Psychiatric Social Work Services In Neurology Emergency Care Setting

Abstract

Background:

Psychiatric social workers are important multi-disciplinary team members, and they assess patients and their families social, emotional, environmental, financial, and support needs in emergency settings. They support patients and their families through difficult times and improve patient lives.

Aim:

To study the profile of patients availed psychiatric social work services in neurology casualty and emergency settings.

Materials & Methods:

The study was retrospective in nature. The ex-post facto research design was used in the study. Data were obtained from a casualty & emergency psychiatric social work referral registry maintained by the psychiatric social work team at the Neurology emergency setting at NIMHANS, Bangalore. Patients referred for psychiatric social work interventions from April 2020 to March 2021 were considered for the study purpose. Frequency and percentages were used to describe the data.

Results:

Psychiatric social work services at the neurology emergency setting were started in July 2018. Social workers get referrals from triage (four hours to 24 hours), followed by priority ward (72 hours to two weeks), observation ward (72 hours days - two weeks) and emergency ICU. There are 100 beds available for neuro-emergency settings. Of ≈15,939 patients who availed the neurology emergency services, 159 patients were referred for psychiatric social work services. A majority (61.6%) received neuro-education about their illness; awareness about their illness were given to patients and their family members. More than half of them were given guidance for availing treatment welfare benefits under below poverty line and Ayushman Bharath Scheme (54%), 43.3% received supportive psychotherapy, 35.2% pre-discharge counselling, one-third received crisis intervention,12.6% family interventions, 10.7% were facilitated for hospital charges waiver off, few unknown patients management and tracing their family members. Most patients were diagnosed with a stroke, GBS, neuro-infections, and seizure disorder patients who sought psychiatric social work services in emergency and casualty settings. Assessment of their functionality revealed that most were partially independent and dependent. Social workers work from 9 am to 9 pm in the neuro-emergency setting. Immediate social work referrals were made for unknown patients, tracing the caregivers who left the emergency ward without permission, which required financial assistance and communicating poor prognosis (breaking the bad news).

Conclusion:

The most common psychiatric social work intervention provided in the neurology emergency care setting were education about the illness, facilitating poor patients to avail social welfare benefits, supportive psychotherapy and crisis intervention.

Introduction

Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. Global burden of disease data over the past 20 years shows a large and growing burden of death and disability caused by neurological disorders. Mental, neurological and substance use disorders cause significant disease burden in the world. Neurological disorders contribute significantly to a global disability, often leading to severe physical, cognitive and psychosocial limitations. Neurological disorders constitute 6.3% of the global burden.

About 30 million people suffer from neurological disorders (excluding neuro-infections and traumatic injuries) in India (Gowri-devi, 2014). In 2019, stroke was the most significant contributor of DALYs in India (37.9%), headache disorders (17.5%), epilepsy (11.3%), cerebral palsy (5.7%), and encephalitis (5.3%) non-communicable neurological disorders accounted for total DALYs in India is 8.2% in 2019 (Singh, 2021).

Acute stroke within three hours to less than a week, seizures within last 24 hours, unconsciousness, excessive drowsiness (non-responsive to verbal command), severe headache with or without fever (neuro-infections, meningitis), sudden weakness in lower and upper limb or any body parts, sudden vision loss and speech disturbances, difficulty in swallowing, breathing, constitutes neurology emergency.

Oomman et al. (1993) reported that most patients attended neurology emergency services for the first time diagnosed with epilepsy. Referrals to other hospitals constituted a major mode of discharge. A majority belong to middle age (35–45 years), lower and middle socioeconomic status, and urban domicile. Fear, anxiety, sadness, shock, and pre-occupied about the patient’s future were common reactions of the family members during their interaction. The majority of the family members do not have scientific knowledge about the illness’s cause and outcome. Most family members expect the hospital staff in neurology casualty settings to reduce their tension, reassurance, relief and welfare measures for the treatment. Almost all the family members expected a cent per cent recovery from the neurological illness. Higher social support was associated with less family burden among family members who availed neurological emergency services for their wards. Most family members opined that they did not face problems while availing neurological emergency services.

Nearly half of the families do not know the outcome of the illness, the majority did not face any problems during admission, and few expressed the concern that doctors should be available and accessible to them all the time. The majority of them expressed more satisfaction about the services provided in neurology casualty services and psychiatric social work services. A majority had a positive attitude towards treatment. More than half of the family members expected the patient’s full recovery. One-third of family members reported that their relatives stopped visiting their house after the illness (Thirumoorthy, 2000).

Jangam et al. (2004) reported that fear, anxiety, shock and denial were the reactions faced by the family members during the acute phase of the illness at Neurology casualty services. Family members’ reactions differ with diagnosis, patient’s age, gender and functionality, number of admissions at casualty services. Family members faced severe financial burdens and psychological and economic impacts during emergency hospitalisation at Neurology casualty. Many family members had disturbed sleep and decreased appetite and faced administrative problems, sudden discharge, admission procedures, and medico-legal problems. Many family members felt comfortable with nursing staff, and they were a source of social support for the family. Doctors were the primary source of information. Many families reported that medical services were not affordable, and sometimes doctors are inaccessible due to the inadequacy of staff to attend to many patients. Most family members expect doctors to spend more time with family and patient, to pay immediate attention, complete cure. The treating team faced language problems, difficulty in communicating prognosis, and treatment modalities.

