Social Work in Primary Care Intervention

The Institute for Geriatric Social Work (IGSW), funded by The Atlantic Philanthropies, and located at Boston University School of Social Work is concluding a large study testing a structured social work intervention within the primary care setting at Kaiser Permanente in California. Scott Miyake Geron, Ph.D., IGSW's Director, is the Principal Investigator of the study, and Bronwyn Keefe, M.S.W., M.P.H., IGSW’s Assistant Director, is the Co-Principal Investigator. The Project Director for the California site is W. June Simmons, LCSW, who is the President/CEO of Partners in Care Foundation, and the Research Director is Susan Enguidanos, Ph.D., MPH, also of Partners in Care.

This study employs a randomized controlled trial to test a social work intervention with frail older adults in primary care. The intervention is designed to improve patient outcomes and reduce unnecessary healthcare utilization. The study population is a group of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment. Master’s-level social workers located in the primary care offices are conducting the intervention. At the core of the intervention is the use of intensive Problem-Solving Therapy (PST), a val idated behavioral change approach shown to be effective in treating depression and other psychosocial problems. This approach emphasizes mutually agreed upon goals for improving the patient’s health status and promoting his/her independence. Behavioral change approaches like PST provide patients with the resources and tools to manage and maintain their health status, and have been shown to improve mental health functioning. The study will compare outcomes for patients randomly assigned to the social work intervention with outcomes for patients receiving usual primary care.

To date, this study has enrolled 258 participants, and the study end date is December, 2007. Patients randomized to the intervention arm received up to eight sessions of Problem-Solving Therapy (PST) or brief, protocolized care management for those declining to participate in PST or who experience an emergent crisis. Preliminary analysis of case records from this study revealed that this intervention was particularly well suited among those individuals experiencing either a change in their health status, such as a newly diagnosed medical condition, or a life changing event, such as a death of a spouse. This is reflected in both problems identified by the patients in PST session and by review of case conference notes. Some of the most frequently identified problems included addressing health related behaviors and accessing information to better manage disease and health conditions, such as weight loss, exercise, medication and pain management, and medical appointments and procedures. Thematic analysis of case conference records revealed that the majority of patients who had successfully engaged in PST were confronting a myriad of psychosocial issues such as loneliness, isolation, a recent loss of a spouse, anxiety, depression, and stress from caregiving and family pressures. In addition, many participants recently experienced a change in their health status, such as a new medical diagnosis or recurrence of an existing medical problem, or an emergent medical problem such as recent stroke, heart attack, fall resulting in a break, or hospitalization.

Results for more than 150 patients who have completed 4-month follow-up surveys show that key intervention effects are in the desired direction, with the biggest impacts on patient satisfaction and physical functioning. Depression scores are also lower (by .2 points on the GDS scale) relative to the usual care control group, but not significantly so at this point in the study. These results, while preliminary, support the use of PST with a frail older population with multiple chronic illnesses.