Msw Service Protocol Stroke Care

Service Protocol for Stroke Care (MSW) Introduction: Depending on individual circumstances and need, medical social services are available to all stroke patients and their families. Medical Social services are provided to patients and their families to meet their medically related social and emotional needs as they impinge on their medical condition, treatment, recovery, and safe transition from one care environment to another. The primary goal of this Service Protocol is to improve the effectiveness of rehabilitation in helping the person with disabilities from a stroke to achieve the best possible functional outcome and quality of life. Overall speaking, this Service Protocol can be applied both for acute and rehabilitation institute. Nevertheless, some stages or functions are only applicable to either one setting. Goals of MSS in Stroke Care: 1. 2. 3.

Enhance stroke patients and family's quality of life, psychosocial and emotional well-beings through provision of a range of psychosocial services. Promote the patient-and-family centred nature of rehabilitation and the importance of capitalizing on patient, family, and community strengths and potentials during the rehabilitation process. Facilitate community integration of the stroke survivor with disabilities.

Major Problems of Stroke Patient and Family 1. 2. 3. 4. 5. 6.

Problems related to patient care and activities of daily living. Patient and family adverse reactions or dysfunctional adjustment to illness and change in functional status Family relationship problems due to the change of roles and functions in the family Emotional problems, including depression, anxiety and career stress Discharge problems Financial and housing problems

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1

Key Stages/Tasks

Principles

Interventions

Recommended Time frame Acute unit

Psychosocial

MSWs should systematically assess the patient’s psychosocial conditions.

2 working days upon Within the 1st week

Assessment

receiving the case

after admission to

z

Idenitify problem area

referral.

hospital or

z

Make intervention plan

Assessment Review or evaluate at key stages throughout acute care and rehabilitation.

Rehabilitation Unit

Conduct Psychosocial

z

3 working days upon receiving the referral.

Crisis Intervention There are times of acute difficulty after stroke, eg. Suicidal ideation, care z

Provide Crisis Intervention,

Response within 1

Response within 1

(if applicable)

problems of dependent family members. MSWs are expected to contact

contact family member/

working day

working day

patients and their families and render necessary services within 1 working day

caregiver (if available)

Anxiety and emotional disturbances are common after stroke. Counselling z

Provide counselling on:

Response within 2

Response within 3

service on patient and family's acceptance of illness and emotion is required.

1.

working days

working days

Problem Solving

Social and emotional functioning of patient and family caregivers

2.

Stress management/ handling of emotions

Social problems, like financial, accommodation, home care and discharge are z

Mobilize appropriate

common after stroke. Hence early mobilization of community resources to

community resources as early

assist patient and family is necessary.

as possible z

Provide psychosocial education & intervention information

2

Key Stages/Tasks

Principles

Interventions

Recommended Time frame Acute unit

Goal Setting and

Facilitate the communication and participation among patient, family and z

Reflect and discuss the

Formulation of

rehabilitation team in goal setting and formulation of rehabilitation plan.

patient's psychosocial needs

Rehabilitation Plan

Rehabilitation Unit

On-going

On-going

2 working days

3 days working before

before discharge

discharge

and family circumstance in the multi-disciplinary care plan. z

Motivate patient and family participation in the rehabilitation process.

Discharge Planning Discharge planning should begin on the day of admission

z

The ability of a stroke survivor to return home depends on the person’s needs

Finalize the discharge plan: 1.

Review psychosocial

and the availability of caregivers support. If patient’s need exceed caregiver’s

conditions for formulating

capabilities, community support services and/or alternate long-term placement

the goal of discharge plan.

should be considered. 2.

Assess caregiver’s capabilities and other practical arrangement to care the stroke survivor.

z

Liaise and mobilize community Upon discharge

Upon discharge

resources. z

Share and discuss the discharge plan with the multi-disciplinary team.

3

Key Stages/Tasks

Principles

Interventions

Recommended Time frame Acute unit

Transition to

MSWs should be sensitive to the impact of care arrangement to patient and z

Complete the pre-discharge

community

caregivers. They should work with the patient and caregivers, to promote their

checklist and take necessary

problem solving ability and facilitate reintegration of the patient into

action as indicated.

Upon discharge

Rehabilitation Unit One working day before discharge

community. z

Complete transfer summary

5 working days after 5 working days after

and send to other MSW/ Send discharge

# remarks

discharge

referral to welfare agencies, if applicable. Post-discharge

Based on existing screening mechanisms for high-risk case eg. CNS, home-

Case review and

help team, informal carer, Allied Health Community Programme etc. to

follow up

identify needy patient and family for case review.

z

Conduct case review

z

Review the pre-discharge

2 working days after 2 working days after receiving notification receiving notification

checklist.

(if applicable) Review on psychosocial, emotional and family functioning. Follow up the identified problems and render appropriate services.

z

Re-assess caregiver’s capabilities and other practical arrangement to care the stroke

# remarks

survivor. z

Liaise and mobilize community resources.

This protocol is based on the Clinical Practice Guideline Post-Stroke Rehabilitation: Assessment, Referral, and Patient Management published by U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1995.

Remarks: # Case can be closed when necessary social work intervention is completed.

