Effects of social work intervention on nonemergent pediatric emergency department utilization.

Effects of social work intervention on nonemergent pediatric emergency department utilization. Clinicians, administrators, and payers agree that the mostefficient and cost-effective use of hospital and financial resources isserved when emergent emergent/emer��gent/ (e-mer��jent)1. coming out from a cavity or other part.2. pertaining to an emergency.emergent1. coming out from a cavity or other part.2. coming on suddenly. care is reserved for people in medical crisis andis confined con��fine?v. con��fined, con��fin��ing, con��finesv.tr.1. To keep within bounds; restrict: Please confine your remarks to the issues at hand.See Synonyms at limit. problems that cannot be managed in primary care settings.Nonemergent cases interfere with the operation of the emergencydepartment (ED), and the cost of such care is excessive (Gadomski,Perkis, Horton, Cross, & Stanton, 1995; Glotzer, Sager, Socolar,& Weitzman, 1991; Hurley Hurley has become the English version of at least three distinct original Irish names: the �� hUirthile, part of the D��l gCais tribal group, based in Clare and North Tipperary; the �� Muirthile, based around Kilbritain in west Cork; and the OhIarlatha, from the district of , Freund, & Taylor, 1989). Moreover, theED is not an optimal setting for primary care, and visits to the ED mayweaken relationships with primary care providers (Gadomski et al.;Glotzer et al.). Other factors preclude treating children for nonemergent problemsin an emergency setting. Each time a child is brought to the ED he orshe will likely see a different physician, usually not a pediatrician pe��di��a��tri��cianor pe��di��at��ristn.A specialist in pediatrics. (Foltin, 1995). The examining doctor typically does not have thechild's medical record. The focus is on the immediate need, and theenvironment does not encourage asking for or providing anticipatoryguidance and preventive education or following up on previous visits.There is no opportunity to develop ongoing relationships (Rosenzweig,1993), and it may be more difficult to diagnose diagnose/di��ag��nose/ (di��ag-nos) to identify or recognize a disease. di��ag��nosev.1. To distinguish or identify a disease by diagnosis.2. pediatric pediatric/pe��di��at��ric/ (pe?de-at��rik) pertaining to the health of children. pe��di��at��ricadj.Of or relating to pediatrics. chronicillnesses or to detect cases of child abuse or neglect. Services provided by social workers, such as service coordination service coordinationCase management, see there ,counseling, referral, and linkages with community resources, whenavailable in emergency settings, are not typically used to promoteprimary care. No reports in the literature could be identified thatdiscussed studies of social work intervention to reduce ED utilizationof children with nonurgent care needs, but as early as 1976 a role foremergency room social workers was defined as helping patients findappropriate alternatives for care (Bergman, 1976). McCoy, Kipp, andAhern (1992) reported that social work intervention reduced repeatutilization 28 percent among older adults with mental health or socialhealth problems who relied on the ED instead of seeking mental healthservices health servicesManaged care The benefits covered under a health contract . Keehn, Roglitz, and Bowden (1994) studied adult ED patientswho received social work services and found that the greatest decline inED recidivism recidivism:see criminology. occurred when social workers used proactive interventionstrategies. Although it has been suggested that managed care would resolve theissue of whether nonemergent cases would be treated in ED settings,research has not demonstrated that turning away nonemergent patientsproduces desired outcomes (Glotzer et al., 1991; Losek, Walsh-Kelly,& Alstadt, 1987; MacKoul, Feldman, Savageau, & Krumholz, 1995;Mayefsky, Shirraway, & Kelliker, 1991). Evaluations of programs withphysician gatekeepers have produced varying results (Hurley, Gage, &Freund, 1991; MacKoul et al.). In one study gatekeeping combined withparent education and 24-hour access to a primary care physician reducedED visits (Franco, Mitchell, & Buzon, 1997). But a brief educationalintervention alone has not been shown to alter utilization habits(Chande & Kimes, 1999; Chande, Wyss, & Exum, 1996). Gadomski andcolleagues (1995) concluded that diverting di��vert?v. di��vert��ed, di��vert��ing, di��vertsv.tr.1. To turn aside from a course or direction: Traffic was diverted around the scene of the accident.2. Medicaid children classifiedas nonemergent in an emergency room to their primary providers was asafe short-term practice. However, denial of an emergency visit had noimpact on subsequent ED utilization (denied patients subsequently usedthe ED as frequently as patients who had not been denied) and wasassociated with a higher rate of hospitalization hospitalization/hos��pi��tal��iza��tion/ (hos?pi-t'l-i-za��shun)1. the placing of a patient in a hospital for treatment.2. the term of confinement in a hospital. . This type ofgatekeeping did not change the health care-seeking behavior of thesepatients and may have resulted in higher costs. The authors argued thatgatekeeping is usually understood as a denial of nonemergent visits buthas been framed as directing into primary care, emphasizing the benefitsthat accrue To increase; to augment; to come to by way of increase; to be added as an increase, profit, or damage. Acquired; falling due; made or executed; matured; occurred; received; vested; was created; was incurred. from