Social Work and
  Psychosocial Services in the Acute Care Medical
• Oxford Handbook of Palliative Care
     References (Cont’d)

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