Standardized screening of elderly patients' needs for social work assessment in primary care: use of the SF-36.
Fewer hospitalizations and decreased lengths of stay in the
hospital have resulted in an increased need for extensive support
services and continuing care planning for elderly people in primary
care. Early identification of elderly patients needing community and
hospital nonmedical services is necessary so that timely appropriate
services can be delivered. This study addresses the issue of whether a
standardized health-related quality of life questionnaire, the SF-36,
can be used independently as a screen predicting primary care elderly
patients' needs for social work assessment. In addition, the
question of what scales on the SF-36 a social worker would use to screen
patients in need of assessment is explored.
Key words: elderly people, primary care, SF-36 questionnaire, social work assessment
(Care and treatment)
Social service (Analysis)
Quality of life (Analysis)
|Publication:||Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 1999 National Association of Social Workers ISSN: 0360-7283|
|Issue:||Date: Feb, 1999 Source Volume: 24 Source Issue: 1|
Growth of outpatient primary health care services has expanded
significantly since the early 1980s because of increasing numbers of
elderly patients presenting with multiple chronic health problems,
advanced technology enabling the substitution of outpatient for
inpatient procedures, reimbursement incentives, and consumer demand
(American Hospital Association, 1990-91). Concomitantly there has been
an increase in the average annual number of outpatient physician visits
per elderly person. The average person age 65 or older, in good or
excellent health, visits his or her physician an average of four times
per year, but if the individual is in fair or poor health, his or her
visits increase to 9.4 times annually. The average annual visits
increase by one-third with the population ages 85 years and older
(Schick & Schick, 1994). Current trends project a rise in outpatient
visits of 106 percent by 2000 (American Hospital Association, 1990-91).
Fewer hospitalizations, as well as decreased lengths of stay in the hospital, have resulted in increased frailty in elderly patients seen in primary care settings (Berkman et al., 1996). Chronic illnesses and their consequences, as well as a variety of psychological ailments (that is, emotional disorders and stress), appear as the major personal and social health problems encountered by health care professionals in working with the elderly people in primary care (Berkman et al., 1996). Chronically ill or disabled elderly people need extensive environmental support services and continuing care planning if they are to remain in the community. However, elderly people in need of such community services often have been overlooked by their physicians, whose traditional diagnostic focus on physiological issues is too restrictive to enable assessment of the overall health concerns of their patients (Azzarto, 1993; Badger et al., 1994; Sloane, 1991). Physicians' difficulties in diagnosing psychosocial problems are compounded by the fact that they reportedly spend less average time per visit with their older patients, leaving little time to accurately diagnose the complicated needs of the elderly patients. Lack of time also limits a doctor's ability to consult with an elderly patient's family, let alone make referrals and coordinate community service needs (Clarke, Neuwirth, & Bernstein, 1986; Gropper, 1988). Unfortunately, extending the initial visit time is not possible for many physicians because of the growing limitations on reimbursement and the mandate to see more patients (Badger et al., 1994; Schauffler & Rodriguez, 1993; Sloane, 1991).
When psychosocial needs go unmet through misdiagnosis, lack of detection, lack of treatment and follow up, elderly patients are at risk of further health problems that can lead to physical deterioration, reduced independence, and eventually to the need for more intensive and expensive services (Shearer, Simmons, White, & Berkman, 1995). Inadequate assessment also can lead to inappropriate long-term care and unnecessary institutional placements. Medical management of the frail elderly patient requires a comprehensive approach that includes careful assessment of complex medical problems and functional capabilities, social supports, and emotional well-being.
Social work screening and assessment of psychosocial and environmental needs of patients in primary care provides valuable patient information in busy physician practices, where doctors do not have time to interpret both the physical and psychological meaning of each somatic complaint (Azzarto, 1993; Berkman et al., 1996). However, the process of screening is often lengthy and labor intensive, thus expensive - involving activities such as conducting interviews, reviewing records, and making direct observations. Attention must now be given to the use of standardized screening tools that will offer an accurate and efficient early prediction of whether a patient needs a social work assessment because of psychosocial health care risks (Azzarto, 1993; Berkman et al., 1996; Clarke et al., 1986; Shearer et al., 1995; Zedlewski, Barnes, Burt, McBride, & Meyer, 1989). In addition to the importance of standardized measures for reliable identification of psychosocial problems, use of these tools could provide standardized documentation across patient groups (Van Hook, Berkman, & Dunkle, 1996).
