The present study sought primarily to determine whether attainment of social service goals was affected by the number of days between admission to home care and referral to medical social services. We also sought to determine if patient residence in a rural or urban area, annual income, and the total number of social service goals affected attainment of social service goals. Using a random sample of 306 home care patients throughout Texas, we found that the length of time between admission to home care and social service referral and annual income did not have a significant effect on social service goal attainment. However, elders living in rural areas and those having a moderate number of social service goals had significantly more unattained social service goals. Social service implications are discussed.
Boockvar, K. S., Halm, E. A., Litke, A., Silberzweig, S. B., McLaughlin, M., Penrod, J. D., et al. (2003). Hospital readmissions after hospital discharge for hip fracture: Surgical and nonsurgical causes and effects on outcomes. Journal of the American Geriatrics Society, 51, 399-403.
2.
Boone, C., Coulton, C., & Keller, S. (1981). The impact of early and comprehensive social work services on length of stay. Social Work in Health Care, 7(1), 1-9.
3.
Brown, R. S., Phillips, B. R., Bishop, C. E., Thornton, C. V., Ritter, G. A., Klein, A. C., et al. (1997). The effects of predetermined payment rates for Medicare home healthcare. Health Service Research, 32(4), 397-414.
4.
Centers for Medicare & Medicaid Services. (1996). Home health agency manual (chapt. 2). Retrieved January 17, 2003, from http://cms.hhs.gov/manuals/11_hha/hh200.asp
5.
Coleman, J. R., & Smith, D. S. (1984). DRGs and the growth of home health care. Nursing Economics, 2, 391-408.
6.
Coward, R. T., & Cutler, S. J. (1989). Informal and formal health care systems for the rural elderly. Health Services Research, 23, 785-806.
7.
Department of Health & Human Services, Office of Strategic Planning, & Health Care Financing Administration. (1999). A profile of Medicare home health: Chart book. Washington, DC: Health Care Financing Administration.
8.
Dyeson, T. B. (2004). Home health outcomes: A systems perspective. Home Health Care Management & Practice, 16(3), 225-227.
9.
Elias, J. W., Ferry, R. W., & Treland, J. (2000). When world views collide: A commentary on home health care case-mix and patient outcomes. Experimental Aging Research, 26, 181-188.
10.
Evans, R., Hendricks, D., Lawrence-Umlauf, K., & Bishop, D. (1989). Timing of social work intervention and medical patients’ length of hospital stay. Health and Social Work, 14, 277-282.
11.
Gibbons, J., Camp, H., & Kaiser, M. (1991). Patterns of long-term care services for the rural elderly: A community approach. Human Services in the Rural Environment, 14, 6-11.
12.
Harmon, G. N., Lefante, J., Roy, W., Ashby, K., Jackson, D., Barnard, D., et al. (2004). Outpatient medication assistance program in a rural setting. American Journal of Health-System Pharmacy, 61(6), 603-608.
13.
Hebert, W. (2000). PPS—how will it impact your agency and your practice?Home Healthcare Nurse, 18(2), 94-97.
14.
Holden, M. (1989). Meeting diagnostic related group goals for elderly patients. Health and Social Work, 14, 12-21.
15.
Horn, S. D., Sharkey, P. D., Chambers, A. F., & Horn, R. A. (1985). Severity of illness within DRGs: Impact on prospective payment. American Journal of Public Health, 75(10), 1195-1199.
16.
Joint Commission on the Accreditation of Health Care Organizations. (1991). How to achieve quality accreditation in a hospital social work program. Oakbrook Terrace, IL: Author.
17.
Kadushin, G., & Kulys, R. (1993). Discharge planning revisited: What do social workers actually do in discharge planning. Social Work, 38(6), 713-726.
18.
Milone-Nuzzo, P. (1998). Beyond venipuncture as the qualifying service for Medicare: Seeing the forest for the trees. Home Healthcare Nurse, 16(3), 177-182.
19.
Morrow-Howell, N., & Proctor, E. K. (1991). Adequacy of discharge plans for elderly patients. Social Work Research & Abstracts, 27(1), 6-13.
20.
Morrow-Howell, N., Proctor, E. K., & Dore, P. (1998). Adequacy of care: The concept and its measurement. Research on Social Work Practice, 8(1), 86-102.
21.
National Association of Social Workers’ Commission on Health & Mental Health & the Society of Hospital Social Work Directors. (1990). NASW clinical indicators for social work and psychosocial services in the acute care medical hospital. Washington, DC: National Association of Social Workers Press.
22.
Naylor, M. D., & McCauley, K. M. (1999). The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing, 14(1), 44-54.
23.
Nyman, J. A., Sen, A., Chan, B. Y., & Commins, P. P. (1991). Urban/rural differences in home health patients and services. The Gerontologist, 31, 457-466.
24.
Pedhazur, E. J., & Schmelkin, L. P. (1991). Measurement, design, and analysis: An integrated approach. Hillsdale, NJ: Lawrence Erlbaum.
25.
Phillips, B. R., Brown, R. S., Bishop, C. E., Klein, A. C., Ritter, G. A., Schore, J. L., et al. (1994). Do preset per visit payment rates affect home health agency behavior?Health Care Financing Review, 16, 91-107.
26.
Potthoff, S., Kane, R. L., & Franco, S. J. (1997). Improving hospital discharge planning for elderly patients. Health Care Financing Review, 19(2), 47-72.
27.
Proctor, E. K., & Morrow-Howell, N. (1996). Implementation of discharge plans for chronically ill elder discharged home. Health and Social Work, 21, 30-40.
28.
Proctor, E. K., Morrow-Howell, N., Li, H., & Dore, P. (2000). Adequacy of home care and hospital readmission for elderly congestive heart failure patients. Health & Social Work, 25(2), 87-96.
29.
Schrager, J., Halman, M., Myers, D., Nichols, R., & Rosenblum, L. (1978). Impediments to the course and effectiveness of discharge planning. Social Work in Health Care, 4(1), 65-79.
30.
Steinman, M. A., Sands, L. P., & Covinsky, K. E. (2001). Self-restriction of medications due to cost in seniors without prescription coverage: A national survey. Journal of General Internal Medicine, 16(12), 793-800.
31.
Yip, A. M., Gorman, M. C., Stadnyk, K., Mills, W. G. M., MacPherson, K. M., & Rockwood, K. (1998). A standardized menu for goal attainment scaling in the care of frail elders. The Gerontologist, 38(6), 735-742.
