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Social needs are factors for health risk and depression that may negatively impact health outcomes and costly services use. Care management addresses social needs that can reduce health risk and depression. An exploratory study of the 5-step Ambulatory Integration of the Medical and Social Model (AIMS) was conducted to examine the effect of steps completed as part of AIMS on patients' depression and health risk outcomes at 6-months. Results reveal steps central to AIMS are significantly related to lower depression and health risk, suggesting AIMS is a valuable intervention for reducing health risk and depression.

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Social needs, which are social risk factors including lack of access to stable housing, healthy food, or reliable transportation, are recognized as integral to health. Free clinics tend to serve patients with social needs, yet, few are screened or receive assistance. Lack of personnel, resources, and procedures to identify and assist patients are reasons few free clinics consider social needs. To address this service gap, a midwestern free clinic and neighboring Masters of Social Work (MSW) program established a partnership. A social needs screen was developed and integrated into health care practice. An MSW intern was also embedded as a member of the health care team to provide social needs assistance. A 6-month pilot study was conducted to assess the value of the screen and use of MSW assistance services. Of the 223 patients screened, 66.4% (n = 146) scored positive for social needs. Only four percent (n = 6) of the patients used MSW services. Chi-square analyses reveal significant differences in social needs by age, gender, race, education, and primary language. The findings suggest that the screening and MSW intern services are valuable; however, they further suggest that screening alone may be insufficient to encourage utilization of MSW services.

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PURPOSE OF THE STUDY: The purpose of this study was to examine the time contribution of social workers in delivering AIMS (Ambulatory Integration of the Medical and Social), a care management protocol designed to address patients' nonmedical needs, and the association of time contribution with patients' depression outcomes. PRIMARY PRACTICE SETTING: The study was conducted in 6 primary care provider clinics housed in a large, urban academic medical center located in the Midwestern United States. METHODOLOGY AND SAMPLE: A longitudinal, quasi-experimental study employing survey procedures and a retrospective review of patient records was conducted. The study included 340 patients 50 years and older with unmet nonmedical needs. Half of the patients received AIMS, which was delivered by social workers. The other half received usual care (UC), which was delivered by other health care providers. RESULTS: Chi-square analysis and independent-samples t tests were performed to compare time spent addressing nonmedical needs with differences in patients' depression levels at 6 months postenrollment. The findings reveal that social workers spend significantly more time with patients than UC providers addressing patients' nonmedical needs (p < .0001). At 6 months postintervention, reduced levels of depression were observed for AIMS patients when compared with UC patients (p = .026). IMPLICATIONS FOR CARE MANAGEMENT PRACTICE: Including social workers as part of health care teams is valuable. Time spent with patients and engaging in care management activities to support patients' needs is linked with positive health outcomes. Given the benefits of care management, opportunities for reimbursement are enhanced.

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PURPOSE OF STUDY: The specific aims of this descriptive study were to (1) examine the relationships between individual-level determinants of health using standard care admission assessments of residents admitted to a skilled nursing facility (SNF) and those residents readmitted to the hospital within 30 days from discharge from the same SNF; (2) identify and describe the risk factors of the residents readmitted to the hospital within 30 days; and (3) use the findings to inform and refine current practice to target the mutable risk factors correlated with 30-day hospital readmission. PRIMARY PRACTICE SETTING: A 180-bed skilled nursing center in Northeastern Pennsylvania. METHODOLOGY AND SAMPLE: A retrospective paper medical record review of patients discharged from an SNF to community living was conducted to examine the relationship between individual determinants of health behaviors and 30-day hospital readmissions. The study sample (N = 221) included adults 65 years and older who were admitted to the SNF from January to December 2014 for subacute physical rehabilitation following an acute care hospital stay with a discharge plan to community living. RESULTS: The 30-day readmission rate was 11%. The results of the logistic regression including diagnosis at readmission showed that the odds of readmission before 30 days were nearly three times greater in patients who had congestive heart failure (p < .02). Patients who were at "very high risk" on the Braden Scale were 20 times more likely to be readmitted before 30 days compared with those at low risk. Age and gender were not predictors. None of the other standard screening assessments for delirium, depression, functional status, and fall risk were predictive of 30-day readmission. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: (1) Care coordination and communication with residents, caregivers, and home health can have an impact on 30-day readmissions post-SNF discharge. (2) Chronic respiratory diseases continue to be a challenge in prevention of hospital readmissions.

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Nonmedical needs are intricately linked to health. Unaddressed nonmedical needs often result in poorer health and increased healthcare costs. Although social workers are well positioned to address nonmedical needs, their role in healthcare environments to address nonmedical needs is limited. The limited role relates to a lack of reimbursement streams, which stems from poor articulation about their unique contributions. An analysis of a case study in which a social worker using AIMS, a protocolized care coordination model, was undertaken to highlight specific activities performed by social workers. Implications for patient health outcomes and healthcare costs are discussed.