Many in the health professions (Ware & Sherbourne, 1992) are proposing the use of standardized conceptual definitions and measurements in which the focus is on health-related components of quality of life that are important to patients, such as, Did the treatment improve mobility, return the patient to work, improve his or her mental state? The value of health-related quality-of-life (HRQL) standardized measures for social work is that they expand health care screening and assessment beyond the physiological to the use of multistage diagnostic screening using multidimensional factors (Berkman & Maramaldi, in press). There is growing recognition of the need to go beyond traditional physiologic variables to include the other psychosocial components of HRQL that, of course, are of importance to social work practice.
Bringing this perspective to social work requires explicit selection and measurement of those dimensions of HRQL most relevant to the goals of social work interventions. In addition, standardization is essential if social workers are to have reliability and validity in screening and is prerequisite for valid detection of clinically important differences among patients. However, social workers in health care settings have had little experience in using standardized questionnaires. Thus, it is important to study the usefulness, as well as the limitations, of standardized measures as a means to screen for psychosocial needs. Social work practitioners can then make an informed decision on whether to adopt this model of screening.
THE QUESTION FOR STUDY
The traditional relationship between social work services and primary care physicians' practices in the outpatient clinics at Massachusetts General Hospital (MGH) is a referral-based system in which the physician or nurse refers the elderly person and his or her family to the Social Service Department when problems in the home situation are recognized, usually at point of breakdown. This system, prevalent in most outpatient clinics, limits the number of patients identified. On the average fewer than 10 percent of patients are referred, and referrals that are made are episodic and crisis oriented. This crisis orientation limits the social work time available for helping the patient and family, restricting the options available to meet patient needs. This practice can result in a dissatisfied consumer, misuse of physician time, inefficient use of physician expertise, and significant amounts of rework by social workers. Early identification by social workers of patients in need of community and hospital nonmedical services is necessary to improve delivery of services to patients and families. Meeting patients' psychosocial needs is necessary for enhancement of their quality of life.
This study examines the viability of using a new model for screening primary care elderly patients with psychosocial needs, the use of a standardized health-related quality-of-life (HRQL) questionnaire (SF-36) to predict need for social work assessment. This standardized HRQL questionnaire allows the patient to self-assess his or her social, environmental, emotional, and functional needs (Ware & Sherbourne, 1992). The study addresses whether the SF-36 can be used as a screen for patients in need of social work assessment independent of traditional social work specific screening questions. (In other words, is it possible to eliminate social work specific questions because one or more of the scales on the SF-36 tap the same problem area?) In addition, we explored the question of how a social worker would use the standardized HRQL questionnaire in screening for patients in need of services: Which SF-36 scale scores were significantly related to the social worker's judgment of who needed an assessment?
Physicians from the 10 MGH Primary Care Practice Groups were asked by the Social Service Department for permission to give their elderly patients a self-administered questionnaire to assess functional and psychosocial needs. Two primary care practice groups agreed to participate, representing 16 physicians. Two convenience methods were used to select the study's sample. In the first approach, during the first three months of study, the clinics' office staff were requested to hand out the questionnaires to all patients 65 years and older while they waited for their medical appointments. Each questionnaire had a cover letter from their physician explaining the project and requesting participation. Although 950 patients ages 65 and older were scheduled for appointments during this time period, there was no way to ascertain the actual number of questionnaires distributed. Only 200 questionnaires were returned. This limitation in the dissemination plan led to the decision that 300 additional questionnaires would be mailed to patients before their scheduled appointments. Questionnaires were mailed based on a computer-generated list of all patients, 65 years of age or older, who were scheduled for appointments at the two participating practice groups during the second three months of the study. Three hundred randomly selected patients were mailed questionnaires. These questionnaires were accompanied by a physician cover letter requesting participation, with a postage-paid response envelope.
