Center of the Hudson Valley
The Pathway to Improving Multidisciplinary Care: Social Worker and Annual Visit
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Suzette Gjonaj MD, Jenny Sung MD, Timothy Collins MD, Alyssa D'Amico RD, Georgette Curcio, Elaine Suderio-Tirone DNP, Addison Forgit LCSW/MHC, Caitlin Lennon LMSW, Boston Children’s Health Physicians, Valhalla,NY, Vassar Brothers Med Ctr, Poughkeepsie,NY, MidHudson Regional Hosp, Poughkeepsie,NY
Background:
Ideally people with Cystic Fibrosis(PwCF) should have a multidisciplinary Cystic Fibrosis(CF) team managing their care. Essential to the team is a social worker (SW). PwCF follow a complex daily care regimen associated with significant biopsychosocial challenges, which places burdens on PwCF and their caregivers. To address the potential barriers that affect management of this chronic illness, individuals benefit from assistance and treatment from a SW. PwCF and their families have added financial challenges, including navigating their health coverage and finding financial assistance. SW within multidisciplinary care teams respond to these needs. SWs play an essential role in preparation for pediatric patients transitioning to the adult CF program, going to school/college, and starting a career/entering the workforce. An expanding number of SWs are credentialed as mental health coordinators(MHC) and can address a patient's mental health wellbeing through screening, managing, and referral processes. Our affiliate center in New York faced a myriad of challenges since accreditation to satisfy this role. Initially administration did not provide a social worker for the affiliate center resulting in referrals out of the CF care team. Then the COVID19 pandemic struck and our affiliate fractured into separate hospitals for pediatric and adult care. In an effort to achieve the highest quality of care for our patients and their families, we embarked on a quality improvement (QI) initiative to secure a SW as a permanent member of the multidisciplinary team, and ensure that our patients have an annual SW visit.
Method:
A review of our internal center data found that not all patients had a SW encounter in 2022.After assessing the barriers to the SW encounters, we started our QI initiative. The global aim is to improve patient access to SW, assessing patients, and meeting their psychosocial needs. The process began with evaluating the number of patients who had an annual visit with our SW and ended with all patients having an annual visit with the SW. The specific aim is to increase the percentage of SW visits from 48% to 90%.PDSA cycles included reminding our patients and parents of the need for a SW annual visit at physician encounters, using an annual checklist, newsletters, and website. In the last quarter, if a patient or parents do not schedule an appointment with our SW then the SW will reach out by phone or text to connect with them. The SW will document any refusals or barriers for visits.
RESULTS:
Our annual visits with the SW increased from 48% to 64%.
Conclusion:
SWs provide support and guidance, helping PwCF and their families to navigate the challenges they encounter, and ensuring they have access to the resources and assistance to manage their condition. Our SWs are certified MHC and can integrate the psychosocial aspect by providing counseling, emotional support, and practical assistance for PwCF and their families to cope with their challenges. At the annual visit, SW does an overall social determinant of health check-in.
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We are continuing this quality improvement initiative with additional PDSA cycles until we achieve our goal of 90% of all our patients having an annual SW visit. We are confident that, with continued monitoring and updating using the quality improvement process, we will achieve our goals shortly.