continuity of care. This effect was not demonstrated bytheir study, in which only 40 percent of those denied care were seen bytheir primary care provider. Other studies suggest that restrictingaccess to emergency care can adversely affect children's health Children's HealthDefinitionChildren's health encompasses the physical, mental, emotional, and social well-being of children from infancy through adolescence. (Losek et al.; Mayefsky et al.), and examination of children'saccess to primary care continues to implicate im��pli��cate?tr.v. im��pli��cat��ed, im��pli��cat��ing, im��pli��cates1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.2. poverty and ethnic orracial minority status with significantly fewer sources of regular care,suboptimal SuboptimalA solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. health supervision, and inadequate prevention services(Newacheck, Hughes, & Stoddard, 1996). States have experimented with diverting children from emergencycare settings into primary care. In Ohio, where children are about 58percent of the Medicaid population, a limited study conducted in1991-1992 demonstrated that some families using the ED for nonemergentcare respond to intervention (Grossman, Fisher, Lancaster, Dietrich,& Cotton, 1992; Grossman, Rich, & Johnson, 1998). Subsequently,the Ohio Department of Human Services contracted with several hospitalsto initiate pediatric emergency room diversion A turning aside or altering of the natural course or route of a thing. The term is chiefly applied to the unauthorized change or alteration of a water course to the prejudice of a lower riparian, or to the unauthorized use of funds. programs to further studythe value of intervention. This article reports on phases 1 and 2 of a program to encouragethe use of primary care among families with children. Social workintervention is highlighted as a means to change patterns of behaviorand promote effective utilization of health care resources. PHASE 1: PRIOR TO INTERVENTION STUDY The MetroHealth System, a 749-bed, university-affiliated, publichospital and a number of community-based clinics and primary care sites,developed the Pediatric Emergency Diversion Program A diversion program in the criminal justice system is a program run by a district attorney's office designed to enable offenders of criminal law (usually minor offenses) to avoid criminal charges [1][2]. in July 1993 basedon a contract with the state of Ohio. The MetroHealth program featured anurse and social worker who interviewed families of pediatric patientsages 16 and under presenting with illnesses that could be treated in aphysician's office. We used the ED diagnosis. The majority ofpatients (73 percent) had Medicaid, 17 percent had no medical coverage,and 10 percent had commercial insurance. Approximately 1,700 familieswere interviewed between November 1993 and March 1995. The interviewobtained demographic information and assessed actual and perceivedbarriers to care. Forty percent of families identified a perceivedemergency as the reason for presenting to the ED; 50 percent identifiedpoor access to care as the reason. Many cases that could easily beperceived by parents as an emergency might not have been seen in the EDif families had access to medical advice or primary care. All of thefamilies received assistance setting up appointments, telephonefollow-up, and health education. Interview data revealed that many factors influence where a childis brought for medical care. Barriers to the use of primary care andfactors leading to ED visits that could have been prevented wereclassified into one of four broad categories: (1) medical/educational,(2) access, (3) environmental, and (4) psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. . Categories wereassigned by the intervener based on information obtained in interviews.Many families were assigned more than one barrier. In phase 1,55 percentof the families experienced medical/educational barriers, accessbarriers were problems for 39 percent, environmental barriers for 33percent, and psychosocial barriers for 19 percent. Predominant pre��dom��i��nant?adj.1. Having greatest ascendancy, importance, influence, authority, or force. See Synonyms at dominant.2. problemsamong medical/educational barriers were difficulty negotiating medicalsystem (51 percent) and symptom symptom/symp��tom/ (simp��tom) any subjective evidence of disease or of a patient's condition, i.e., such evidence as perceived by the patient; a change in a patient's condition indicative of some bodily or mental state. recognition (15 percent); among accessbarriers were doctor unavailable (39 percent) and evening or weekendappointment unavailable (28 percent); among environmental barriers werefinancial (26 percent), transportation (31 percent), and no telephone(22 percent); and among psychosocial barriers were lack of parentingskills (58 percent) and family crisis (19 percent). It is interestingthat problems with chronic illness, wound care, and medicationadministration were rarely cited. Linkage with a primary provider, theprimary goal for phase 1, was established for most patients. Overall, anappointment show rate of almost 90 percent was achieved, comparingfavorably fa��vor��a��ble?adj.1. Advantageous; helpful: favorable winds.2. Encouraging; propitious: a favorable diagnosis.3. with the 50 percent rate of appointment compliance in thegeneral pediatric clinics. Despite the excellent outcomes of the initialphase of the program, a substantial number of patients who had beenlinked to a primary pediatric care provider continued to visit the EDfor nonemergent