FAYETTEVILLE, Ark. — Hospice programs are designed to help people cope with the loss of life. But as hospices across the nation cut back their social work services in an effort to save money, they may be setting themselves up for a loss of their own — a financial loss, says one University of Arkansas researcher.

Dona Reese, assistant professor of social work, and Mary Raymer of the National Hospice and Palliative Care Organization (NHPCO) have completed a nationwide study of hospice programs, which shows that providing adequate social work services in conjunction with physical care significantly reduces overall hospice costs. Additional benefits include fewer hospitalizations for the patient, decreased nursing costs and higher client satisfaction.

Reese and Raymer’s findings are particularly important in light of recent cutbacks in the hospice field. Medicare reimbursement has never been sufficient to cover hospice costs, according to Reese. As a result, many hospice administrators must design services around financial constraints rather than around an ideal model of patient care.

"The original vision for hospice consisted of an interdisciplinary team of professionals who would make visits to the home to provide not only for the patient’s physical needs but also to offer social services and psychological and spiritual counseling," Reese explained. "But across the country, we’ve seen the non-medical services — including social work services — minimized under the rationale that it’s more important to provide for the patient’s physical needs."

In fact, initial findings of Reese and Raymer’s study showed that nurses outnumbered social workers three to one in the average hospice. The researchers also documented five times as many nursing visits as social work visits to each hospice patient.

Reese and Raymer believed that such a singular focus on physical health compromised the holistic philosophy behind hospice services and disregarded the impact of emotional and social stability on physical well being. On behalf of the NHPCO, the researchers set out to discover how social work services affected hospice outcomes.

Taking a random, stratified sample from the membership of the NHPCO, the study assessed 66 home hospice programs and examined 330 individual patient cases. The researchers designed their study to address numerous variables related to hospice outcome, including number of nights patients required continuous care, number of hospitalizations, client satisfaction, the functioning of the hospice team, pain costs, nursing costs and overall costs of hospice care.

Participating hospice programs contributed information through three steps. First the social worker with the greatest experience in hospice filled out a social work questionnaire, which described the qualifications of social workers employed at the hospice, the duties of those social workers, the overall functioning of the hospice team and the demographics of the clients they served.

The most experienced social worker also selected five recent patient cases and completed a chart review. This review described each social work visit to each patient, recorded visits from other hospice workers, detailed the social characteristics of the patient and family, and documented the outcome of the case (factors such as place of death, amount of continuous care required, severity of case and number of crisis calls to nurses).

Finally, hospice directors answered a questionnaire, which profiled the hospice program as a whole. They provided information about social workers’ salaries and responsibilities in comparison to those of other hospice workers. They listed the number of social workers and nurses employed as well as the average number of patients in their program. They described their own qualifications as directors, and they offered information about hospice costs as well as a variety of other hospice outcomes.

Reese and Raymer used several respected measurement scales as well as measures designed for the study and analyzed the data to reveal average social work services provided, average hospice outcomes, and whether the prevalence of social work services predicted those outcomes.

"We collected so much data because we wanted a comprehensive look at how social work services impact hospice outcomes," Reese said. "Knowing exactly how these services benefit hospice programs can help administrators design hospice care so that it fully meets patients’ needs while still being cost conscious."

The results of the study showed that increased social work services lowered overall hospice costs. This alone constitutes a good reason to stop cutting social work from the protocol, Reese said. But the statistics also revealed specific correlations, which prompted Reese and Raymer to recommend changes that will help hospice programs run more effectively and economically.

For example, the presence of a social worker at the patient’s first interview with hospice representatives contributed to lower hospice costs, lower labor costs, lower home health aide costs and improved functioning of the hospice team.

According to Reese, early participation provides an opportunity for the social worker to evaluate factors such as family dynamics, social support systems, personal beliefs, customs and concerns, among other things. Such information enables the social worker to identify problems that the patient will likely encounter and begin building support networks that will address the problems in a preventive manner.

Though this seems to constitute a psychosocial and spiritual undertaking, the work affects a patient’s physical health, Reese said. Patients who receive adequate psychosocial and spiritual care demand fewer nursing visits and experience less anxiety.

"Most emergency calls that a patient or family member makes to a nurse are the result of anxiety rather than true medical emergencies," she explained. "Regular social work intervention takes that pressure off the nurses and reduces the number of crises and unnecessary hospitalizations."

Social workers also tackle issues that nurses routinely encounter but are not trained to address — cultural differences, fears about death, family conflicts, all of which can complicate a patient’s care. In fact, social workers often serve the nurses as well as the patients, counseling their hospice team members, facilitating communication and offering guidance. Reese and Raymer’s study found that such support helped the hospice team function more efficiently.

Meeting the needs both of the patients and the hospice program requires a sufficient number of social workers on staff, Reese cautioned. Many hospices may be laying off non-medical personnel in an ill-founded attempt to save money. Ultimately those programs will pay the price.

"It’s clear that social workers provide a number of vital services within hospice," Reese said. "This study shows that cutting them out of the picture lowers the quality of hospice care and raises the cost. We hope administrators will recognize that this makes terrible business sense."