Areas of crisis assessment in an emergency setting include physical assault, sexual abuse, injuries, vulnerability, counselling needs, alcohol and drugs abuse, shelter needs for homeless persons, identifiable information. A social worker is a valuable multi-disciplinary team in a casualty and emergency setting. They engage in multiple roles for the welfare of the patients and their family members, and their services were under-utilised as resource persons. Social workers in emergency and casualty settings find a lack of community resources a significant barrier to their services (Fusenig., 2012).

Emergency hospitalisation is a stressful event that disturbs the physical and psychological well-being, which can, in turn, affect physical recovery and medical compliance (Raju et al., 2017). Especially setting like casualty and emergency requires a medical/psychiatric social work team to address the acute crisis of patient and caregiver to cope with the crisis.

Most patients brought to casualty and emergency services were diagnosed with a stroke, Guillain-Barré syndrome, neuro-infections, and seizure disorder. They were referred for psychiatric social work services to address various acute psychosocial stressors that patients and caregivers go through, such as lack of understanding about illness, prognosis, financial constraints. Medical and Psychiatric social work services are an integral part of casualty and emergency services in a neurology setting. Social workers play a vital role as a multi-disciplinary team in dealing with cases like Medico-legal cases and unknown cases brought by police or bystanders. Thus this paper aimed to understand the needs, roles and reasons for referral to psychiatric social workers at casualty and emergency settings.

MATERIALS AND METHODS

The study was retrospective in nature. Ex-post-facto research design was used. The study was conducted at Government-run tertiary care neuroscience teaching hospital in Bangalore. Data were derived from the psychiatric social work referral registry maintained by the psychiatric social work team at Neurology Casualty and the emergency setting from April 2020 to March 2021. Frequency and percentages were used to describe the data. Neurology Emergency consultation: patients requiring neurology emergency care would be first screened by a casualty medical officer (CMO) in the emergency ward. After an initial assessment of patients, CMO would make an appropriate referral to neurologists. Then patients would be initially seen by neurology residents, and if required, necessary investigations would be advised. After the investigation findings, treatment would be given accordingly. If investigations reveal a non-neurological medical problem, patients would be discharged to a general hospital. Neurology emergency has five wards with 100 beds; Triage, Priority I and II, Short-stay ward, observation ward and ICU.

RESULTS

Totally 159 patients were referred for psychiatric social work services out of 15,939 patients who sought treatment at neurology casualty and emergency settings. A majority (61.6%) received neuro-education about their illness, followed by treatment welfare benefits under below poverty line(54%), 43.1% received supportive psychotherapy, 35.2% pre-discharge counselling, one-third received crisis intervention,12.6% family interventions, 10.7% were facilitated for hospital charges waiver off, 2.5% working with unknown patients and tracing their family members. Most patients had a diagnosis of Stroke, GBS, neuro-infections, and few seizure disorder patients sought psychiatric social work services in an emergency setting. Assessment of their functionality revealed that they were partially independent and dependent. Social workers work from 9 am to 9 pm in the neuro-emergency setting. Immediate social work referrals for unknown patients would be made to trace the caregivers who left the emergency ward without permission, who require financial assistance, communicate poor prognosis (breaking the bad news).

Psychosocial Assessment

A psychosocial assessment was administered to arrive at a plan of psychosocial management specific to patients and their clinical diagnosis. The psychosocial assessment consists of information such as patient demographic details, chief complaints, brief clinical history, duration of illness, medical history, family history, pathways of care, explanatory model about illness, knowledge about illness, support system, current functionality (ADL, IADL), Caregiver burden, patient and caregiver felt needs. Case formulation and intervention plan will be planned, followed by a comprehensive assessment.

Table 1 depicts the intervention carried out at the time of admission. A majority (61.6%) received neuro-education about their illness to patients and their family members treatment welfare benefits for families under below poverty line (54%). About 43.3% received supportive psychotherapy 35.2% pre-discharge counselling. One-third received crisis intervention, 12.6% family interventions, 10.7% were facilitated for hospital charges waiver off, 2.5% working with unknown patients and tracing their family members.

Table 1:

Psychosocial Interventions at neurology emergency

Psychosocial interventions	Frequency	Percentage
Neuro-education	98	61.6%
Facilitating welfare benefits	86	54.0%
Supportive Psychotherapy	69	43.3%
Pre-discharge counselling	56	35.2%
Family interventions	20	12.6%
Waiver-Off of hospital charges	17	10.7%
Unknown patients’ management	04	2.5%

Patient Education

Patient education is a systematic experience in which a combination of methods such as the provision of information and advice and behaviour modification techniques, which influence the way the patients experience their illness and knowledge and health behaviours, aimed at improving or maintaining or learning to cope with a condition, usually a chronic one (Hunderfund et al., 2010). Neuro-education (education about neurological illness) was carried out with patients and caregivers around 61.6%. Patients and their family members received information about the nature of the illness, causes, prognosis and importance of continuing medication, medication side effects if any, relapse prevention and sensitising them to the role of other supportive therapies such as physiotherapy, occupational therapy, speech therapy, neuro-rehabilitation, and how it plays a role in recovery.