problems. PHASE 2: INTERVENTION STUDY Identification of High-Risk Group Our charge in phase 1, inherent in our contract with the state, wasto see as many patients as possible, which precluded conductingcomprehensive psychosocial assessments with every family. Manypsychosocial problems were not detected or could not be addressedbecause of the focus on primary care linkage and the narrow range ofintervention that could be implemented in a brief time period. Althoughphase I confirmed that a limited intervention could affect utilizationfor some patients, a group emerged that did not benefit from this typeof intervention. We speculated that families that continued to visit theED had greater needs and might benefit from more intensive intervention.These high-risk families became the focus of phase 2. High-risk families were defined as families who brought their childto the ED three or more times after the initial interview over thecourse of one year. We hypothesized that intensive social workintervention with high-risk families would result in improvedutilization of hospital resources compared with both previous usage andwith control groups. Improvement was defined as decreased number ofnonemergent visits to the ED during the period of intervention andincreased number of scheduled pediatric visits during the period ofintervention. Nonemergent visits were defined by our ED as visits fortreatment of illnesses that could be treated in a physician'soffice. Comparison periods for all groups were the same length of timeas the intervention. We controlled for the specific time of year becauseof the seasonal nature of certain childhood infections. Sampling Study patients (n = 663) were drawn consecutively from those whowere enrolled in phase 1 from January through June 1994. Forty-ninepercent of these patients (n = 309) continued to use the ED in the yearafter the initial interview. In the repeater (1) A communications device that amplifies (analog) or regenerates (digital) the data signal in order to extend the transmission distance. Available for both electronic and optical signals, repeaters are used extensively in long distance transmission. group, we identified ahigh-risk cohort cohort/co��hort/ (ko��hort)1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group.2. of 114 patients (37 percent) who had three or moreepisodes of ED care during the one-year period. High-risk patients andtheir families were randomly placed in the intervention ornonintervention non��in��ter��ven��tion?n.Failure or refusal to intervene, especially in the affairs of another nation.non (control) group by assignment of every other patient andhis or her family to the control or intervention group. Initially, therewere 57 control and 57 intervention families included in the sample. Thefinal number for each group was 52 as a result of transfer to anotherprovider, refusal by some families to participate, and double counting Double counting may refer to: Double counting (proof technique), a proof technique in combinatorics whereby one set is counted in two different ways Double counting (fallacy), a fallacy in combinatorics and probability theory whereby objects are counted more than once of sibling sibling/sib��ling/ (sib��ling) any of two or more offspring of the same parents; a brother or sister. sib��lingn. patients with different last names. Each patient in the finalsample was from a separate family. Outcomes Measurement We defined appropriate well-child care utilization as being seen atscheduled primary care visits. Inappropriate utilization was defined asED visits for nonemergent reasons. Hospitalizations were not defined asappropriate or inappropriate, but they were tabulated and the resultsare reported. Visits to the ED for emergent indications were nottabulated for this study. Utilization was measured for the period of theintervention. Data Analysis Control and intervention groups were compared on the outcomesappropriate and inappropriate utilization as defined earlier. We alsocompared outcomes between intervention and control groups as well aswithin groups for pre- and postintervention utilization. All resultswere tested for significance by a two-tailed t test, with significancedefined at the .05 level. Description of Intervention Intensity and type of social work intervention were based on apsychosocial assessment, a history of health care utilization andcompliance obtained from the medical record and data collected in theinitial interview, an analysis of the barriers to primary care, andsocial worker clinical judgment. Our study did not have the power toexamine the efficacy of the different levels of intervention. Wetherefore dichotomized social work intervention for the purposes ofanalysis. Standard, moderate, and intense interventions are reported inthe intervention group (see Table 1). The control group did not receiveintervention. The psychosocial assessment and intervention plan highlighted thefamily's use of the health care system and the identified barriers,which were communicated to the health care provider and team. Otherpsychosocial problems and needs were addressed. Although not directlyrelated to utilization, resolution of these problems, which includedfamily dysfunction dysfunction/dys��func��tion/ (dis-funk��shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc��tionalerectile dysfunction? impotence (2). , parenting issues, inadequate housing, mental healthproblems, and chemical dependency chemical dependencyn.A physical and psychological habituation to a mood- or mind-altering drug, such as alcohol or cocaine.chemical dependency, facilitated