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TriageServicesMaria Berg-Weger PhD,LCSW a ,Jane GockelLCSW b , DorisMcGartlandRubio PhD c &Rachelle DouglasMSW da Practicum ,Saint LouisUniversitySchool ofSocial Service ,3550 LindellBoulevard,St. Louis, MO,63103, USAb St. LouisVeteransAdministrationMedical Center ,915 NorthGrand, 122/JC,

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St. Louis, MO,63106, USAc Departmentof ResearchMethodology ,Saint LouisUniversity ,3663 LindellBoulevard,St. Louis, MO,63108, USAd St. LouisVeteransAdministrationMedical Center ,915 NorthGrand, 122/JC,St. Louis, MO,63103, USAPublishedonline: 24 Oct2008.

To cite this article: Maria Berg-Weger PhD,LCSW , Jane Gockel LCSW , Doris McGartlandRubio PhD & Rachelle Douglas MSW (1998) TriageServices, Social Work in Health Care, 27:1, 15-31,DOI: 10.1300/J010v27n01_02

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To link to this article: http://dx.doi.org/10.1300/J010v27n01_02

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A Triage Services:

Profile of High Utilization Marla Berg-Weger, PhD, LCSW

Jane Gockel, LCSW Doris McGartland Rubio, PhD

Rachelle Douglas, MSW

ABSTRACT. With challenges continuing to be prcscnted to health care delivery, inappropriate out-patient service utilization is of ut- most concern to al l health care servicc providers. This study is an examination of thc utilization panerns of 189 veterans in an urban Vctcrans Administration Mcdical Center (VAMC). Factors Sound to be related to high utilization of amhulalory carc triage clinic services for veterans who had presented for at least two unscheduled visits in the past s ix months include: paticnt percepliun of health status; num- ber of prescription medications; and social needs. Implications for social work practice, program devclopment and rcsearch are dis- cussed. [Article copies awilable for a p e J b m 7he HuworlR Documenr Deliverj Semite. 1-800-342-9678. Emrail oddrws grrhfo@hawo~~h.com/

INTRODUCTION

The cost for health care serviccs has become an issuc of grave national conccm. Numerous attempts havc been made to gain insight into utiliza-

Marla Berg-Weger is Assistant Profesror and Direnor of Pncticurn. Saint Louis University School of SKldl Servicc, 3550 Lindell Boulcvard, SI. Louis, MO 63103 (E-mail: bergwm~sluvca.slu.edu). Jane Gockel is Social Worker Supervisor, St. Louis Veterans Administration Medical Center, 915 Nonh Grand, 122/JC, St . Louis. MO 63106. Doris McGartland Kubio is Assistant Professor, Department of Research Methodology, Saint Louis Universily, 3663 Lindell Bou- levard, St. Louis, MO 63108. Rachelle Douglas, st the lime of the study, was a social work pmcticum sludcnt, St. ILouis Vclemns Adrninlmation Mcdical Center, 915 North Grand, 122/1C, St. Louis, MO 63103

Social Work in Health Care, Vol. 27(1) 195’8 0 1998 by The Hawonh Pres$ Inc. All rights reserved 15 Dow

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16 SOCIAL WORK IN HEALTH OlRE

tion patterns and trends as well as strategies for providing services in a more efficient and effective manner. Shrinking resources is a challenge that has faced the Veterans Adminismation Medical Center system (VAMC) and other segments of the health care service delivery system in recent years. The VAMC, the largest health care entity in the world and exclu- sively funded by the U.S. government, is converting to a capitation reim- bursement slructure, similar to private-sector managed care models (Kizer, 1996).

In an era of increasing demands and decreasing reserves, social work practitioners and their colleagues within the VAMC system are examining the complex issues related to providing care to aging veterans. Social work- ers employed at the project site anecdotally shared concerns that patients over-utilize the ambulatory care triage clinic and raised the possibility that unmet social needs (to include: lack of social support, preoccupation with health concerns, conipliance issues, financial constraints, etc.) inay con- tribute lo a patient requesting an unscheduled medical visit. Such prob- l e m as those noted above occurred with increasing frequency, thus, prompting the authors to embark on an exploration to better understand health care utilization patterns.