Supportive Psychotherapy

Supportive psychotherapy was developed early in the 20th century to describe a treatment approach. In supportive Psychotherapy, the therapist’s role is to support and strengthen the individual’s potential for better functioning of both adaptation and developmental tasks (Gilbert & Ugelstad et al. 1994). In neurology casualty and emergency settings, supportive

Psychotherapy plays a vital role with patients and caregivers. About 43.3% of the cases referred to the social work team availed supportive psychotherapy in emergency settings. Neurological conditions like stroke, GBS, neuro-infectious conditions like encephalitis and meningitis lead to mild, moderate, and severe disability. This creates a dependency on others for their basic needs and causes psychological distress among patients. Caregivers also go through a significant amount of stress and caregiver burden. In this context, social casework focusing on identifying their strength rather than their disability makes them feel completely dependent on their emotional well-being. The caregivers are more focused on facilitating them to share their caregiving difficulties, positively reinforcing their caregiving for patients, and taking role reversal to avoid caregiver burden.

Family Intervention

The family intervention involves education about illness (such as its course, causes, treatment, and prognosis), counselling, coping, and dealing with a family member having a chronic illness. Few (12.6%) patients’ family members had received the family intervention. The family intervention is provided when multiple psychosocial and interpersonal issues can be a risk factor for relapse. The family intervention focuses on addressing the interpersonal issues and how it impacts patient health and enhance family support for the patient. Family interventions may cover specific aspects such as future plans, job prospects, medication supervision, marriage and pregnancy (in women), behavioural management, improving communication between the family members (Varghese, 2021). Family interventions are aimed at preventing relapse enhancing role functioning and family well-being. Family intervention in the context of a family member having an illness is the family members’ ability to maintain cohesive relationships with one another, fulfil family roles, cope with family problems, adjust to new family routines and procedures and effectively communicate with each other and to identify strengths and rehabilitation potentials to improve family functioning and rehabilitation of patients (Zhang et al. 2018).

Welfare Benefits

Financial constraints are another major crisis caregivers face in emergency settings. Half (54%) of the patients admitted in casualty and emergency wards availed treatment welfare benefits. Following welfare benefits schemes are available in financial assistance for patients below poverty line, Ayushman Bharath Pradhan Mantri Jan Arogya Yojana, Sarojini Damodar fund for children, Bharat Petroleum Corporate Limited fund and Malankara fund for persons affected with COVID-19.

Waiver-off of Hospital Charges

The objective of waiving off of treatment charges for a few patients with neurological conditions is to ensure that patients are not deprived of treatment due to their financial crisis to seek treatment for neurological complaints. 10.7% of the cases in emergency settings availed waive off. The Social worker does their income assessment by administering the modified Kuppusamy Scale (Ananathan, 2020). The unknown patients brought by police or public, destitute brought by a government agency, migrant workers, and seasonal workers who do not have valid documents to avail lower-cost treatment would be considered for a partial or complete waive off based on socioeconomic assessment findings. Social Workers make recommendations to the Resident Medical Officer, Medical Superintendent, and Treating team through proper channels to waiver the hospital treatment charges.

Management of Unknown Patients

Many patients are admitted to government hospitals in large metropolitan cities without personal, family details, or any identifications details (especially at the time of admission). These patients get admitted under the ‘unknown’ category. Thus, an unknown patient can be defined as “the patient whose identity cannot be ascertained at the time of arrival to the hospital” (Umesh et al., 2017). Few (2.5%) neurology patients were referred to the psychiatric social work team to manage unknown patients, handle the administrative issues, and trace the family for reintegration.

Fig 1 depicts the psychosocial management of unknown patients in neurology emergency.

Fig 1:

Psychosocial Management of Unknown Patients in Neurology Emergency Setting

Pre-discharge counselling

Pre-discharge counselling prepares the family and the patient to get a smooth discharge from the hospital (Raju et al., 2017). More than one-third, 35.2% of cases received pre-discharge counselling, in which their understating about illness is reviewed, ensuring medication compliance and regular follow-up. In pre-discharge counselling, the following aspects are covered regarding continuing other therapies such as occupational therapy and physiotherapy as advised by the treating team; the decision on who will supervise the patient medication at home to avoid poor drug compliance, daily routine for patient, medicine side effects. In case of relapse or any other emergency, patients are advised to consult the nearby doctor with the discharge summary for immediate management. Later, patients may visit the treating team at outpatient service or in the casualty and emergency ward based on their symptoms.

Conclusion

The role of a medical and psychiatric social worker in casualty and emergency settings is essential in addressing the various psychosocial issues and psychological concerns. The psychiatric social work intervention such as education about the illness, providing supportive psychotherapy, facilitating welfare benefits, pre-discharge counselling, addressing the acute crisis are the most common services provided to help the patient and the caregivers in a much better way.