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An exploratory, retrospective evaluation of Ambulatory Integration of the Medical and Social (AIMS), a care coordination model designed to integrate medical and non-medical needs of patients and delivered exclusively by social workers was conducted to examine mean utilization of costly health care services for older adult patients. Results reveal mean utilization of 30-day hospital readmissions, emergency department (ED) visits, and hospital admissions are significantly lower for the study sample compared to the larger patient population. Comparisons with national population statistics reveal significantly lower mean utilization of 30-day admissions and ED visits for the study sample. The findings offer preliminary support regarding the value of AIMS.

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Elder abuse (EA) case resolution is contingent upon victims accepting and pursuing protective service interventions. Refusal/underutilization of services is a major problem. This study explored factors associated with extent of EA victim service utilization (SU). Data were collected from a random sample of EA cases (n = 250) at a protective service program in New York City. In cases involving financial abuse, higher SU was associated with females, poor health, perceived danger, previous help-seeking, and self or family referral. In physical abuse cases, higher SU was associated with family referral and previous help-seeking; lower SU was related to Hispanic race/ethnicity, being married, and child/grandchild perpetrator. In emotional abuse cases, higher SU was associated with self or family referral, victim-perpetrator gender differential, perceived danger, and previous help-seeking; lower SU was related to child/grandchild perpetrator. Findings carry implications for best practices to retain and promote service use among elder victims of abuse.

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This study introduces a conceptually based, systematic evaluation process employing multivariate techniques to evaluate a multidisciplinary social work-lawyer intervention model (JASA-LEAP). Logistic regression analyses were used with a random sample of case records (n = 250) from three intervention sites. Client retention, program fidelity, and exposure to multidisciplinary services were significantly related to reduction in mistreatment risk at case closure. Female gender, married status, and living with perpetrator significantly predicted unfavorable outcomes. This study extends the elder mistreatment program evaluation literature beyond descriptive/bivariate evaluation strategies. Findings suggest that a multidisciplinary social work-lawyer elder mistreatment intervention model is a successful approach.

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Little is known about conditions associated with favorable elder mistreatment (EM) case outcomes. The fundamental goal of EM protective service programs is to alleviate risk associated with substantiated cases of elder abuse and neglect. Using the EM socio-cultural model, this study examined victim, perpetrator, victim-perpetrator relationship, social embeddedness, and socio-cultural factors predicting risk alleviation of EM cases. Data from a random sample of EM protective social service cases (n = 250) at a large community agency in New York City were collected and coded by multiple, independent raters. Multinomial and binary logistic regression were used to examine undifferentiated risk alleviation for the entire sample of EM cases as well as differentiated financial, emotional, and physical abuse sub-types. Undifferentiated EM risk alleviation was associated with male victim gender, older victim age, previous community help-seeking, and victim-perpetrator dyads characterized by a separate living arrangement and shorter term abuse longevity. Financial abuse cases with younger perpetrators were less likely to have risk reduction. Physical abuse risk reduction was less likely when the perpetrator was male and the victim-perpetrator dyad included different genders. Distinct findings across EM sub-types suggest a need to develop targeted practice strategies with clients experiencing different forms of EM. Findings highlight a need to develop EM protective service infrastructure around perpetrator rehabilitation.

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Practice skills are believed to improve practice, yet, little is known about the extent to which skills affect outcomes. This exploratory study examined the extent to which 3 practice skills specific to a care management context for family caregivers, including communication skills, supportive skills, and linking skills, were associated with fidelity of a care management process. Twenty-one care managers who used a single process to serve 113 family caregivers were included in the study. Bivariate correlation analysis revealed the 3 practice skills are positively associated with process fidelity. Implications for social work practice, education, and research are discussed.

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PURPOSE: Multiple group analysis is used to determine whether the health-related quality of life (HRQoL) model developed by Wilson and Cleary (1995) is equivalent across racial categories. Using data from the Centers for Disease Control's Behavioral Risk Factor Surveillance System, this study compares racial groups (African American vs. White; Hispanic vs. White) to determine whether they perceive HRQoL similarly. METHODS: This secondary data analysis of 2007 New York State Behavioral Risk Factor Surveillance System data (n = 6,103 cases) uses the multi-group analysis function in structural equation modeling to test for equivalency across the named ethnic/racial groups. RESULTS: The White subsample achieved good fit indices and produced significant estimates for all structural components of the hypothesized model. Noteworthy differences, however, were found for the African American and Hispanic samples. In both cases, the data failed to support the Wilson and Cleary model as operationalized. This was most pronounced in the Hispanic versus White comparison, where the findings suggest fundamental differences between the two groups at the basic concept measurement level. CONCLUSIONS: The substantial discrepancies that the findings suggest for the subsamples call into question not only the structural integrity of the Wilson and Cleary model for minorities but also suggest that racial groups, particularly Hispanics, may perceive concepts of health-related quality of life differently than Whites.

