Decision Cases for Advanced Social Work Practice

Confronting Complexity

Terry Wolfer, Lori Franklin, Karen Gray

• Publisher: Columbia University Press
• Year: 2013
• ISBN:
  9780231536486
• Topic: Sciences sociales
• Subtopic: Travail social

These fifteen cases take place in child welfare, mental health, hospital, hospice, domestic violence, refugee resettlement, veterans' administration, and school settings and reflect individual, family, group, and supervised social work practice. They confront common ethical and treatment issues and raise issues regarding practice interventions, programs, policies, and laws. Cases represent open-ended situations, encouraging students to apply knowledge from across the social work curriculum to develop problem-solving and critical-thinking skills.

An instructor's manual with teaching notes is available by emailing: [email protected].

1

NO PLACE LIKE HOME

Lori D. Franklin

Medical social worker Sandy Deloach located Lucy Haskins in the TV room and sat down across from her. Lucy was a sixty-three-year-old patient on the Geriatric Psychiatric Services Unit at Durant Regional Health Services.

“Lucy, great news,” Sandy began. “We’re going to discharge you soon. Have you given any more thought to where you would like to go?”

“To my daughter’s.” Lucy’s tone was flat, and her voice quiet.

“Lucy,” Sandy said calmly, “remember, we told you we spoke with her and she said no. You can’t go back there.”

“She says stuff like that, but she’ll let me. Just get me back there, and it will be okay.”

“Lucy,” Sandy said, “your daughter said you couldn’t come back this time.”

“It will be fine,” Lucy spoke evenly. “Just take me to my car, and I’ll get there myself then.”

“Lucy, your car really isn’t a safe place for you right now.” Sandy felt herself getting frustrated. “It’s summer, and it’s hot out. It’s too hot to be in a closed-up car. And your car isn’t working.”

“That’s okay, I don’t need housing. I just like it with my daughter. And if she doesn’t want me, it’s okay in the car. I’ll figure it out; I’ve done it before.”

DURANT REGIONAL HEALTH SERVICES

Durant Regional Health Services (DRHS) was the largest hospital in southeastern Oklahoma and housed the only inpatient psychiatric unit for the elderly in that area. Typical patients of its rural service area generally had much lower income than the rest of Oklahoma. Many of the patients were on Medicaid or had no pay source at all. The hospital had a full range of general medical services, including inpatient mental health care, but the Geriatric Psychiatric Services Unit (GPSU) was the only “specialty” service the hospital offered.

In 2008, DRHS faced many challenges as a for-profit hospital. The large hospital was often under capacity, and these vacancies created a strain on profits. Many of the patients in this rural area of the state lived in poverty. They did not qualify for Medicaid, so their medical services were not reimbursed. The large indigent population had always strained emergency care services, utilizing the emergency room as a source of primary care, and reimbursement for these services was very low. The hospital often sacrificed profits when serving low-income patients without a pay source yet had to provide emergency medical care for all patients in need. Many of these patients were treated in the emergency room and discharged and did not utilize other hospital services. But the hospital was for profit, so it relied heavily on insured patients and the income-generating units that served them in order to stay afloat.

THE GPSU

The GPSU was a successful unit in terms of reimbursement rates. The hospital’s chief financial officer had referred to the GPSU in open meetings as “our greatest revenue producer” and part of the reason the hospital could stay open. Most of the geriatric clients were either on disability or Medicare, which obviously led to a higher rate of reimbursement than units that primarily served the indigent population. But even though the rates of reimbursement were high, the unit had twelve rooms, and the daily census was usually only seven or eight patients. The staff was adequate for this census and spent a great deal of time with patients individually and in group work.

The unit itself had a homey appearance, despite being a locked unit. It was rectangular, with two long hallways of individual patient rooms on each side and locked doors at either end. In the middle, there was a nurses’ station, group rooms, and a kitchen and dining room. The floor was nicely carpeted, and there were comfortable couches and rocking chairs in the common areas. The chairs were vinyl and easy to clean, but they were not attached to the floor and had decorative floral prints.

The staff on the geriatric unit were very experienced and worked well together as a supportive team. The program was directed by Marjorie Adams, a licensed clinical social worker (LCSW) who had almost twenty years of experience working with the elderly. The outpatient social worker, Pam Carson, was an experienced LCSW who was a mentor to the staff. Sandy Deloach, MSW, was the discharge planner. The professional team also included two geriatric certified nurses, a recreation therapist, and a psychiatrist. They all got along well and seemed to respect each other as people and as professionals.

SANDY DELOACH

Before Sandy Deloach began working at the hospital, she had spent ten years in sales at a large company and found herself enjoying a nice income, but not feeling much satisfaction in her work. She decided to make a dramatic career change and pursue a bachelor’s and then a master’s degree in social work.

