The 131st Annual Meeting (November 15-19, 2003) of APHA

Abstract #63178

Jeremy Boal, MD and Katherine Ornstein, MPH. Visiting Doctors Program, Mount Sinai Hospital, Box 1216, New York, NY 10029, 212-241-4141, jeremy.boal@mssm.edu

The Mount Sinai Visiting Doctors program delivers primary medical care to 600 frail and predominantly elderly homebound patients in Manhattan annually. An assessment of the unmet program needs revealed a lack of readily accessible and ongoing social work services for patients and their caregivers. In August 2001 a private grant enabled the program to hire one full-time social worker. The frequency and reasons for referrals were recorded as well as all social work contacts, including type of contact (home visit/telephone/in hospital), length of contact, level of urgency, who the contact involved, issues addressed and any new services added. During a 14-month period the social worker was involved in the care of more than 300 homebound patients and/or their families. The most common reasons that providers made a referral to social work services were caregiver coping issues, patient difficulties in coping with their situations, home care coordination issues, obtaining adequate benefits, and referral to community resources. 17% of the social worker’s time was spent counseling family caregivers. The social worker categorized 15% of the cases she worked with as being high risk, meaning that immediate need for intervention was required. On average, the social worker worked with each client 5 times, ranging from 1-2 encounters for acute interventions to more than 20 for long-term counseling sessions. A follow-up evaluation of caregivers and providers revealed that ongoing collaboration between medical and social services is crucial to addressing the complex needs of the homebound.

Learning Objectives:

• Identify the non-medical problems faced by homebound persons and their caregivers
• Describe the nature and scope of social work interventions that are undertaken in a medical care program for homebound elderly
• Discuss how medical programs that serve the homebound can incorporate social work services into their care models

Keywords: Social Work, Home Visiting

Presenting author's disclosure statement:
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: employment