more appropriate use ofthe system. Interventions were based on standard social work practice inhealth settings grounded in the literature, centered on the wholefamily, and focused on counseling, education, referral, servicecoordination, follow-up, and consultation and collaboration with theprimary care provider, health care team, and community affiliates, ifapplicable (Carlton, 1984; Caroff & Mailick, 1985; Coulton, 1981;Ell & Northern, 1990; Ross, 1995). Assistance with priority setting,communication skills, and problem solving problem solvingProcess involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. , along with otherinterventions, helped change patterns of ED utilization. The socialworker endeavored to address the barriers affecting each family andproblems that had an adverse effect on family functioning. Once thebarriers were sufficiently resolved and the child was being seen forscheduled visits in primary care, regular contacts with the socialworker were discontinued dis��con��tin��ue?v. dis��con��tin��ued, dis��con��tin��u��ing, dis��con��tin��uesv.tr.1. To stop doing or providing (something); end or abandon: . The intervention ranged from six to 10 months; the mean was sevenmonths. Most families (71 percent) received intensive social workintervention. The period of observation was matched for control andintervention groups. RESULTS Description of Population There were no significant differences between groups for age andgender, insurance, primary caregiver care��giv��ern.1. An individual, such as a physician, nurse, or social worker, who assists in the identification, prevention, or treatment of an illness or disability.2. , two-parent involvement, chronicillness and connection to well-child care provider (Table 2). The meanage for both groups was 4.1 years (range = 1-18). Most children, 83percent for the intervention group and 81 percent for the control group,were ages five or younger, with the largest cohort in both groupsbetween ages two and three. Ninety percent of the control group receivedMedicaid compared with 79 percent of the intervention group. Withinthese groups 17 percent of the controls and 14 percent of theintervention families were in Medicaid HMOs. A higher percentage ofintervention families had no insurance (15 percent) compared withcontrol families (6 percent), but these differences were notsignificant. The mother was the primary caregiver for both groups (98percent), and 53 percent of the primary caregivers in each group wereunder age 26. Cleveland was the predominant city of residence (98percent for the control and 94 percent for the intervention group). Inabout 50 percent of the families in both groups, two parents wereinvolved in the child's care. The number of chronically illchildren was 21 percent in the control group and 25 percent in theintervention group. Eighty-eight percent of the control group and 73percent of the intervention group reported being connected with awell-child care provider. We confirmed these reports by checkingscheduled appointments. The intervention and control groups differedsignificantly by race or ethnicity ethnicityVox populi Racial status–ie, African American, Asian, Caucasian, Hispanic (p < .001); the intervention groupwas predominately white (67 percent), and the control group had a largecohort of Hispanic families (42 percent). Interviews with the intervention group families yielded demographicinformation not available for the control group. Only 15 percent of theintervention group primary caregivers were employed, most primarycaregivers (52 percent) had at least two years of high school, and 17percent had greater than a high school education. More than half of theintervention patients (52 percent) were firstborns, the next largestgroup was the next-to-oldest child in the family (23 percent). A thirdof the patients had no siblings siblingsnpl (formal) → fr��res et s?urs mpl (de m��mes parents); 21 percent and 25 percent had two andthree siblings, respectively; and 12 percent had four or more siblings. Intervention and control groups were compared on the presence ofbarriers identified in phase 1 (see Table 3). The number of barriers foreach of four variables (medical/educational, access, environmental, andpsychosocial) was significantly different for control and interventiongroups. The intervention group experienced more barriers (that is, had ahigher mean) than did the control group for all of the variables. In-depth interviews with families in the intervention groupexpanded our understanding of the barriers to care (see Table 4).Several barriers had not been catalogued in phase 1. The variety andcomplexity of these barriers is striking and suggests the need for amultifaceted approach to the problem. Patterns of utilization for study and control group patients in thepreintervention period were not significantly different (p = 0.14);however, the number of ED visits was higher for the intervention group(143 compared with 117) (see Table 5). Emergency visits declined forintervention and control groups in the postintervention period, but thedecrease in emergency visits was significantly higher in theintervention group (p [greater than or equal to]0.000), and the decreasein the control group was not significant (p =. 