Sandy’s marketing background helped her get her foot in the door, and she was hired in DRHS’s Community Relations Department while she began work on a bachelor’s degree. She was able to do a bachelor’s field practicum in the GPSU while still employed in the Community Relations Department, and Pam Carson had been her practicum supervisor. Sandy was organized and efficient, so she managed the difficult schedule of a full-time marketing job, coursework, and the practicum. A paid position in discharge planning became available as she finished the bachelor’s degree, so she happily applied, was hired, and left marketing behind. Even though the job was technically a master’s level position, her performance record was such that the hospital made an exception and hired her with a bachelor’s degree, knowing that she had plans to pursue an MSW. The position served as her master’s field practicum, and after graduating in May 2008, she kept the job.

Sandy had now been out of school for almost two months but had been at the hospital for nearly five years. She was glad to have the stability of the now familiar job as a discharge planner. She enjoyed her job and loved knowing she was helping people instead of just selling products. Her husband was also in marketing, so her family was able to endure the reduced income that came with her career change. She cared about her elderly clients and took pride in helping those who desperately needed services.

DISCHARGE PLANNING … AND MORE

Sandy’s job title was officially “discharge planner,” but the small unit worked closely as a team, and she did many different things on the unit. Now that Sandy had her MSW, Marjorie assigned her not only psychosocial assessments and discharge planning, but some group therapy as well. She ran a daily group that focused on cognitive and recreational therapy. This group was challenging to lead because the unit accepted patients with a wide range of levels of functioning. If group participants were higher functioning, they would do more traditional group therapy, focusing on the cognitive patterns associated with depression or behavioral concerns using a cognitive-behavioral model. On those days, the patients interacted with each other, and Sandy often saw real changes as they realized how their relationships and thinking patterns affected their moods.

But on other days if group participants were more cognitively impaired, she kept the groups more activity oriented. For example, patients might toss a beach ball while saying their favorite color or do some other type of group activity. These group sessions were less satisfying to her, but at least she was working toward engaging the patients in something. Many of the geriatric patients suffered with dementia and other conditions that reduced awareness of their surroundings, so any progress in connecting them to others was a success.

It was more difficult, though, to handle a mix of cognitive levels in the group or when a patient had severe anxiety or another condition that impaired his or her ability to participate or interact. The wide variation of cognitive functioning as well as the continual turnover of an inpatient environment made it nearly impossible to follow a curriculum or plan ahead for group. When the group was mixed, Sandy would often divide the group into a cognitive therapy group and a recreational therapy group. She could then have the recreational therapist work with the lower-functioning group and do some activities geared toward their abilities. It was difficult to decide how to divide the group, though. Sandy would begin with an analysis of the scores on the Mini Mental Status Exam, the Geriatric Depression Scale, and the general assessment. But making the division was always more complicated than that because many people were not clearly cognitively impaired yet still didn’t seem appropriate for an insight-oriented group. So she sometimes would ask the recreational therapist to cofacilitate with her, and they would try to tailor the group to the needs that emerged.

Sandy’s job as a discharge planner was also becoming increasingly complicated. With new patients, her approach was to start planning for discharge from the very beginning. When she first began, it seemed as if most of the discharge plans were to nursing homes or assisted-living facilities, or patients just returned to the family members who had brought them to the hospital. Most patients were not voluntary but arrived with adult protective services or with family members who had durable power of attorney. Some were referred by nursing homes and hospitals. There were many with Alzheimer’s disease and other kinds of dementia. Perhaps a third of the patients had some kind of chronic depression. Sometimes patients were there because of a suicide attempt, but many were there because of ongoing symptoms of mental illness that interfered with the ability to care for themselves.

For involuntary patients detained against their will on an emergency basis, the unit had seventy-two hours to assess the patient’s needs and initiate treatment. After seventy-two hours, the patient would be released if there was no court order to continue the detention. To obtain a court order, Sandy would write a petition to the court, which generally included a description of how the patient presented to the unit, details of specific behaviors, past and current diagnoses, and a summary of assessment results. She wrote the petitions, and then the psychiatrist, Dr. Hamilton, whom she kept informed of patient information, signed them. The unit enjoyed good relationships with most of the county courts, so Sandy’s recommendations on the petitions were usually honored. A court order to continue detention gave the unit additional time to stabilize a patient’s condition and Sandy time to create a robust discharge plan that would fully address the patient’s needs.

Sandy usually had some idea at intake about where the patient would go at discharge. But lately there seemed to be more patients trickling through with more complicated situations. The unit had always defined “geriatric” as fifty-five and older, but now some patients in their early fifties or even late forties were coming to the unit. Some came with no family connections, no stable housing, and increasingly severe mental illnesses. In the past, patients stayed an average of ten days, but more and more this set period didn’t seem to be enough time to stabilize the patients. Sandy was used to getting them in, completing the psychosocial assessment within three days, putting services into place for the family within five days, and preparing the discharge plan. But the more severe patients took more staff time and were more difficult to place. Sandy also felt pressure to move faster as the number of vacant beds on the unit gradually decreased.