The study's final sample size of 313 patients was a combined total of the 200 respondents who completed questionnaires in the doctors' waiting rooms and the 113 who returned questionnaires from the mailing. There was no way to determine the rate of completed questionnaires in the office sample because there were no hard data on the number of questionnaires actually distributed in the offices. However, both groups were based on a population of patients for a three-month period, and the mailed-questionnaire group was a random sample. There was a 38 percent rate of return from the mailing. The questionnaire included the 36 questions comprising the eight SF-36 scales and 21 social work specific questions traditionally used in screening.
The SF-36 is a health-related quality-of-life questionnaire constructed to survey health status (Ware & Sherbourne, 1992). This survey instrument is based on an increasing consensus in health care that values the "centrality" of the
patient's point of view in monitoring medical care outcomes (Ware, Snow, Kosinki, & Gandek, 1993). It measures how a patient functions in the context of his or her life and how a health problem may be affecting the patient's ability to perform a job or a task or how she or he relates to family and friends. There are 36 questions, which when grouped comprise eight scales: limitations in physical activities due to health problems, limitations in social activities because of physical/emotional problems, limitations in usual role activities due to physical health problems, bodily pain, general mental health (that is, psychological distress and well-being), limitations in usual role activities due to emotional problems, vitality (that is, energy and fatigue), and general health perceptions.
The measure is constructed for self-administration by people 14 and older or may be administered by a trained interviewer in person or by telephone. The questionnaire can be filled out in 10 to 15 minutes. For each scale, responses to questions are summed and scores are converted to a scale of one to 100 with the higher scores indicating the best functioning level or overall well-being. The SF-36 is a standardized measurement that has been found reliable in measuring various health factors. A study found coefficients for the multi-item health scale to range from 0.81 to 0.88, thereby supporting the reliability of this scale (Stewart, Hays, & Ware, 1988). The researchers further studied reliability with two subsamples, those with less than a high school education and those over 75 years of age. Results showed similar findings for all groups with ranges from 0.76 to 0.89 for both subgroups, thus lending weight to the sensitivity and reliability of this measure. Factor analysis has supported the construct validity of the SF-36 scales (Ware et al., 1993). Previous empirical studies also have shown that the SF-36 effectively measures factors related to physical and mental health. Clinical tests of validity also were performed based on criteria used to form mutually exclusive patient groups. The fact that the instrument is standardized, is brief, can be self-administered, and is easy to score all contribute to its usefulness to social workers as a clinical measurement of effect of illness on health-related quality of life (Van Hook et al., 1996).
Social Work-Specific Questions
The 21 social work screening questions, which were used in addition to the SF-36 questions, were specific problems that social workers traditionally use in screening patients for psychosocial need. Supported by a John A. Hartford grant at Huntington Memorial Hospital in Pasadena, California, the questions were developed by interdisciplinary focus groups so that they specifically related to issues of concern to social workers in screening and assessing elderly patients in primary care (Berkman et al., 1996). The 21 social work-specific questions focused on two broad categories: (1) functional status (physical, social, and mental health), and (2) socioeconomic and environmental factors (see Table 1). The focus group members believed the social work-specific questions had face and content validity (Berkman et al., 1996). Construct validity is supported by the fact that significant correlations were found between patients' answers to questions and theoretically expected directions of responses (Berkman et al., 1996). Although no formal tests of reliability were conducted, the preciseness of the social work-specific questions tends to support the assumption of reliability. Before they were used in this study, a focus group of social workers at MGH reviewed the 21 social work-specific questions, previously used in California, and agreed they served as an excellent screen of psychosocial needs in primary care. Thus, patient questionnaires included the SF-36 questions and the 21 social work-specific psychosocial questions, so that we could assess whether the eight standardized SF-36 scales could serve as an independent screen of some or all of the psychosocial needs.