Health care providers and rcsearchcrs have long known thar a imnority of patients receiving medical services use the majority of health cam providers’ time and resources. As early as 1959, one-fourth of clinic visits were made by only 4% of the patients, while 12% of the clients received half of the services provided (Densen, Shapim 8: Einhorn, 1959). Later examinalions iifhealth care utilization continued to support the early work of Densen and colleagues. McCall and Wait (1983) found that 18% of an elderly Medicare population received 88% of services provided over a four-year span. Further, Freeborn, Pope, Mullooly and McFarland (1990, pp. 533-534) report that, while high users of health care comprised only 26% of the sample studied, they “accounted for 51% of the total ambula- tory care contacts, 47% of the ofice visits and 55% of the hospital admis- sions.’’ This group cost the health care system four times more per year than their counterparts who were identified as “low users” (Freeborn et al., 1990). Freehorn and colleagues (1990) further imply that consistently high use of health care resources may be symptomatic of patients’ generally poorer health, suggesting that decreasing the availability of health care services may actually result in overall increased costs for the future (Free- born et al., 1990, p. 538).

Nationally, the VAMC conducted over 26 million outpatient visits for the fiscal year 1995 (Summary of Medical Program, National Center for Veteran Analysis and Statistics, 1995). A total of 289,700 annual outpa-

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Berg- Weger el ol. I7

tient visits occur at the project site (VAMC MIS, 1996). Of these appoint- ments, approximately 23,690 are non-emergency, unscheduled visits to the ambulatory care triage clinic at a cost of $205.00/visit (VAMC MIS, 1996). Overall, the annual operational cost of this clinic to this particular facility is approximately $4,856.450.00 (VAMC MIS, 1996).

This study seeks to further understand the multifaceted issues related 10 the over-utilization of ambulatory health care services by frequently served patients. The issues surrounding modem day medical care have reached crisis proportions in the US., thus prompting this research to be initiated. Social workers, as integral members of multidisciplinary teams, are able to develop creative and effective responses to the challenges facing the health care delivery system. Understanding the extent ofservice usage and factors related to over-utilization can provide needed insight. As long ago as 1983, researchers were calling for empirical evidence to char- acterize the high users of health care services (e.g., services delivered, health conditions, level of need and resources and identily of providers) (McCall& Wail, 1983). Erective trealment strategies may result from the inforniation derived from this study.

REVIEW OF LITERATLXE

The wealth of hcalth carc utilization research highlights a number of factors related to patients’ usage of available services. Patient perception ofhadlth status has been identified as an important predictor urhcdlth care utilization (Yealts, Crow & Folls, 1992; Rivnyak, Wan, Stegall, Jacobs & Li, 1989: Freeborn et al., 1990). Freeborn and colleagues (1990) found that 57% of patients who were consistently high uscrs of mcdical scrviccs perceived themselves as being in poor or fair health. They defme consis- tent high use as four or more years (out ofsix examined) of being placed in the top one-third of the patient utilization rates studied. Cwk, Chadiha, Schmidt, Holloway and Sattcnrhitc (1992) furthcr rcport that paticnts with high social risk factors do have more chronic and life threatening illnesses.

Actual physical health status can certainly attect a patient’s use ofthe health care system. Consistently high users of health care have a greater number of chronic, medical conditions (Freeborn et al.. 1990). Cook and colleagues (1992) suggcst that paticnts with chronic and lifc thrcatcning illness are at high social risk and, thus, use social services at higher rates. Moreover, Cook and colleagues (1992, p. 109) found that four factors predict social service utilization: ( I ) advanced age (80 years or older); (2) multi- system illness; (3) psychiatric illness; and (4) being unmarried.

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18 SOCIAL WORK INHEALTH CARE

Not surprisingly, patients who are consistently high users of health care services also report higher levels of depression and verbalize more con- cems to providers about cmotional distress than do low users of services, although they seldom scek mcntal health care (frccbom ct al., 1990). Addi- tionally, this group also expcricnccs a higher proportion of discases that include a significant cmotional componcnt, cncompassing thosc conditions “emotionally produced or aggravated” (Freeborn et al., 1990, p. 534). This possible unwillingness to risk being labeled with a psychiatric diagnosis may lead the elderly patient to “medicalize” problems to gain “legiti- mate” entry into the health care system (McCoy, Kipp & Ahern, 1992). McCoy and colleagues furthcr report that GG% of adults who report to the emergency room with complaints of chcst pain are actually experiencing depression and panic and soniatization disorders.

Other factors relatc to scrvice usage. Living arrangements influence service use as reported by Spence and Atherton (1991). Elderly African- Americans who live alone are more likely to use community-based ser- vices (45.5%) lhan their peers who live with others (25%). Income may also be a factor-56% of respondents in Spence and Athrrlon’s (1991) study were receiving supplemental security income, while unly 27% of those receiving social secunty retirement repurled using services.