ADMITTING LUCY

Arriving at work on Monday morning, Sandy looked over the chart of Lucy Haskins as she prepared to meet with Lucy for her initial assessment. Lucy had been admitted during the night shift, so Sandy hadn’t got to meet with her from the beginning, as she would have preferred. She stopped at the nurse’s station to speak with Cynthia Crowder, who was just ending her night shift. Cynthia was the head nurse on the unit and had admitted Lucy when the police brought her in.

“Cynthia,” Sandy asked, “I know you’re on your way out, but could you bring me up to speed quickly on Lucy Haskins?”

“Sure,” Cynthia said, “the police brought her in last night, and she was really upset. The police said, ‘Boy, you sure got a live one there, good luck,’ when they dropped her off. The police said she was found wandering around on the highway, and when they tried to talk to her, she started throwing rocks at them. The police said it took three of them to restrain her and get her in the car, so she was in handcuffs when she got here, of course.”

“What did the police say she was like once they got her in the car?” Sandy asked.

“She was really angry and was yelling things like, ‘This is bullshit, and you should be arresting my daughter!’ It sounds like Lucy had been staying with her daughter, and then they had a big fight. The police report says that Lucy threatened her daughter with a knife, broke a window, and kicked a hole in the wall. Then she drove off in her car, but it broke down outside of Hugo, and that’s when the police found her wandering around on the highway.”

“Hugo is in Choctaw County, though,” Sandy said, puzzled. “I guess they had to bring her here to Bryan County because no hospital out that way could help her. We sure are getting folks from far and wide lately, aren’t we? I see she’s just sixty-three, too.”

“Well, I guess we have room for her,” Cynthia stated. “She wasn’t easy last night, though.”

“What happened?” Sandy asked.

“She was pretty agitated and difficult to talk to,” Cynthia explained, “you know, angry about being here. She wouldn’t go to sleep but just kept pacing up and down the hallway. She was kind of mumbling to herself, and if anyone spoke to her, she would shout, ‘No! I am not going to answer any of your damn questions right now! Leave me the hell alone!’”

“Did she eventually calm down?” Sandy wondered.

“Yeah, after a Haldol and Ativan cocktail. She finally sat in one of the rocking chairs and was quiet, but I don’t think she slept. She just rocked and rocked in the chair. And this morning so far, she has refused breakfast, refused to take a shower, and said she wouldn’t participate in the group activities. So she’s all yours now, Sandy!” Cynthia picked up her purse and started toward the door. “See you tomorrow!”

This all sounds pretty typical, Sandy thought. No one is happy about being dragged in by the police in the middle of the night. But she does sound pretty agitated.

INTERVIEWING LUCY

“Lucy, tell me about where you were living before you came here,” Sandy prompted gently after they exchanged some initial small talk.

“At my daughter’s,” Lucy began softly. “When can I go back there?”

“I’ll need to speak to her and see if she will let you go back,” Sandy responded. Relatives were often hesitant to take back their family members after a conflict, so Sandy would not assume that returning Lucy to her daughter’s house was a viable plan until she spoke to the daughter.

“She will,” Lucy assured.

“Well, you might be right. But if she doesn’t, where else would you like to go?” As a discharge planner, Sandy knew she needed to begin thinking about placement now.

“Just take me to my car.” Lucy’s voice was so even, almost emotionless, that Sandy couldn’t determine what she thought of this option.

“I don’t know, Lucy. Your car is more than a hundred miles away in Choctaw County. Let’s talk first about what to do while you are here.”

“I don’t need a hospital. I just need to get out of here!” Lucy raised her voice and fidgeted in her chair. “I don’t need to answer any questions, I just need my car! You don’t have any right to keep it from me!”

“Lucy,” Sandy responded, “I can imagine that you are feeling upset, and I want to help you get to your car. Let’s talk a minute about it.”

“Shut up, I don’t want to talk to you.” Lucy rose out of her chair and began pacing around the room. “You have no right to keep me here.”

“I know you don’t want to be here,” Sandy responded. “But it will help me get you out of here if you can tell me a bit about what’s going on.”

“Nothing is going on. I just want to get back to my car and back to my daughter’s house. She was mad at me, but it will be okay. I’ve lived there some over the years, and she’ll let me come back.”

“Okay,” Sandy said. “Maybe we can give your daughter a call. Have you ever been in a place like this hospital before?”

“I am not crazy, and I have never been somewhere like this. This is a prison. Go ahead, call my daughter! Tell her to come get me out of here now.”

TRACY SAYS NO

Lucy signed release forms for Sandy to call her daughter, Tracy Bryson. Tracy lived in Idabel, Oklahoma, with her husband, two sons, and two stepchildren. Sandy caught her up on how Lucy had arrived at their unit.

“Does your mom have a history of mental ...