198) (see Table 6).Scheduled visits declined significantly in the control group in thepostintervention period compared with preintervention (p = .001).Although the intervention group showed a 26 percent increase inscheduled visits, this increase was not statistically significant (p =.070). Hospitalizations did not change significantly in either group(see Table 5). Social work intervention with high-risk families made adifference in ED utilization as defined by our criteria. DISCUSSION A comparison of barriers identified in the preintervention periodrevealed that the number of barriers to primary care for theintervention group exceeded the number for the control group, and EDutilization was higher for the same time period. Thus interventionfamilies, although randomly selected, had more identified problems andmore entrenched en��trench? also in��trenchv. en��trenched, en��trench��ing, en��trench��esv.tr.1. To provide with a trench, especially for the purpose of fortifying or defending.2. patterns of ED utilization than control group families. The difference in ethnicity between control and intervention groupsis a potential weakness of our study; therefore, we compared theHispanic control families with the rest of the control group and withthe intervention group to determine whether this cohort was differentalong other dimensions Other Dimensions is a collection of stories by author Clark Ashton Smith. It was released in 1970 and was the author's sixth collection of stories published by Arkham House. It was released in an edition of 3,144 copies. . For example, some studies have shown thatassimilation AssimilationThe absorption of stock by the public from a new issue.Notes:Underwriters hope to sell all of a new issue to the public.See also: Issuer, UnderwritingAssimilation , age o f mother, and other characteristics may affectutilization patterns in Latinos (Zambrana, Ell, Dorrington, Wachsman,& Hodge, 1994). Aside from cultural background, the demographiccharacteristics of this subgroup sub��group?n.1. A distinct group within a group; a subdivision of a group.2. A subordinate group.3. Mathematics A group that is a subset of a group.tr.v. were almost identical to those of theintervention and control groups. Parental inexperience InexperienceSee also Innocence, Naïveté.Bowes, Major Edward(1874–1946) originator and master of ceremonies of the Amateur Hour on radio. [Am. , as demonstrated by birth order of thepatient and age of parent, has been shown to influence ED utilization(Franco et al., 1997; Millar, Gloor, Wellington, & Joubert, 2000;Oberlander, Pless, & Dougherty, 1993; Tessler, 1980). Our studycorroborated cor��rob��o��rate?tr.v. cor��rob��o��rat��ed, cor��rob��o��rat��ing, cor��rob��o��ratesTo strengthen or support with other evidence; make more certain. See Synonyms at confirm. these findings; a little more than half of the patients inthe intervention group were firstborns and a third had no siblings. Theprimary caregivers were predominately under age 26. Caregiverinexperience may account in part for the lack of knowledge in ourpopulation regarding symptoms of normal childhood illnesses and for theperception of urgency that was reported by 40 percent as the reason forthe ED visit. This corresponds to reports in the literature (Feigelman,Duggan, Bazell, Baumgardner, Mellits, & DeAngelis, 1990; Gill gill, in weights and measuresgill,in weights and measures: see English units of measurement. &Riley, 1996). Our study did not find an association between maritalstatus marital status,n the legal standing of a person in regard to his or her marriage state. and utilization reported by other investigators (Millar et al.,2000; Phelps et al., 2000). In half of the families, two parents wereinvolved in the care of the children. Having a regular physician has also been associated with moreappropriate ED utilization (Oberlander et al., 1993). Most of ourpatients reported having a primary care provider (73 percent), yet theystill frequented the ED. For the provider to be seen by the caregiver asa source of help when a problem arises, there must be a preexisting pre��ex��istor pre-ex��ist ?v. pre��ex��ist��ed, pre��ex��ist��ing, pre��ex��istsv.tr.To exist before (something); precede: Dinosaurs preexisted humans.v.intr. relationship. It is also essential that the provider be accessible bytelephone and for planned and unplanned visits (Kini & Strait strait(strat) a narrow passage.straits of pelvis? the pelvic inlet(superior pelvic s.) and pelvic outlet(inferior pelvic s.) .straitn. ,1998). Twenty percent of the families in our study reported physicianunavailability and appointment unavailable as barriers. It is notablethat difficulty negotiating the medical system was a barrier for 71percent of the intervention group, which underscores the fact thathaving a primary physician is necessary but not sufficient to deternonemergent ED visits. Does not recognize symptoms and nonadherence tomedical plan were barriers for 69 percent and 37 percent, respectively.The high frequency of these two barriers may be related to difficultiesprocessing medical advice or instructions and misperceptions regardingthe seriousness of problems and suggests that medical providers may notcommunicate effectively with caregivers. Although previous studies have shown that addressing particularbarriers to care, such as the need for medical advice or connection to aprimary care provider, can be effective (Chande & Kimes, 1999;Mayefsky et al., 1991), we could find no reports of studies that usedsocial work intervention to mediate MEDIATE, POWERS. Those incident to primary powers, given by a principal to his agent. For example, the general authority given to collect, receive and pay debts due by or to the principal is a primary power. pediatric ED utilization. Socialwork has been shown to be effective in diverting nonemergent use of theED with other populations (Keehn et al., 1994; McCoy et al., 1992).Families using the ED for nonemergent