Social Service Department
This department provides a variety of services to Leahi residents and Adult Day Health Participants. The department aims to ensure that the participants achieve the highest feasible health outcomes, such as physical, mental, and psychosocial well-being. Department involvement in patient well-being begins from the time the patient is admitted into the facility. This continues throughout the participants’ residency. Upon admission, the resident is subjected to psychosocial assessment to help identify their strengths and areas that require interventions. The department also provides residents with emotional support, advance directives/surrogate decision-makers, and information regarding insurance, such as Medicare and Medicaid (Leahi Hospital, 2020). The department is also involved in planning discharges as needed by the facility.
Nursing Level of Care
The nursing unit provides short-term and long-term care to patients, including acute care. The facility offers two levels of nursing care: Skilled Nursing Care (SNF) and Intermediate Nursing Care (ICF). Intermediate care involves intermittent nursing care, while skilled nursing care requires 24-hour skilled nursing monitoring (Leahi Hospital, 2019).
Admission Process
- Check PASSR
- Meet with resident/family to adjust to Leahi
- The baseline Care Plan is done within 48 hours after admission
- Social work history assessment done within seven days of admission
- Review of POLST, Advanced Healthcare Directive, Living Will, and code status
- MDS section D (PHQ-9), E, Q within five days and 14 days as scheduled
- Adjustment to facility Care Plan with periodic visits
- Community Care Plan
- Care Plan as applicable (behaviors, psychosocial, moods
- Admission conference- prepare conference notes on Leahi IDT
- Collateral calls to POA
Sample Social History Assessment Form
Leahi Hospital uses a social assessment form that focuses on interpreting and making meaning of the patient’s social history. Humans are complex, and their biological, psychological, and social relations affect their behavior(Chhabra et al., 2019). The hospital uses the social assessment form as comprehensive guidance to compose a patient’s social history. The social history assessment form helps the caregiver with the ground for mutual client professional assessment. This form is filed within seven days of admission of the patient at the facility (Leahi Hospital, 2020).
Physician Orders for Life-Sustaining Treatment (POLST)
Physician Orders for Life-Sustaining Treatment (POLST) is a medical form that is designed to aid critically ill patients in communicating with healthcare providers about their end-of-life treatment preferences (Tark, 2021). It contains specific instructions outlining the medical interventions the patient wishes to receive or avoid.
PHQ-9 Form
Patient Health Questionnaire-9 (PHQ-9) is the most commonly used tool for screening patients with symptoms of depression. The form is made up of nine items that relate well to the Diagnostic and Statistical Manual of Mental Disorders (Costantini et al., 2021). The outcome results from the PHQ-9 are important in providing useful information about the patient’s level of depression and symptom severity. The score on the form ranges from 0 to 27, with a higher score linked to greater symptom severity (Costantini et al., 2021).
Importance of PHQ-9
The results or outcome of the PHQ-9 are important to therapists in the mental health segment.
It is important in treatment decision-making and monitoring of the interventions over some time (Costantini et al., 2021).
It facilitates communication between patients and healthcare providers.
The decrease in the patient’s PHQ-9 score over some time indicates an improvement in the patient’s status (Costantini et al., 2021).
The increase in the score may suggest the need for further assessments or improvement of the treatment (Costantini et al., 2021).
It is critical to note that this tool is very important in screening patients. Still, it should not be employed as a sole diagnostic tool, and comprehensive clinical evaluations and interventions are needed to support it in identifying depression disorders (Costantini et al., 2021).
Commonly Used Cut-off Scores for PHQ-9
- Score 0-4: Minimal symptoms of depression
- Score 5-4: Mild symptoms of depression
- Score 10-14: Moderate symptoms of depression
- Score 15-19: Moderately severe symptoms of depression
- Score 20-27: Severe symptoms of depression.
Roles of Social Workers in Filling Forms
Social workers are critical in filling out the medical forms that influence patient care outcomes. A social worker can help the patient understand the purpose and implications of the POLST form. The social worker can help facilitate communication between patient and their support system. The social worker can administer the PHQ-9 form, a depression screening tool, and provide the necessary support to a patient with depression (Marlow et al., 2023). Social workers also help the patients understand the outcome of the screening process and provide them with education about depression, available treatment options, and coping strategies. The social worker can utilize the social history assessment form to gather information about patients’ social, cultural, financial, or economic history and their support systems and resources. This information is vital to healthcare providers to understand patient needs and develop a more comprehensive treatment plan.