4

Case Evaluation Form on Service Protocol for Stroke Care in Acute Unit (MSW) MSS No.:

Age/Sex:

Key Stage/ Tasks

Appendix 1

Aged home resident: yes/no Specialty: Med/Geri/Rehab/Stroke Care Unit/ Other Intervention

Done

Not Done

Length of Stay:

Time Frame

Done

State reasons I

Days N/A

(State Reasons for Variance)

Psychosocial

1) Conduct psychosocial assessment

2 working days upon receiving the

Assessment

2) Identify problem area

case referral

3) Design intervention plan Provide Crisis Intervention

Response within 1 working day

III Problem Solving 1) Provide Counselling (pls refer to protocol p.2)

Response within 2 working days

II

Crisis Intervention (if applicable)

2) Mobilize appropriate community resources 3) Provide psychosocial education & intervention information IV Goal Setting &

V

1) Reflect & discuss the patient’s psychosocial needs & family

On-going

Formulation of

circumstances in the multi-disciplinary care plan

Rehabilitation

2) Motivate patient & family participation in the rehabilitation

Plan

process

Discharge

1) Review psychosocial condition & finalize the discharge plan

2 days before discharge

Planning

2) Liaise & mobilize community resources

Upon discharge

(Not applicable)

3) Share & discuss the discharge plan with the multi-disciplinary team

VI Transition to community

1) Complete the pre-discharge checklist and take necessary action

Upon discharge

as indicated. 2) Complete transfer summary & send to other MSW/ Send referral

5 working days after discharge

to welfare agencies, if applicable VII Post-discharge

Reason for post-discharge review eg. Financial problem, caring problem etc:

Case review &

1) Conduct case review

2 working days after receiving

follow up

2) Review the pre-discharge checklist

notification

(if applicable)

3) Re-assess caregiver’s capabilities & other practical arrangement to care the stroke survivor 4) Liaise & mobilize community resources Ver-402

Name of Hospital:

Completed by :

Date:

Case Evaluation Form on Service Protocol for Stroke Care in Rehabilitation Unit MSS No. :

Age/Sex:

Aged home resident: yes/no

Key Stage/ Tasks

Specialty: Med/Geri/Rehab/Stroke Care Unit/ Other

Intervention

Done

Not Done

Appendix 2

(MSW)

Time Frame

Length of Stay: Done

(State reasons)

I

1) Conduct psychosocial assessment

1 week after admission to hospital or

Assessment

2) Identify problem area

3 working days upon receiving the

3) Design intervention plan

referral form

Provide Crisis Intervention

Response within 1 working day

III Problem Solving 1) Provide Counselling (pls refer to protocol p.2)

Response within 3 working days

Crisis Intervention

N/A (State Reasons for Variance)

Psychosocial

II

Days

(if applicable)

2) Mobilize appropriate community resources 3) Provide psychosocial education & intervention information IV Goal Setting & Formulation of

1) Reflect & discuss the patient’s psychosocial needs & family

On-going

(Not applicable)

circumstances in the multi-disciplinary care plan

Rehabilitation Plan 2) Motivate patient & family participation in the rehabilitation process

V

Discharge

1) Review psychosocial condition & finalize the discharge plan

3 days before discharge

Planning

2) Liaise & mobilize community resources

Upon discharge

3) Share & discuss the discharge plan with the multi-disciplinary team

VI Transition to community

1) Complete the pre-discharge checklist and take necessary action

1 working day before discharge

as indicated. 2) Complete transfer summary & send to other MSW/ Send referral

5 working days after discharge

to welfare agencies, if applicable VII Post-discharge

Reason for post-discharge review eg. Financial problem, caring problem etc:

Case review &

1) Conduct case review

2 working days after receiving

follow up

2) Review the pre-discharge checklist

notification

(if applicable)

3) Re-assess caregiver’s capabilities & other practical arrangement to care the stroke survivor 4) Liaise & mobilize community resources Ver-402

Name of Hospital:

Completed by :

Date:

MSW Transfer Summary

Appendix 3

From :

To:

Ref:

Ref:

Fax/ Tel:

Fax:

Date:

Date:

I)

Particulars

Name of patient:

(

)

Sex:

HKIC/BC No.:

M/F*

Marital Status: S / M / W / D / Cohabited / Separated*

Address:

Tel. No.:

Accessible by lift □ Yes □ No Climb Occupation: II)

Age/D.O.B:

Income:

floor. Type of accommodation Diagnosis:

Dialect Date of Discharge/Transfer:

Particulars of Family Members: (Please provide telephone no. and address as far as possible.) Name

III)

Problem Nature:

IV)

Service rendered:

Relationship

1.

… Social Investigation/ Enquiry

2.

… Counseling on:

3.

… Financial assistance: A total sum of $

… Marital

Sex/Age

Occupation/Income

… Relationship

Telephone No.

… Child Care

from

Remarks

…Others:

Trust Fund for the purpose of

was granted on 4.

… Full/ partial waiver of medical charge (amount waived: $

per day / attendance) from/on

to

.

(for details pls refer to “Application for Waiving of Medical Charges”) 5.

… Processing of:

… MEF

… MAF(CSSA/SSA)

SSFU ref:

6.

… Referrals Made:

… Residential Service for Elderly … Home help / Home care

… Day Care Centre for Elderly

… Enhanced Home &Community Care Services

… Halfway House

… Sheltered Workshop

… Supported Employment

… Selective Placement

… Long Stay Care Home

… Day Activities Centre

… MH Hostel

… Others: V)

Suggested Follow Up Area(s):

VI) Remarks:

Signature:

Counter-signed by:

Name of Referring MSW:

Name/Post :

Telephone No.: * delete if not applicable

Date:

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Appendix 3

Reply Note From : Ref:

To: Date:

(Please Affix Patient’s Label Here)

We will follow up this case and render appropriate assistance to the above-name. For enquiries, please contact the responsible Medical Social Worker Mr/Mrs/Ms at . Other remarks:

Signature: Name of MSW:

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