Having established lhal patienl characteristics do have an impact on health care and social service utilization rates and patterns, the literature further provides a basis for intervention to affect change. Research does suggest that the provision of non-medical supports to patients (mental health services, case management, etc.) may result in decreased misuse of health care services (Freeborn et al., 1990). Following the implementation of social work interventions with emergency room patients, 28% of pa- tients identified as inappropriately using the emergency room stopped this misuse for a potential saving of approximately $250,000 (McCoy et a]., 1992). Along with social work interventions, pliysiciaii involvement may have a positive cffect on patient experiences with the health care delivery system. Mullan and Stross’ (1990) exploration of resident physicians sug- gests that, provided with appropriate training, physicians can accurately conduct clinic-based assessments of patients’ psychosocial issues. Psycho- social concerns identified most often by patients include: responsibility for a significant othcr, somatic complaints, use of leisure time, depression, and religion (Mullan & Stross, 1990).

The findings regarding health care and related service utilization pre- sented in the literature suggest that service usage encompasses many com- plex issues. Identifying physical health and illness factors alone does not provide a complete and accurate profile of the patient who uses an ambula-

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Be,-g- weger '3 a/. 19

tory carc clinic for scrvicc. Thcrcforc, cxploring thc rclationship betwccn biopsychosocial factors and health care utilization can furthcr cnablc health care team members to maximize patient care and control costs

METHODOLOGY

Sasiple Selection

Patients requesting services h m the ambulatory care triage clinic of a Veterans Administration Medical Center (VAMC) in a large, mdwestern city comprised the sample of this study. Thc mcdical center has two sepa- rate facilities. The inner city medicallsurgical hospital houses the ambula- tory care triage clinic. The second facilily includes inpatient psychiatric and long term rehabilitation units located on a suburban, campus setting. At thc outpaticnt ambulatory carc triagc clinic, thc paticnt can rcccivc medical services without a scheduled appointment. Following the comple- tion of a medical assessment, the patient may be treated at the clinic, referred to another service, returned to hisher primary care physician or hospitalizcd.

Twenty ambulatory care triage clinic patients participated in an initial pilot study. This effort provided preliminary data on the population being served by the ambulatory care triage clinic. ' I l l h e swvey insrrument devel- oped for this pilot effort included items regarding patients' perceived needs, a measure of depression (Radlnff, 1977) and VAMC management inrormalim system data. Considering the pilot data, the research team was able to determine that the needs were more complex than inilially envi- sioned. Such evidence as a mcan dcprcssion scorc of 17.4 (range 0-57) suggested the presence of significant psychosocial problem. Second, the participants identified several complex needs: ( I ) being a burden (53.3%); ( 2 ) needing help with daily living (66.7%); (3) concerns regarding medica- tions (80.0%); and (4) concerns rcgarding physicians (73.3%). In fact, almost two-thirds (60.0%) of thc pilot rcspondcnts cxprcsscd zcro to thrcc concerns, whilc 40% idcntificd four or more conccms.

From a review of the pilot data, the authors concluded that unmet social needs were not the sole determinant ofunscheduled visits to the ambulato- ry care tnage clinic. Instead, patient perception of poor physical health was tltcir primary concern. Kcvisions to thc intcrvicw schcdulc includcd thc addition of a formal mcasurc of paticnt-pcrccivcd social nccds (Cook, Frccdman, Frccdman, Anck & Millcr, 1996) and providcr asscssmcnt regarding type of needs and necessity of visit.

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20 SOCIAL WORK IjV HEALTH CARE

AS paticnts rcquested unscheduled triage services, they werc identificd for possible participation in thc study. Potential participants wcrc random- ly identified from the daily triagc roster and assigned to one of two groupsnon-target or target. Selection into the target group required a t least two visits to the ambulatory care triage department within the six months bcfore the date of the interview. This measure constitutes frequcnt use (Freeborn et al., 1990). Paticnts assigncd to thc non-targct group had not reported for an unscheduled visit in thc past six months.

Patients voluntarily participated in personal interviews in the clinic area as they waited for their medical appointment. A graduate social wark practicum student completed all the interviews. Over a three month period, the interviewer approached two hundred and Seven patients waiting for an appointment in the ambulatory carc triage clinic for participation in the study. Seven persons refused to participate for unknown reasons. One hundred ninety-four interviews were completed From the sample of 200 patients who agccd to participate. Six patients called for thcir medical appointments during the waiting period were, therefore, unable to be com- plete the interview.

Measures

To gain insight into the biopsychosocial factors related to o patient’s unscheduled visit to the ambulatory care triage clinic, the interview fo- cused on three primary areas: medical, psychiatric and social. Along with patient demographic information, mcdical assessments provided data on chronic andlor urgent physical dysfunction (including self-perception of health, diagnoses and medications). The VAMC management information system provided infomation regarding patients’ current diagnoses, num- ber of scheduled and unscheduled visits (past twelve months), current number of medications and hospitalization history (past twelve months).

