Quality assurance and program evaluation

For a long time, rehabilitation lacked quality control regulations, particularly for patient outcomes. The development of voluntary accreditation of rehabilitation facilities developed by the Commission on Accreditation of Rehabilitation Facilities (CARF) is a beginning step toward this effort. Just as the Joint Commission for Accrediting Hospitals has defined specific standards for rehabilitation programs, so has CARF. Starting with the earlier Professional Standards Review Organization (PSRO) legislation, a series of methods to examine health care practice has evolved; these include peer review, medical audit, and quality assurance. Similarly, the National Association of Social Workers (NASW) has identified needs for quality of care and competence. A joint committee representing the Social Work Section of the American Public Health Association and Health Quality Standards Committee of NASW compiled a policy statement (1981) entitled NASW standards for social work in health care settings.6 It is significant that they listed 11 standards that describe the director's responsibilities, program structure and functions, policies and procedures, budget, space and equipment, and documentation. The last standard requires review and evaluation of social work services, at least yearly, with written records and pre-established criteria and standards. The standards indicate feedback mechanisms and implementation for corrective measures.

The AHA Joint Commission Manual is specific about rehabilitation services; it indicates individual criteria for each discipline and interdisciplinary collaboration.1 For social work the manual indicates assessment and intervention relative to psychosocial factors and the social context of the disabled patient; the scope of patient's coping history and current psychosocial adaptation to the disability; assessment of immediate and extended family members; assessment of housing and living arrangements, and source of income. It also includes casework counseling, education groups, and community linkages. The monitoring of goals relevant to discharge planning is stressed.

It is clear that a major effort is being directed toward eliminating duplication of services and achieving efficient care and competent standards of practice for all health-care practitioners, not just social workers. The threat of loss of accreditation has caused institutions offering all forms of health care to be vigilant and concerned about defining and meeting the highest-quality standards by which services can be measured and evaluated.

Future implications

Within health-care systems, there are mounting pressures lo deal with the increasing costs of care through cost-containment measures and quality assurance standards. At the same time, other changes are taking place in the form and structure of health-care organization. Above all, the notion of "for profit" is entering the health-care scene. Hospitals are buying hotels, health spas, restaurants, and shopping centers; the intent is to acquire income-producing services that will return funds to the institution. Mount Sinai Hospital in New York City has recently mounted an aggressive public relations marketing campaign to advertise .its services through the media at a cost of approximately $3 million. It stresses quality of care at the hospital and pushes for higher census rates (maximal bed utilization). There is also a trend toward hospital mergers, which would consolidate resources and diversity of services. The impact of diagnostic related groups (DRGs) has led to increasing use of home health-care services in a variety of forms.

Most social workers are not familiar with the determination of costs in the hospital setting. Currently social workers are a component of the per diem rate for almost all third party payers. Ambulatory care social services are not covered except as a portion of Medicare and Medicaid physician visits. Thus all ambulatory care programs impose a deficit on their institutions. If fee-for-service continues as major source of health care payments, social workers will have to modify their "philanthropic" philosophy to a more realistic appraisal of their value and what to charge reimbursement agents. Possible solutions have been suggested by the passage in 1977 of the third-party payments law, which recognizes qualified social workers as vendors of services to patients who are insured for mental health services, just as with psychologists and psychiatrists. There must be certification and licenses to ensure social work competence, which has been defined by NASW at different levels of performance.

As with the acute care patients, it appears that disabled patients will be receiving increasing amounts of care in their home rather than in institutional settings. Technologic advances and computer systems have enabled severely handicapped persons to function remarkably well as homemakers, office workers, and in all types of occupations that were impossible in the past. These changes may create other kinds of problems as the number of elderly persons increases and as more persons with disabilities are sustained with devices that prolong life and maximize social functioning. Social workers must adapt their own skills, values, and roles to meet these rapid changes in the health-care field.

Establishments of social service irrespective of patterns of ownership are:

•   the complex centres of social service of the population;

•   the territorial centres of the social help to  family and children;

•   the centres of social service;

•   the socially-rehabilitation centres for orphaned babies;

•   the centres of the help to children who have remained without the care of parents;

•   social shelters for children and teenagers;

•   the centres of the psychologico-pedagogical help to the population;

•   the centres of the emergency psychological help by phone;

•   the centres (branches) of social home visiting service;

•   houses of night stay;

•   special houses for the lonely aged;

•   stationary establishments of social service (residential homes for the aged and invalids, psychoneurological residential homes, children's homes - boarding schools for mentally retarded children, houses - boarding schools for children with physical defects);

•      the gerontological centres;

•      other establishments, rendering social services.