pediatric care may benefit from abiopsychosocial approach to the problem. As in other research (Keehn etal.), in 50 percent of the 1,700 cases in the pre-social workintervention phase of our project, linkage with a primary care providerand instructions to call for advice did not change patterns of healthcare utilization. The large number of families in our study who requiredthe highest level of social work intervention (72 percent) demonstratesthat the factors affecting ED utilization are complex and that familieswith chronic inappropriate use may require intensive services. Focus on the family as a unit of concern for social workers inhealth settings and typologies that help to identify patients in need ofattention and suggest specific interventions suited to the short-termepisodic episodicsporadic; occurring in episodes. e. falling a paroxymal disorder described in Cavalier King Charles spaniels in which affected dogs, starting at an early age, experience episodes of extensor rigidity, possibly brought on by stress. e. nature of health care have been addressed in the social workliterature and remained consistent for decades (Carkon, 1984; Caroff& Mailick, 1985; Coulton, 1981; Ell & Northern, 1990; Ross,1995). We used standard social work intervention in our study, whichincluded education, counseling, service coordination, and regularinteraction and coordination with medical providers. Interventions wereselected on the basis of a thorough assessment of the psychosocialenvironment and the high-risk families' care-seeking patterns. Theimportance of scheduling and keeping regular appointments for well-childcare was stressed. Consistent follow-up with each family was important.We also addressed access issues and facilitated communication This article or section reads like a and may need a .Please help [ to improve this article] to make it in tone and meet Wikipedia's . betweencaregivers and providers. These interventions produced significantdifferences in utilization compared with matched controls and topreintervention patterns. The number of nonemergent ED visits was 66percent lower after the intervention and 48 percent lower than controlgroup ED visits. The number of scheduled primary care visits increasedby 35 percent and was 300 percent higher than for the control group.These outcomes are even more notable considering that the interventiongroup was a higher risk cohort, established by the greater number ofbarriers and higher ED utilization preintervention. The striking difference between the intervention and control groupsin the number of scheduled primary care visits could be an indicationthat establishing a positive relationship with a medical provider is acritical factor in deterring inappropriate ED utilization andencouraging primary care, but that relationship may need to befacilitated. The social worker routinely interpreted family issues toproviders and encouraged communication between providers and familycaregivers, sometimes by accompanying the family to medical visits.Social work intervention was individualized in��di��vid��u��al��ize?tr.v. in��di��vid��u��al��ized, in��di��vid��u��al��iz��ing, in��di��vid��u��al��iz��es1. To give individuality to.2. To consider or treat individually; particularize.3. ; some families received moreservices than others, depending on the type and number of barriers andthe complexity of problems. That not all families received the sameintervention may also be a study limitation. The results of our study have important implications. The abilityto ensure well-child and preventive care Preventive care is a set of measures taken in advance of symptoms to prevent illness or injury. This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur. See alsoPublic health for vulnerable children with arelatively inexpensive short-term intervention (mean of 7 months) isdesirable. There are financial advantages to diverting nonemergent casesinto primary care and preventing more costly problems that could beanticipated and treated in prevention rather than in a crisis mode.Social workers in ambulatory Movable; revocable; subject to change; capable of alteration.An ambulatory court was the former name of the Court of King's Bench in England. It would convene wherever the king who presided over it could be found, moving its location as the king moved. pediatric and ED settings primarilyintervene with cases of child abuse and neglect, mental health,environmental, and financial problems; they may also participate inservice coordination for developmentally delayed, chronically ill, andother high-risk children. Social workers' skills are commonly notused to promote primary care and assist with utilization patterns exceptin some instances of noncompliance. Social workers can make importantcontributions to improving children's access to primary care.Table 1. Summary of Social Work Intervention (n = 52 patients and theirfamilies) Intensive Moderate Intervention InterventionStandard Intervention Standard Intervention Standard InterventionAll Patients Plus: (27%) Plus: (71%)* Preparation: Review * Ongoing consultation * Intensive, ongoing of health care and collaboration consultation and utilization, with PCP and health collaboration with psychosocial care team of patient PCP, health care history, Phase I and possibly other team, and community involvement family members affiliates of* Psychosocial * Consultation and patient and family assessment, focus on collaboration with members use of health care patient's and * Routine meetings system, possibly other with parent and identification of family members' other family other