Objective: 1) To describe the role of social workers in managing the care coordination of homebound patients with advanced Parkinson’s disease (PD); 2) to demonstrate whether social workers increase access to needed services and 3); to determine whether multiple visits have added value.

Background: As PD progresses, the burden of motor and non-motor symptoms as well as other comorbidities increases, eventually leading to a homebound state. Patients lose access to essential services, resulting in reduced quality of life, hospitalization, and greater care partner burden. Homebound patients are eligible to participate in the Interdisciplinary Home Visit Program (HVP) at the Fresco Institute for Parkinson’s and Movement Disorders. Visits include cross-discipline evaluations. The social work role is to identify unmet needs, provide diagnosis-specific education, counsel the patient and care partner, provide crucial resource referral, and coordinate care following each visit to ensure patients are connected to services. The value of multiple visits is unknown.

Methods: We examined social work effort and dyad need by the number and type of referrals delivered through the HVP caring for the first 26 enrolled patients. We collected data across multiple visits to determine the value of repeat visits. Referrals here are defined as a successful connection to a referred service.

Results: We observed a mean referral rate of 2.69 for the first visit. Although referral numbers decreased at each visit, the need for new referrals continued to be identified (0.5 referrals at the fourth visit). Referrals were diverse in type but specific types were frequent across patients: physical therapy 73%; speech therapy 58%; psychotherapy 54%; home safety assessment 27%; and psychiatry 15%. Other referrals included support group, visiting primary care physician, medical alert system, home care, and elder care attorneys.

Conclusions: Homebound patients with advanced PD are in need of a variety of referrals to improve care. Through repeated social work assessments, new needs continue to be identified. Follow up home visits provide the social worker with the opportunity to facilitate continued assessment, connections to new resources, reinforce previously identified unmet needs, and provide supportive counseling that adapts to patient and family evolving circumstances as PD progresses.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/assessment-and-connection-to-care-the-vital-role-of-the-social-worker-in-an-interdisciplinary-home-visit-program-for-advanced-parkinsons-disease-patients/