Types of Patients by Diagnosis and Service Category
RN Case Managers and Clinical Social Workers in the Department of Care Coordination and Clinical Social Work at UCLA Health are available to serve patients with any diagnosis (and their families) referred from:
- All in-patient adult and pediatric medical, surgical, transplant, and rehabilitation services
- The Emergency Department
- All in-patient or Emergency Department.
- All in-patient or Emergency Department elder/dependent adult abuse/neglect referrals
- All in-patient or Emergency Department adult domestic violence referrals
Additionally, Clinical Social Workers in the Department of Care Coordination at UCLA Health are available to serve patients with any diagnosis (and their families) referred from:
- All out-patient pediatric services
- Out-patient adult oncology and adult pre- and post-transplant services
- Out-patient child abuse / neglect referrals
- Referrals of in-patients and of out-patients in clinics having social work coverage can be made by any UCLA Medical Center employee, by patients/families themselves, and/or by the community. Social work consultation about patients is also available to patient care staff and to community agencies, as long as HIPAA guidelines are closely and correctly adhered to.
Ages of Patients Served
All adult patients, aged 21 and over, are served. Ages of pediatric patients range from birth to 21.
100% of pediatric and adult inpatients receive case management activity.
On the pediatric in-patient services, approximately 85% of patients are seen and evaluated by Clinical Social Workers. For pediatric in-patients with California Children's Services (CCS) diagnoses and coverage, 100% are seen by social work. 100% of pre and post-organ transplant patients who are to be transplanted in our hospital are seen and evaluated by Clinical Social Workers in either the out-patient or the in-patient settings.
On the adult medical and surgical services, approximately 50-60% of patients are seen by Clinical Social Workers. When issues of child abuse/neglect, domestic violence, elder/dependent adult abuse/neglect, risk of self-harm, and homelessness arise regarding any pediatric or adult in-patient or any out-patient pediatric patient, 100% of such referrals are addressed by Clinical Social Workers.
Hours of Care Coordination: Administrators' Availability: Care Coordination staff and managers are generally available between 0800 and 1700. All carry pagers, phones and can be located urgently or emergently. There is always a Care Coordination administrator on-call 24 hours/7 days a week.
Hours of Care Coordination Staff Availability
- Care Coordination assessments and interventions generally take place during the work week – Mondays through Fridays, between 0800 and 1630, and on Saturdays and Sunday between 7am and 530pm. Care Coordination staff at UCLA are exempt from a finite schedule, and work as long as necessary, as situations dictate. Variation in work schedules to benefit the services they cover can make necessary changes in their schedules with supervisory permission
- Likewise, most out-patient clinics staffed by Clinical Social Workers operate Mondays through Fridays 0830-1700 hours. Some clinics have later hours, and can elect to have Clinical Social Workers in attendance later into the evening.
- Additionally, Clinical Social Workers cover the weekend from 9am until 530pm for all inpatient needs with overlap coverage from the ED Clinical Social Worker to complement coverage 24/7.
- The Ronald Reagan UCLA Medical Center Emergency Department is covered 7 days per week by a Case Manager and a Clinical Social Worker. Case Manager and Clinical Social Worker coverage is provided on-site 24/7.
- The Santa Monica Hospital Emergency Department is covered 7 days per week by a Case Manager and a Clinical Social Worker. Case Manager and Clinical Social Worker coverage is provided on-site 24/7.
- The Case Manager and Clinical Social Worker working on Saturday and Sunday also assist with admitted patients.
On Weekends and University holidays
Weekend case management is available 0700-1730.
On University holidays, there is 24 hour coverage by one or more on-site Clinical Social Workers
There will be case management staff available on the following holidays: Martin Luther King Jr. Birthday, President's Day, Cesar Chavez Day, Memorial Day, July 4th, Labor Day, Veteran's Day, Friday following Thanksgiving Day. Other university holidays are on voluntary basis.
Hours of Care Coordination Support Staff Availability: The senior administrative analyst and the administrative assistants generally overlap their work hours so that the office and tasks are covered by one support staff member or another from 0800 to 1630 hours.
Location of Care Coordination at UCLA Health
Our main office (B788 RR), which serves as a communications hub for all department staff, is located in the main hospital building. Each Case Manager and Clinical Social Worker has another (usually shared) office location either in the hospital building or off-site. Offices are equipped with computers and telephones, and all employees have their own individually-assigned voice-mail boxes and pagers. All Case Managers and Clinical Social Workers have mobile telephones (with the exception of the off-site Revenue and Resource Case Managers). Efficient and timely communication among Care Coordination staff and with interdisciplinary teams is expected.
Scope and Complexity of Patient Care Needs
Frequent Procedures, Services, Processes
Our model of Care Coordination is an integrated model comprised of nurses (Case Managers and Resource Case Managers, and Advanced Practice Nurses), Clinical Social Workers, who provide case management, utilization review and social work functions. Job descriptions for each professional group are distinct; although there is some overlap.