Social Worker's Use of SF-36 Scales in Screening
To explore the question of which SF-36 scale scores were significantly related to the social worker's judgment of who needed an assessment, the following procedure was used. After the questionnaires were returned, the SF-36 questions were separated from the social work-specific questions. The social worker assigned to the primary care unit determined which elderly patients needed an assessment on the basis of her screening of the patients' answers to the SF-36 questions. Although the social worker reviewed the patient's responses, she did not know the actual SF-36 scale scores, because those scores were calculated later during computer analyses. Her judgment was conceptual, based on her professional view of the patients' responses to the questions.
The primary goal of analysis was to determine whether the SF-36 scales could be used independently (without social work-specific questions) as a screen of psychosocial needs. It was important to determine whether patients' self-reported problems on social work-specific questions were correlated with poorer HRQL scores as measured by the SF-36 scales. A social work-specific question was only considered for exclusion from future screening if patients reporting problems on that specific question had significantly lower mean scores (than patients not reporting the problem) on five or more of the eight SF-36 scales and, if those patients reporting the specific problem made up a significantly larger proportion of those who scored under 50 (than those patients not reporting the problem) on the same SF-36 scales. When both criteria were met, consideration was given to the assumption that the SF-36 could serve as an independent screen for the social work specific psychosocial question and that the specific question could be excluded from future screening tools.
How the social worker would use the SF-36 scales to screen for psychosocial need of assessment was a secondary focus for analyses. The question addressed was, Which of the eight SF-36 scales were most related to the social worker's decision that an assessment was needed? t test was used to compare differences on SF-36 scale scores between those patients who were identified as needing assessment and those who were not. The relative risk ratio was computed for each SF-36 scale. In addition to the low scores on scales that always seem to generate an intervention, the other scales with the largest relative risks were identified.
The data in this study indicate that nine of the 21 social work-specific problems were significantly related to poorer HRQL scores as measured by the SF-36. The following social work-specific psychosocial problems were significantly correlated (p [less than or equal to] .001) with poorer HRQL scores on a minimum of five SF-36 scales: appetite, falling, food preparation, getting about the home, doing housework, doing laundry, shopping, taking medications, and getting to appointments. These nine problems met both criteria for possible exclusion from future screening. The SF-36 does not adequately tap other specific physical and mental difficulties that might indicate the need for a social work assessment. The problems reported in sleeping, memory, compliance with dietary restrictions, concentration, alcohol or drug abuse, hearing, sex, dizziness, managing money, vision, urinary incontinence, and use of telephone were not significantly correlated with SF-36 scale scores.
RELATIONSHIP OF SOCIAL WORK SCREENING DECISIONS AND SF-36 SCALE SCORES
Thirty-six percent of the patients were identified by the social worker as needing further assessment. Although the social worker did not know what the patients' scores on the SF-36 scales were at the time of her screening review, there was a significant relationship between mean scores on each of the eight SF-36 scale and screening statuses. Patients screened as needing an assessment by the social worker had significantly lower mean scores (p [less than or equal to] .0001) than those not determined to need as assessment (Table 2).
Relative Risk Ratios
The relative risk ratios related to screening decisions for each SF-36 scale were calculated, and the scores with the highest relative risks were physical functioning, bodily pain, vitality, mental health, social functioning, and general health. Patients whose scores were less than 50 on the SF-36 scales of physical functioning, bodily pain, and mental health were always screened as needing an assessment by the social worker. Those patients who scored less than 50 in vitality had a 132 times greater chance of being screened as needing an assessment. Those patients who scored less than 50 on social functioning and on general health were 35 and 39 times, respectively, more likely to be screened as needing an assessment. Two SF-36 scales, role physical and role emotional, had relative risk ratios of less than 15 (Table 3).
IMPLICATIONS OF FINDINGS
Findings have shown that the SF-36 clearly captures some important psychosocial risk factors in elderly patients, such as problems with instrumental activities of daily living (IADLs), which social workers traditionally screen to determine need for assessment. Thus, it is suggested that specific social work questions in these functional areas could be eliminated from a future screening tool, facilitating the goal of keeping the questionnaire brief and user-friendly as well as standardized for IADL needs.