problems community members at system affecting family affiliations encounters and also functioning * Regular meetings apart from medical* Consultation with with parent and visits PCP, nurse other family members * Regular, ongoing practitioner, or MD at time of system intensive encounters individual family * Intermittent counseling, individual or family education, and counseling, service education, and coordination service coordination involving multiple * Telephone calls, systems cards, or letters * Telephone calls, reminding patient cards, or letters and possibly other regarding regular family members of appointments for medical appointments the patient and other family membersTable 2. Demographic Characteristics, Control and Intervention Groupsin ED Intervention Study Control Intervention (n = 52) (n = 52)Characteristic n % n %Gender Male 25 48 27 52Race White 17 33 35 67 Hispanic 22 42 6 12 African American 13 25 11 21Residence Cleveland 51 98 49 94Primary caregiver Mother 51 98 51 98Chronic illness (patient) 11 21 13 25Connected with well-child 46 88 38 73 care providerInsurance Medicaid 38 73 34 65 HMO Medicaid 9 17 7 14 Private insurance 2 4 3 6 No insurance 3 6 8 15Both parents involved 23 44 25 48Child's age (a) Mean (range) 4.1 (1-18) 4.1 (1-18)Mother's age (a) Mean (range) 25.5 (18-48) 27.0 (18-38)NOTE: ED = emergency department.(a) Age at time of study.Table 3. Comparison of Number of Barriers Identified at InitialInterview, Phase 1, Control and Intervention GroupsGroup Environmental Medical/Education PsychosocialControl 40 = 0 37 = 0 46 = 0n = 52 12 [greater than 15 [greater than 6 [greater than or equal to] 1 or equal to] 1 or equal to] 1Intervention 25 = 0 3 = 0 8 = 0n = 52 27 [greater than 49 [greater than 44 [greater than or equal to] 1 or equal to] 1 or equal to] 1p .001 * [less than or [less than or equal to] .000 * equal to] .000 *Group AccessControl 27 = 0n = 52 25 [greater than or equal to] 1Intervention 13 = 0n = 52 39 [greater than or equal to] 1p .002 ** Significant at .05.Table 4. Intervention Group Barriers to Primary Care in InterventionGroup Families: Description, Consequences, and Frequency (N = 52)Barrier (a) Description ConsequencesMedical/EducationalDifficulty Lacks information or does Does not access primarynegotiating not understand when and caremedical system whom to call with problems or how to arrange medical appointmentsDoes not Lacks understanding of Every cough or feverrecognize normal childhood seems like a serioussymptoms diseases; unable to condition identify signs and symptomsNonadherence to Difficulty processing Cannot formulatemedical plan verbal or written medical questions or follow information and directions instructionsLacks basic Ignorance of proper Cannot evaluateknowledge of nutrition, hygiene, seriousness of problemschild care/child developmental milestones, or prevent problemsdevelopment and general needsDoes not ensure Lack of supervision; poor Harmful substanceschild safety judgment regarding within reach of potentially harmful children; injuries situations; no limit leading to repeated use setting for older of ED; underlying children parenting problems not addressedInability to Cannot maintain or Crises are precipitatedmanage chronic initiate required that require ED visitsillness lifestyle changes such as for asthma or diabetes; unfamiliar with symptomsEnvironmentalFinancial strain Lost work means lost pay; Unable to keep daytime no funds for medications; appointments; medical obtaining daily needs problems compounded; creates stress medical concerns seem less importantTransportation Public transportation: Difficulty keepingproblems difficulty traveling with scheduled appointments young children; unreliable service; safety issues; no money for fare. Private vehicle: no funds for fuel, repairs, or parkingProblems with Difficult to manage Misses appointments;child care clinic visits with more responds to perceived than one child emergencies onlyNo telephone Difficulty scheduling, No ability to plan, canceling, and obtain information to rescheduling deal with nonemergent appointments; no access problems to medical advice lines or messages not passed along or received in timeProblematic Inconvenient or too far Prefers to use EDgeographic from primary caregiver;location ED may be easier to get to than PCPAccessNo PCP No access to MD advice Problems not foreseen by and anticipatory guidance MD; ED is only recourse or education; unable to when child is ill. schedule appointments.PCP unavailable No procedures in place to Family must seek manage after-hours emergent care. problems; PCP may instruct family to use ED.Appointment Appointment schedule Unable to scheduleunavailable filled; no evening hours; appointments, must seek telephone delays. care in ED.Difficulty using Does not understand how Inappropriate ED use.managed care to use system; unaware ofsystem (a) resources available through managed care.Other: no Family and provider Does not anticipatelanguage unable to communicate; problems; unable to askinterpretation, provider may not ensure for or follow advice;other family understands cannot schedulecommunication information provided; appointments.problems (a) communication barriers create problems arranging appointments and obtaining advice.PsychosocialConflicting Responsibility for other Waits until crisis toresponsibilities family or household seek medical care. members overwhelming, inhibits ability to plan and manage care of child.Lack of Unable to set limits, Accidental injuries;parenting skills manage child's behavior, crises; nonadherence to follow medical advice, medical