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A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care. 2016

Stephen M Rose, and Stephanie Hatzenbuehler, and Erika Gilbert, and Mark P Bouchard, and Debra McGill

Chronic diseases disproportionately occur among people from disadvantaged backgrounds. These backgrounds correlate with poor health in adulthood. Capacity for patients' to collaborate in their care tends to be lower than among other patients, leading to inefficient uses in medical services and higher risk of adverse events. In the course of this study, social workers engaged patients with increased inpatient and emergency department (ED) use and barriers to self-management, and evaluated them for lifetime exposure to material disadvantage and violence. Intervention focused on creating a primary care team that improved patients' self-efficacy, increased locus of control, and improved capacity for engagement. Results include a 49 percent decrease in admissions and a 5 percent decrease in ED utilization with significant cost savings. Authors recommend further study to analyze social, clinical, and financial risk in a larger sample, which may yield information about a health care provider's most at-risk patients for early targeted intervention.

UI MeSH Term Description Entries
D008281 Maine A state bounded on the east by the Atlantic Ocean, on the north by Canada, and on the south and west by New Hampshire.
D008297 Male Males
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D010865 Pilot Projects Small-scale tests of methods and procedures to be used on a larger scale if the pilot study demonstrates that these methods and procedures can work. Pilot Studies,Pilot Study,Pilot Project,Project, Pilot,Projects, Pilot,Studies, Pilot,Study, Pilot
D011320 Primary Health Care Care which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (JAMA 1995;273(3):192) Primary Care,Primary Healthcare,Care, Primary,Care, Primary Health,Health Care, Primary,Healthcare, Primary
D002908 Chronic Disease Diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care (Dictionary of Health Services Management, 2d ed). For epidemiological studies chronic disease often includes HEART DISEASES; STROKE; CANCER; and diabetes (DIABETES MELLITUS, TYPE 2). Chronic Condition,Chronic Illness,Chronically Ill,Chronic Conditions,Chronic Diseases,Chronic Illnesses,Condition, Chronic,Disease, Chronic,Illness, Chronic
D004636 Emergency Service, Hospital Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient. Emergency Outpatient Unit,Emergency Services Utilization,Hospital Emergency Room,Hospital Emergency Service,Hospital Emergency Services Utilization,Accident and Emergency Department,Emergency Departments,Emergency Hospital Service,Emergency Room,Emergency Units,Emergency Ward,Hospital Service Emergency,Service, Hospital Emergency,Department, Emergency,Departments, Emergency,Emergencies, Hospital Service,Emergency Department,Emergency Hospital Services,Emergency Outpatient Units,Emergency Room, Hospital,Emergency Rooms,Emergency Rooms, Hospital,Emergency Services, Hospital,Emergency Unit,Emergency Wards,Emergency, Hospital Service,Hospital Emergency Rooms,Hospital Emergency Services,Hospital Service Emergencies,Hospital Service, Emergency,Hospital Services, Emergency,Outpatient Unit, Emergency,Outpatient Units, Emergency,Room, Emergency,Room, Hospital Emergency,Rooms, Emergency,Rooms, Hospital Emergency,Service Emergencies, Hospital,Service Emergency, Hospital,Service, Emergency Hospital,Services Utilization, Emergency,Services Utilizations, Emergency,Services, Emergency Hospital,Services, Hospital Emergency,Unit, Emergency,Unit, Emergency Outpatient,Units, Emergency,Units, Emergency Outpatient,Utilization, Emergency Services,Ward, Emergency,Wards, Emergency
D005260 Female Females
D006301 Health Services Needs and Demand Health services required by a population or community as well as the health services that the population or community is able and willing to pay for. Health Services Needs,Needs,Needs and Demand, Health Services,Target Population,Health Services Need,Need, Health Services,Needs, Health Services,Population, Target,Populations, Target,Target Populations
D006305 Health Status Indicators The measurement of the health status for a given population using a variety of indices, including morbidity, mortality, and available health resources. Health Risk Appraisal,Health Status Index,Health Status Indexes,Appraisal, Health Risk,Appraisals, Health Risk,Health Risk Appraisals,Health Status Indicator,Health Status Indices,Index, Health Status,Indexes, Health Status,Indicator, Health Status,Indicators, Health Status,Indices, Health Status,Risk Appraisal, Health,Risk Appraisals, Health

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