Complex patients Social Workers understanding of complexity in

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Complex patients: Social Workers’ understanding of complexity in patient care Glenda Kerridge – Eastern

Complex patients: Social Workers’ understanding of complexity in patient care Glenda Kerridge – Eastern Health Dr. Helen Cleak – Associate Professor QUT Angliss Box Hill Hospital Healesville & Maroondah Peter James District Hospital Centre Wantirna Yarra Ranges Yarra Valley Health Community Health Turning Spectrum Point

Context of study • Demand for health care is growing in Australia with an

Context of study • Demand for health care is growing in Australia with an ageing population, who are developing multiple and chronic illnesses as they age (Duckett, Breadon, & Farmer, 2014 ) • Hospital systems face increasing pressure to improve patient flows and improve how they deal with a growing range of such challenges, including an overall population growth, technological advances and improved treatment options • The case complexity associated with serious medical conditions, life crisis, and multiple agency involvement can result in extended hospital stays ; this can be further complicated by uncertainty around prognosis, and the influence of existing or acquired disability on people’s potential to resume their previous lifestyle (Redfern, Burton, Lonne, & Seiffert, 2015).

Social work response • Increasing patient complexity, increasing numbers of patients with chronic health

Social work response • Increasing patient complexity, increasing numbers of patients with chronic health problems, and the emergence of risk assessment to minimize poor outcomes for the organization as well as the patient (Scott, 2010), has led to social workers spending increasing amounts of time in negotiation and conflict resolution tasks to assist patients and their significant others in negotiating the health care system • More than ever, social workers are asked to articulate what particular expertise they bring to patient care and multi-disciplinary teamwork; often they respond that it is: their ability to deal with “complexity”

Unpacking “complexity” • Are social workers referring to “the multiple issues, disabilities and health

Unpacking “complexity” • Are social workers referring to “the multiple issues, disabilities and health problems presented to them by their patients? • Or to the complex interventions required of them? • Or to the health and other social systems within which they work? ” • And what are the implications of this complexity and how shall we understand how social workers best grapple with the myriad of issues which impact on their patients’ health experiences and outcomes?

Previous research Monash Health (Melb) undertook a small study of complexity in subacute services

Previous research Monash Health (Melb) undertook a small study of complexity in subacute services in 2012. Their findings indicated that social workers’ understanding of complexity refers to five interrelated themes: § multiple competing demands; § uncertainty; § patient and family characteristics; § pending breakdown; § systems challenges The results also showed a link between Grade level and experience and the social workers’ ‘confidence and capacity in managing complex cases’.

Aims of the Study Ø The aim of the present study was to add

Aims of the Study Ø The aim of the present study was to add to the investigation of the experience of health social workers in working with complexity It was hoped that by investigating workers’ experience and perception of complexity, we could use this knowledge to: Ø prioritise workloads and use the information in workforce development, such as training and professional development Ø develop a set of clinical priorities for social work practice Ø build the business case for hospital social work in a modern context

The Research Questions were: To explore social workers’ understanding of complexity in relation to

The Research Questions were: To explore social workers’ understanding of complexity in relation to inpatients in acute and sub-acute sites across Eastern Health. are: Ø What cases do social workers consider to be complex? Ø What factors do social workers consider that makes a case complex? Ø What are the similarities and differences between a complex and non-complex cases? Ø What is the impact on social workers of them working with complex cases?

Methodology Ø Semi-structured interviews, replicating the tool used by Mc. Alinden, Mc. Dermott and

Methodology Ø Semi-structured interviews, replicating the tool used by Mc. Alinden, Mc. Dermott and Morris (2013) Ø All social workers from both acute and sub-acute sectors at Eastern Health were invited to participate, with 31 taking part Ø Participants were asked to bring their patient list for that day and identify those which were most complex and then to describe 5 of those in more detail. Ø They also commented on the impact of complex cases on them Ø The data was then collated and results were analysed using both descriptive and qualitative thematic analysis Ø Ethics approval was granted by the Eastern Health Human Research Ethics Committee

Demographics n = 31 Grade Experience (years) Acute Subacute Total 1 5 (36%) 4

Demographics n = 31 Grade Experience (years) Acute Subacute Total 1 5 (36%) 4 (24%) 9 (29%) 2/3 9 (64%) 13 (76%) 22 (71%) ≤ 5 8 (57%) 11 (65%) 19 (61%) ≥ 5 6 (43%) 6 (35%) 12 (39%) 5 (36%) 7 (41%) 12 (39%) 5 (36%) 5 (29%) 10 (32%) 4 (29%) 5 (29%) 9 (29%) 20 -30 Age 30 -40 (years) ≥ 40

Categories of complex cases ØMultiple, complex medical conditions ØPsychosocial problems ØMental health issues ØInter-professional

Categories of complex cases ØMultiple, complex medical conditions ØPsychosocial problems ØMental health issues ØInter-professional & team issues –including ethical stress ØSystems issues ØPersonal (pt) behaviours

Comparing complex case definitions with the sectors Demographics Acute Sub-acute TOTAL 10 (71%) 9

Comparing complex case definitions with the sectors Demographics Acute Sub-acute TOTAL 10 (71%) 9 (53%) 19 5 (36%) 5 (29%) 10 11 (79%) 15 (88%) 26 4. Mental health issues 4 (29%) 13 (76%) 17 5. Personal (pt) behaviour/issues 3 (21%) 8 (47%) 11 6. Systems issues 1 (7%) 1 (6%) 2 COMPLEX CASE INDICATORS: 1. Multiple, complex medical conditions 2. Inter-professional & team issues 3. Psychosocial problems Ø Mental health issues emerge as a primary indicator of a complex case definition in the sub-acute sector as compared to the acute sector.