Methodological issues related to the validity of the remaining 12 social work-specific questions, reflecting other physical and mental functioning areas, may explain why these factors did not correlate with the SF-36 scales. For example, questions regarding problems with dizziness, sleep, hearing, drug and alcohol abuse, and sex required simply a yes or no response. (Yes, meaning difficulties exist in this area; or no, there are no difficulties in this area.) This type of simple categorical question leaves little room for variance. It requires that the respondent state that a problem exists or does not exist. Thus, it may not allow for specificity of the true picture of the subject's sense of difficulty. A physical and mental functioning question that asks "Do you have problems with your memory?" or "Do you have problems with sex?" would clearly be harder for the elderly person to answer unequivocally, compared with a specific IADL question that would ask "Do you have difficulty doing laundry or light housework?" Thus, these questions may have lost the specificity necessary to show any significant differences in the extent of the problem, thus limiting the chance for correlation with the SF-36 scores.
Concomitantly, many of these mental and physical functioning difficulties could be considered sensitive topics that an elderly person might not be so willing to admit exists. For example, difficulties with memory and concentration have stereotypically been associated with senility, and drug and alcohol abuse and difficulties with sex are topics that the elderly person might not be comfortable in addressing. Asking about these questions in a more sensitive standardized fashion may elicit more valid discriminating responses. In the future study of the use of the SF-36, it will be important to refine the remaining 12 social work-specific questions. In addition, other focused standardized measures that address psychosocial issues should be tested, such as the Prime MD (Spitzer et al., 1994), to see if they addresses the additional areas of need not identified through the SF-36.
One limitation of this exploratory study was the use of a sample that was self-selected on many levels. The sample consisted of elderly individuals who were scheduled for appointments with primary care physicians. Generalizability was limited to the two group practices that agreed to participate. In the first part of the study the secretaries were inconsistent in handing out the questionnaires, distributing them to patients on the basis of their own idiosyncratic judgment of who might need or not need services, rather than to all patients 65 and older. In addition, the mailed questionnaires were limited to those respondents who agreed to answer and return them, even though the mailed survey was based on a random sample.
There may also be limitations in how the questionnaire was used. The respondents who received mailed questionnaires may not have completed the questionnaire independently, having bad a family member, caretaker, or friend help fill it out. The individual elderly participant may not have filled out the form honestly because he or she did not want to be labeled as sick, needy, or unable to live independently. Some of the elderly people may not have been able to fill out the SF-36 because of their limited educational level, cognitive impairment, or lack of English-speaking ability. Because of the makeup of this study population, many people of color and low-income people were excluded. The SF-36 used in this study was directed toward white, Anglo-Saxon patients. At the time of the study, culturally sensitive study forms in other languages were not available. These versions have now been developed for Hispanic populations and should be tested in a future study.
The exploration of how the social worker would use the SF-36 questions proved interesting, although only qualified interpretations should be made because of the limitations in method. It is not surprising that there was a significant increase in patients identified as needing an assessment under the new model of screening, because under the traditional referral system so few patients reach social work services. In addition, the fact that the social worker's decision making was closely related to six of the SF-36 scales is not surprising, because the questions making up each of these scales are very similar to the psychosocial questions that social workers address in screening. A limitation was that there was funding for only one social worker to screen whether an assessment was needed. This social worker brought to the study her own personal workstyle, ethics, and skills. As a highly trained professional, 15 years post-master's degree, who had worked with primary care patients for five years, she made every effort to give consistent unbiased decisions, based on her review of the patients' responses to the questionnaires.
It is not unusual for there to be only one social worker covering a large number of primary care practices. However, usually the coverage is based on a limited referral system in which the doctors, nurses, patients, or family members request social work services for situations that have reached a crisis in psychosocial need. The model of coverage in this project differed in that the project social worker reviewed the patients' answers to the SF-36 questions and, independent of referral, made a screening decision as to whether assessment was warranted. It is clear that this social worker was able to use the SF-36 as a screen and that certain scales were reflective of the way she made screening judgment.
Further study is needed to demonstrate the validity of the SF-36 as a standardized screen for identifying patients in need of social work services. Such a study should have multiple social workers using the SF-36 in screening and would need to address the predictive validity of its use through follow-up on whether an assessment then indicated the need for social work intervention.
