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A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care
An Evidence-Based Practice
Description
Social workers perform counseling and case management as members of a multidisciplinary team to help improve patients’ self-efficacy, locus of control, and capacity for engagement. This includes evaluating patients for exposure to material disadvantage, violence,
and trauma and referring patients to community resources to address social needs including safe/affordable housing, food security, and social isolation.
The study included primary care patients with uncontrolled complex chronic conditions, high inpatient service use (4 or more admissions in 24 months), and at least 12 months of engagement in the program.
and trauma and referring patients to community resources to address social needs including safe/affordable housing, food security, and social isolation.
The study included primary care patients with uncontrolled complex chronic conditions, high inpatient service use (4 or more admissions in 24 months), and at least 12 months of engagement in the program.
Goal / Mission
Patients with the highest medical and social vulnerability require a population-specific social work intervention in primary care to achieve positive medical outcomes and to decrease inefficient use of services, especially inpatient admissions and ED visits.
Impact
The study exhibits promise in decreasing inpatient visits and cost. The evidence also supports population-specific social work interventions integrated in primary care.
Results / Accomplishments
Program participants had a 49% reduction in inpatient encounters (from 98 to 50) and a 5% reduction in ED visits (from 66 to 63) from 12 months before to 12 months after the intervention, which was associated with a cost reduction of approximately $107,800 per year.
About this Promising Practice
Organization(s)
Maine Medical Partners Family Medicine
Topics
Health / Other Conditions
Health / Health Care Access & Quality
Health / Health Care Access & Quality
Organization(s)
Maine Medical Partners Family Medicine
Source
Health Soc Work
Date of publication
3/7/2016
Date of implementation
2014
Location
Portland, Maine
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