advice. attend to child's needs, or take safety precautions.Parental Impaired physical or Child's needs not met;physical or mental functioning; lack of preventive care,mental illness, complex parental needs; anticipation, orcognitive lacks judgment; inability understanding of problemdeficits to attend to child's precipitates crisis. needs; cannot follow medical advice, process or provide information, or negotiate systems.Poor support No family or friends to No back up resources tonetwork provide emotional or avert crises; difficulty financial assistance, trusting others, parenting advice, or communicating, or respite. building relationships with health professionals.Family Family operates in Impaired ability to usedysfunction-- violent, chaotic first aid, call forresponse to environment, medical advice, schedulecrisis (a) disorganized, unable to appointments; serious plan. Dysfunctional symptoms and need for response to medical medical attention problems, reactions to unrecognized or minor symptoms are impulsive symptoms perceived as and anxious. emergent.Domestic Contact with health care Care sought only inviolence (a) provider may be prevented perceived emergencies; by perpetrator or avoided no relationship for fear of revealing established with information about abuse. provider.Barrier (a) Frequency (b)Medical/EducationalDifficulty 37negotiatingmedical systemDoes not 36recognizesymptomsNonadherence to 19medical planLacks basic 13knowledge ofchild care/childdevelopmentDoes not ensure 6child safetyInability to 5manage chronicillnessEnvironmentalFinancial strain 18Transportation 12problemsProblems with 10child careNo telephone 8Problematic 5geographiclocationAccessNo PCP 14PCP unavailable 11Appointment 11unavailableDifficulty using 8managed caresystem (a)Other: no 18languageinterpretation,othercommunicationproblems (a)PsychosocialConflicting 32responsibilitiesLack of 16parenting skillsParental 14physical ormental illness,cognitivedeficitsPoor support 9networkFamily 5dysfunction--response tocrisis (a)Domestic 5violence (a)NOTES: ED = emergency department; PCP = primary care provider.(a) Barrier not catalogued in phase 1.(b) More than one barrier assigned to each case.Table 5. Intergroup Comparison of Utilization, Pre- andPostintervention Control InterventionVariable n = 52 n = 52 pPreintervention emergency visits 117 143 0.14 NSPostintervention emergency visits 94 49 0.004 (a)Preintervention scheduled visits 60 72 0.465 NSPostintervention scheduled visits 24 97 [less than or equal to] 0.000 (a)Preintervention hospitalizations 4 7 (b)Postintervention hospitalizations 6 4 (b)NOTES: All utilization outcomes corrected so that control andinterventions were measured for the same amount of umr. NS = notsignificant.(a) Significance is measured at p [less than or equal to] .05.(b) Statistical significance could not be assessed as a result of thesmall number of events.Table 6. 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The relationship between psychosocial status ofimmigrant Latino mothers and use of emergency pediatric services. HealthSocial Work, 19, 93-102. ABOUT THE AUTHORS Judith W. Ross, MSW (MicroSoft Word) See Microsoft Word. , formerly director of Social Work, MetroHealthMedical Center, is now director of Development, Cleveland Public Theatreand a consultant to nonprofit A corporation or an association that conducts business for the benefit of the general public without shareholders and without a profit motive.Nonprofits are also called not-for-profit corporations. Nonprofit corporations are created according to state law. organizations, 3729 Montevista Road,Cleveland Heights Cleveland Heights,city (1990 pop. 54,052), Cuyahoga co., NE Ohio, a residential suburb of Cleveland; inc. 1903. It is known for its beautiful homes and interesting shops. Forest Hills Park, once part of an estate owned by John D. Rockefeller, offers recreational facilities. , OH44121; e-mail: judithross@msn.com. Diane Roberts,MSW, is social work specialist, MetroHealth Medical Center, JamesCampbell For other people named James Campbell, see James Campbell (disambiguation).James Campbell (February 4, 1826 – April 21, 1900) is the founder of the Estate of James Campbell , MD, MS, is chain Department of Family Medicine Geriatrics geriatrics(jĕrēă`trĭks), the branch of medicine concerned with conditions and diseases of the aged. Many disabilities in old age are caused by or related to the deterioration of the circulatory system (see arteriosclerosis), e.g. ,MetroHealth Medical Center, and associate professor, School of Medicine,Case Western Reserve University. Karen Sofranko Solomon, MSSA MSSA Methicillin-Sensitive Staphylococcus AureusMSSA Microscopy Society of Southern AfricaMSSA Maryland Saltwater Sportfishermen's AssociationMSSA Military Selective Service ActMSSA Mid-South Sociological AssociationMSSA Minnesota Social Service Association , was (atthe time of this study) a social worker, MetroHealth Medical Center. BenH. Brouhard, MD, is executive vice president and chief of staff,MetroHealth Medical Center, and professor of Pediatrics, School ofMedicine, Case Western Reserve University, Cleveland, OH. This work wasconducted by the Department of Social Work at MetroHealth Medical Centerand was supported in part by a grant from the Ohio Department of HumanServices. The authors acknowledge the contributions to this project ofMary Ann Kerr, MSW, and Amy Marzinski, RN, and appreciate the helpfulcomments of Dr. Robert Bilenker in the preparation of this article. Original manuscript received October 29, 2001 Final revisionreceived May 21, 2002 Accepted June 25, 2002