No of complex cases per worker DEMOGRAPHICS ACUTE SUB-ACUTE TOTAL 0 -3 complex cases

No of complex cases per worker DEMOGRAPHICS ACUTE SUB-ACUTE TOTAL 0 -3 complex cases 10 (71%) 7 (41%) 17 4 -6 complex cases 3 (21%) 7 (41%) 10 7 -10 complex cases 1 (7%) 3 (18%) 4 NO OF COMPLEX CASES

No of complex cases by Grade level GRADE LEVELS 1 COMPLEX CASE 2 COMPLEX

No of complex cases by Grade level GRADE LEVELS 1 COMPLEX CASE 2 COMPLEX CASES 3 COMPLEX CASES GRADE 1 4 4 1 GRADE 2 7 5 3 GRADE 3 6 1 -

Comparing grade, age and experience with the definitions of case complexity Ø Grade 1

Comparing grade, age and experience with the definitions of case complexity Ø Grade 1 social workers were more likely to believe that “multiple, complex medical conditions” is one of the main perceptions of complexity Ø Otherwise, there was consistency in the perception of complexity across all grades, ages and years of experience

The impact of working with complex cases Even when comparing age, grade level and

The impact of working with complex cases Even when comparing age, grade level and experience, all social workers showed similar perceptions of the impact of working with complex cases. The impact included: Ø knowledge and skills tested Ø invigorating, satisfying and interesting Ø pressurised, stressful and time-consuming Ø Compromised professionally/ in conflict with the organisation Ø emotional impact

“Time taken with complex patients reduces the time available for other patients”. (Gr 2

“Time taken with complex patients reduces the time available for other patients”. (Gr 2 sw) In a complex case , there a lot of pieces in the puzzle. It feels like putting a jigsaw puzzle together without being able to look at the picture”. (Gr 2 sw) “It motivates me. You need to be inspired and energised by it, or it won’t suit you”. (Gr 2 sw) “Everyone else can pull out, but social work can’t”. (Gr 3 sw)

Findings Ø This workforce was characterised by being a young group but were in

Findings Ø This workforce was characterised by being a young group but were in more senior roles and over 60% had been social workers for less than 5 years Ø The largest category of complexity was ‘psychosocial’ which confirms that social workers are being referred appropriate cases. This was also a common finding in the previous study Ø Sub-acute workers reported twice as many ‘patient behaviours/ issues’ than acute; this may reflect the non-acute medical complexities that this group need to address which may not be so compelling in the acute setting. Perhaps also the length of stay. Ø Lack of differentiation between grade levels and complexity may reflect our larger sample size and including acute services Ø Workers across both sites can perform interventions with complex cases ; does this present opportunities for working across the sector when gaps and vacancies arise?

Is complexity the new black? Ø Social workers are consistent in their perceptions of

Is complexity the new black? Ø Social workers are consistent in their perceptions of complex cases Ø Some differences exist between acute and sub-acute sectors, with sub-acute workers carrying a greater number of complex cases Ø Mental health issues stood out as a more significant factor in the sub -acute sector Ø Unlike the Monash study, we found little differentiation between grade levels in terms of the impact of working with complex cases ENABLES US TO: Ø More clearly articulate those cases which are deemed “complex” Ø Promotes workforce development and planning Ø Informs student and worker education

Where to from here? • Findings pose interesting questions around job satisfaction for hospital

Where to from here? • Findings pose interesting questions around job satisfaction for hospital social workers, given the link between job satisfaction and turnover intent [Pugh (2016), O’Donnell et al (2008)] Ø Follow-up studies could further explore the link between complexity and job satisfaction and retention rates

Bibliography • • • Duckett, S. , Breadon, P. and Farmer, J. (2014). Unlocking

Bibliography • • • Duckett, S. , Breadon, P. and Farmer, J. (2014). Unlocking skills in hospitals: better jobs, more care, Grattan Institute Mc. Alinden, F. Mc. Dermott, F. , & Morris, J. (2013) Complex Patients: Social Workers' Perceptions of Complexity in Health and Rehabilitation Services, Social Work in Health Care, 52: 10, 899 -912 O’Donnell , P. , Farrar, A. , Brintzenhofeszoc, K. , Conrad, A. , Danis, M. , Grady, C. and Ulrich, C. (2008) Predictors of Ethical stress, moral action and job satisfaction in health care workers. Social Work in Health Care: 46(3), 29 -51 Pugh, L. G. ((2016). Job satisfaction and turnover intent among hospital social workers in the United States. Social Work in Health Care: 55: 7, 485502 Redfern, H. , Burton, J. Lonne, B. , & Seiffert, H. (2015): Social Work and Complex Care Systems: The Case of People Hospitalised with a Disability, Australian Social Work, DOI: 10. 1080/0312407 X. 2015. 1035295 Scott, I. (2010). Public hospital bed crisis: too few or too misused? Australian Health Review, 34, 3, 317 -24

helen. cleak@qut. edu. au Glenda. kerridge@easternhealth. org. au

helen. cleak@qut. edu. au Glenda. kerridge@easternhealth. org. au