The Case Management Team works together to coordinate timely and effective service delivery by facilitating referrals to continuum services, communicate potential payor issues, provide for clinical and therapeutic interventions, and manage variance to the plan of care. The discharge planning process begins during the patient screening and assessment. Based on the assessment, a preliminary determination is made about the types of services the patient may need post-discharge. Within the parameters of a patient's health care plan and coverage, the Case Management Team begins to plan for the anticipated types of services.
Advanced Practice Registered Nurses in the Department of Care Coordination and Clinical Social Work provide clinical care in select post-acute facilities for some adult patients. These nurse practitioners provide management of health and illness in the Skilled Nursing environment, as well as assist with the coordination of post-Skilled Nursing Facility care.
Clinical Social Workers in the Department of Care Coordination at UCLA Medical Center provide psychosocial assessments, clinical interventions, resource referral, and assistance with post-hospital planning for patients and families who have social, emotional, language/cultural, and/or environmental needs related to their illness or injury, recovery, and future healthcare needs. Special attention is paid to patients' psychosocial adjustment to illness/injury, motivation for recovery, and relationships within the family and in the community which might enhance or detract from optimal health outcomes. For transplant services, all potential candidates are evaluated by a Clinical Social Worker and a comprehensive psychosocial assessment is completed.
Clinical social work assessment and treatment include crisis intervention and attention to loss of functional ability; alteration of body image; change in occupational capacity; dependency issues; financial concerns; family availability for care-taking; changes in traditional gender or generational roles; cultural/ethnic responses to illness/injury and concomitant treatment; response to cumulative losses; non-compliance with medical regimens and/or follow-up care; anticipatory grief; and bereavement. Social work assessments and interventions are mandated in cases of suspected child abuse/neglect, allegations of domestic violence, and suspected elder/dependent adult abuse/neglect. After receiving referrals, Clinical Social Workers usually perform face-to-face psychosocial assessments with patients and perhaps other family members as appropriate. Interpreter assistance is sought when Clinical Social Worker and patient/family do not speak the same language. Occasionally (and less optimally), an assessment may be accomplished by telephone when the patient is geographically far away from the hospital. Sometimes, a brief social work evaluation is all that is needed for something very specific, such as a community resource.
Types of Staff Available to Serve the Patient/Family
All Case Managers are licensed registered nurses as are resource case managers. Clinical Social Workers at UCLA Health System (line staff, managers, and the director) are required to hold the master of social work (MSW) degree from a program in the United States accredited by the Council on Social Work Education.
UCLA line staff Clinical Social Workers at UCLA Health System are hired at the Clinical Social Worker II (unlicensed) or Clinical Social Worker III (California-licensed) levels. Although post-Master's State of California social work licensure is not required at UCLA Medical Center, Clinical Social Workers are strongly encouraged to prepare for licensure by arranging weekly clinical supervision for two years after receiving the Master's degree and by taking the requisite two California State examinations authorized by the California Board of Behavioral Sciences. Post-Master's weekly individual supervision is provided by our department for Clinical Social Workers pursuing licensure. Clinical and administrative supervision are also offered as needed for licensed line staff members. Continuing professional education is highly valued by our department, and we provide for all MSWs five days paid educational leave per year. Our Master's level line Clinical Social Workers are divided into focus groups based on their areas of practice. Meetings of these groups occur every month or every other month for the purpose of sharing effective procedures and processes, developing new practices, and solving problems which hamper more effective work with patients and families and with each other and our interdisciplinary staff members. Traditionally, we have:
An Adult Services Focus Group
A Maternal/Child Health (MCH) Focus Group (Obstetrics, NICU, and pediatric services)
An ad hoc adult/pediatric Transplant Focus Group (meeting less regularly, since transplant Clinical Social Workers are already part of the Adult or MCH groups)
Social workers who are managers/ director must hold California licensure (or if from out of state, must qualify for California licensure as quickly as possible). Managers and the director must have at least several years of clinical social work experience in health care settings plus requisite administrative experience. Although usually involved with supervisory and administrative matters, our social work managers and the social work director may become involved in direct patient care, usually either to assist with coverage or to mediate patient / family concerns.
Departmental Acuity System
Care Coordination staff members, managers, and the director all must prioritize daily the order in which referred cases are seen and evaluated. Each Case Manager/discharge planner is responsible for communicating closely with interdisciplinary team members regarding prioritization of referred cases. Managers and the director may assist, and coverage plans can be initiated when necessary.
Social work line staff members, managers, and the director all must prioritize daily the order in which referred cases are seen and evaluated. Types of clinical situations seen in order of most crucial to less so generally include: patient death or imminent death; trauma in the Emergency Department; any alleged child or adult abuse situation; alleged domestic violence; emergent transplant psychosocial evaluation; new catastrophic diagnoses; patients threatening to leave the hospital against medical advice; and psychosocial or systems problems re: patients scheduled to be discharged. Each Clinical Social Worker is responsible for communicating closely with interdisciplinary team members regarding prioritization of referred cases. Managers and the director may assist, and coverage plans can be initiated if/when a particular Clinical Social Worker experiences referral of an unusual number of clinical cases at any given time.