Chronic illness, its functional consequences, and a number of psychological problems appear to be the major personal and social health care problems that patients bring into the primary care setting. A missed or misdiagnosed problem or psychosocial risk factor is costly to both the patient and the health care system. Presently, many patients relying on their primary physicians for psychosocial supports are not getting their needs met. Social workers using reliable and valid standardized screening mechanisms to identify patients in need of psychosocial assessment can offer timely appropriate services to meet the identified psychosocial needs, saving the patient and doctor time and money and lowering the patient's health care claim costs (Azzarto, 1993; Clarke et al., 1986; Gropper, 1988; Loomis, 1988). Greater attention must be given to the testing and use of standardized screening tools in social work that use predictive factors that can result in assessment of patients at risk for psychosocial needs.
The SF-36 is one such standardized approach that will help social work identify patients with significant IADL problems resulting in poorer HRQL. Social work needs to continue to develop and adopt standardized approaches to screening. Screening in primary care settings using a standardized health-related quality-of-life questionnaire should result in improved relationships with patients by providing earlier intervention, enabling efficient linkages with needed services, and saving time for the doctor, office staff, and the patient through quick access to assistance.
Table 1. Social Work Specific Screening Factors
a. doing the laundry b. doing light housework c. following any dietary restrictions d. getting about in your home e. getting to appointments f. going shopping g. managing money/paying bills h. preparing food i. taking medications j. using the telephone
a. alcohol/drug abuse b. appetite c. concentration d. dizziness e. falling f. hearing g. memory h. sex i. sleeping j. urinary incontinence k. vision
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ABOUT THE AUTHORS
Barbara Berkman, DSW, LICSW, is Helen Rehr/Ruth Fizdale Professor, School of Social Work, Columbia University, 622 West 113th Street, New York, NY 10025; e-mail: firstname.lastname@example.org. Susan Chauncey, MSW, LCSW, LICSW, is faculty social worker, University of Florida Pediatric Pulmonary Center, Gainsville, FL. William Holmes, PhD, is visiting associate professor, College of Public and Community Service, University of Massachusetts, Amherst. Ann Daniels, PhD, is clinical director of social services, and Mark Robinson, is information systems manager, Massachusetts General Hospital, Boston. Evelyn Bonander, MSW, ACSW, is executive director of social services, Massachusetts General Hospital, Boston. Suzanne Sampson, BS, RN, is lab administrator, Department of Neurology, Massachusetts General Hospital, Charleston, MA. This study was partially supported by a Massachusetts General Hospital Practice Efficiency Award and the Ruth D. and Archie A. Abrams Interdisciplinary Research Fund. The authors are indebted to the following students at Simmons College School of Social Work who participated in various stages of this project: Lorraine Shona Brown, Diane Mungenast Crowley, Jennifer Farrington, Jennifer Kaplan, Lehana A. Leifer, Hope A. Lenkin, Jill R. Nechin, Elizabeth A. O'Brien, Tasia Polemenakos, Suzanne Tuchin, and Susan Williams.
Table 2. Significant Differences in Mean SF-36 Scores for Patients Screened as Needing an Assessment and Those Not Needing an Assessment by the Social Worker. Needs Does Not Need SF-36 Scale Assessment (M) Assessment (M) Physical functioning 49.48 84.39 Role physical 38.96 81.31 Role emotional 54.50 89.37 Bodily pain 54.46 81.56 Vitality 46.10 72.55 Mental health 65.74 82.83 Social function 63.66 93.62 General health 52.50 76.77 NOTE: All mean differences were significant at a minimum of p [less than or equal to] .0001 Table 3. SF-36 Scales, Significantly Related to Need for Assessment, with Largest Relative Risk Ratios Significant Scales Relative Risk Ratio SF-36 Physical functioning [less than] 50 (*) SF-36 Bodily pain [less than] 50 (*) SF-36 Mental health [less than] 50 (*) SF-36 Vitality [less than] 50 132 SF-36 Social functioning [less than] 50 35 SF-36 General health [less than] 50 39 NOTE: * = Relative risk ratio was not computed, because all patients scoring below 50 were assessed.
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