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PURPOSE: This study uses structural equation modeling to assess the utility of the behavioral risk factor surveillance system (BRFSS)--the Centers for Disease Control's premier surveillance tool for monitoring behavioral risk factors-in predicting health-related quality of life (HRQoL). METHODS: Using SPSS/AMOS (version 18), the study utilizes New York State data extracted from the 2007 BRFSS national dataset to test a well-known HRQoL model developed by Wilson and Cleary (J Am Med Assoc 59-65, 2). The analysis represents an exploratory study that seeks to identify new applications for this important epidemiological database as well as a theoretical evaluation that examines the robustness of our current understanding of HRQoL. RESULTS: Findings support the Wilson and Cleary (J Am Med Assoc 59-65, 2) model, with the final model producing fit indices well within the thresholds traditionally used as benchmarks of good fit. CONCLUSIONS: The integrity of the Wilson and Cleary (J Am Med Assoc 59-65, 2) model was substantiated, and the utility of BRFSS data for operationalization of HRQoL concepts was demonstrated successfully. This study has: (1) expanded the role of epidemiological research to include whole theory testing; and (2) successfully operationalized the Wilson and Cleary (J Am Med Assoc 59-65, 2) model using available, non-clinical data, which represents a major methodological contribution to the study of HRQoL.

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OBJECTIVE: To evaluate the Advanced Illness Coordinated Care Program (hereafter AICCP) for effects on health delivery among patients and caregivers, quality of life, advance planning, and health service utilization. STUDY DESIGN: Prospective trial involving 532 patients and 185 caregivers. AICCP consisted of care coordination, health counseling, and education delivered in cooperation with physicians. METHODS: Patients with advanced disease and their caregivers were assigned to AICCP or usual care (UC). Data sources included self-report, medical record review, and health plan databases. Statistical analyses used t test, chi(2) test, regression analysis, and analysis of variance. RESULTS: Compared with those in UC, AICCP participants had improved communication and care concerning symptoms (P = .02), support in understanding and coping with their illness (P = .01), advance planning (P <.001), support in managing family decision making (P = .002), and help in accessing spiritual support (P <.001). AICCP caregivers received more attention for emotional and spiritual needs (P = .02). AICCP participants were 2.23 times more likely to formulate an advance directive (P <.001) (5.5 months sooner [P <.001]) and were 1.26 times more likely to agree to a do-not-resuscitate or do-not-intubate order (P = .04). AICCP participants had on average 1.89 fewer inpatient admissions (P = .045). There was no difference in 1-year survival (P = .80). CONCLUSIONS: AICCP improved communication and care delivery, advance planning, and do-not-resuscitate or do-not-intubate orders in a population at risk to use them. AICCP had fewer admissions. Coordination and health counseling seem matched for those coping with advancing illness.

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In recent years, increasing attention has been paid to the delivery of primary care services to underserved populations. This paper presents a subset of data from a larger exploratory study that examined how three professional groups (social workers, physicians, and administrators) in neighborhood health centers perceived the type and extent of psychosocial problems in their patient populations and the roles of their staff in addressing these problems. We examined the perceptions of physicians, administrators, and social workers as to who handles various psychosocial problems and whose responsibility it is to perform a range of psychosocial functions, with a focus on the function of social work. Social workers were highly praised and valued by administrators and physicians. While the respondents in neighborhood health centers confirmed the value of social work, public and private funders are reluctant to reimburse for social services beyond limited clinically diagnosed mental health services. Outcomes studies focused on the efficacy and efficiency of social work practice in neighborhood health centers are necessary to begin to overcome this barrier to social work services.

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This study aims to better understand the influence of social work support services on the efficient use of rehabilitation services (LOS-EFF) and total hospital charges for individuals participating in an inpatient physical rehabilitation program following stroke. Although the effects of the social work support services on stroke outcomes were modest, the study found that these services influenced stroke outcomes. Most importantly, the study revealed that higher levels of informational social work support services were associated with lower total hospital charges.

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Little is known about how health care professionals perceive and understand the psychosocial problems of individuals receiving services in neighborhood health centers (NHCs). We conducted interviews with health care professionals in NHCs in New York City. The respondents identified seven problems, including a lack of financial resources, unsafe housing, and emotional distress/depression as affecting large portions of their patient populations. Respondents reported that they are presently meeting many of the psychosocial needs of their clients, but they were pessimistic about their ability to continue to do so due to a lack of funding streams to support their provision of comprehensive health care that includes psychosocial services. The findings suggest that while NHCs may be "holding their own" in providing quality services to their clients, this will be harder to sustain in the future if the numbers of the uninsured served continues to increase, and the revenues generated continue to decrease.

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