The CES-D Scale (Radloff, 1977) assessed patients’ psychiatric status, specifically depression. This 20-item, dichotomous scale de-emphasizes physical health issues, hypolhesized to be a predonunant aspect of the patient’s presentation in this situation. VAMC management information system data provided current psychiatric diagnoses.

Thc intcwicw addrcsscd cach psticnt’s social conccrns and nceds. The patient described hisher social support system. Additionally, the Social Needs Checklist (Cook et al., 1996) assessed the patient‘s social needs. This checklist measures the patient’s self-perceived severity in twelve areas, to include: health, family, fmancial, legal, activities of daily living, employment, transportation, leisure time and future concerns. Cook and collcagucs (1996) found that approximatcly 90% of rcspondcnts rcportcd

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Betg-Weger el 01. 21

having social needs and approximately two-thirds of that group experi- enced at least two or more social needs.

Whilc thc work of Mullan and Stross (1990) docs not provide a link between physician assessments and health care utilization, the implica- tions of the Mullan and Sl~oss research may suggest an area of further exploration. Specifically, identifying patienls’ needs with medical, psy- chiatric and social issues may enable social work practitioncrs to dcvclop morc cffective interventions. Scesny’s (1996) work informcd an analytical framework to furthcr cxplorc thc relationships between patient factors and unscheduled visits. Psychiatric, social and/or medical terms categorized patients’ needs. These variables have been operationalized for this study as: (1 ) psychiatric needspresence of a psychiatric diagnosis; (2) social needspatient self-report of at least one social need (utilizing the Social Needs Chccklist (Cook et al., 1996)); and (3) medicakecord documenta- tion stating patient requested services from the ambulatory care clinic for medical reasons (versus medication refill, psychiatric or other). Analyscs determined the patients’ needs most likely to predict unscheduled visits to the triage clinic.

FIXDINGS

Description nfsaiiiple

As notcd, this sample was exclusively a U.S. military veteran popula- tion. One hundred and eighty-nine completed surveys were used in the analyses. As previously notcd, the groups were categorized as non-target (n = X2) and Larget (n = 107). Table 1 descrihes the overall sample along with the characteristics of such interview grouping. Overall, the respon- dents wcre primarily middle-aged (mean age = 54.8 years), African-Amen- can (56.7%), unmarricd (56.7%) males (94.8%). The majority of respon- dents (57.3%) lived with family or a significant other; however, almost one-third (3 I .4%) lived alone. Respondents reported receiving help and support from a variety of sources, primarily spouse and family (68.6%). Despite the evidence to suggest this population receives social support, the rcspondents identified a moderately high level of social nccds. Using thc 12-itcm Social Needs Checklist (Cook ct al., 1996), thc avcragc number of social needs reported was 3.35 (sd = 2.4; range 0-12).

In general, the respondents rated themselves on the low to moderate range of the physical and emotional health scale. On a five-pain1 Likert scale ( 1 = excellent and 5 = poor), the veterans scored a mean physical

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22 SOCIAL WORK I N HEALTH CARE

TABLE 1. Sample Characteristics (n = 194)

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Berg- Wegw el a/. 23

health rating as 2.9 (sd = 1.2) and an emotional health rating as 2.7 (sd = 1 S) . Moreover, respondents reported a moderately high lev-el of potential deprcssion. Using 16 as a critcrion for idcntificarion of dcprcssion (Rad- loff, 1977), the mean depression score reported was 13.4 (sd = 11.4; range 0-54). Over three-fourths (78.8%) reported having experienced pain in the past meek before the Interview.

The VAMC computer database provided information regarding the re- spondents’ medical records and appointmcnt history. Spccifically. thc av- cragc numbcr of appointments for the respondents in the past twelve months was 18.6 (sd = 27.6; range 0-264 (Note: 264 denotes a participant in a substance abuse program)) with the mean number of appointments not kept being 2.3 (sd = 4.2; range 0-28). The average number of prescription medications per veteran was 5.3 (sd = 4.3; range 0-22). Thc avcragc numbcr of diagnosedpatient was 3.5 (sd = 2.2; range 1 - 1 5 ) . Finally, the mean of the dependent variable, number of unscheduled visits to the ambulatory care tnagc clinic was 10.8 (sd = 8.3; range 0-50).

Bivariate AnaIysis

The data were analyzed using Statistica 6.0. Following univariatc anal- ysis, the data were subjected to bivarjate analyses. Each variable included in the study was analyzed to determine the existence of a relationship to the dependent variable, unscheduled visils to the arnbulalory care lriagr clinic. ANOVAS were calculated for categorical variables, while correla- tions were calculatcd when the independent variable was continuous. If the variable was blvariately relatsd to unscheduled visits, it was retained for further analyses.

Additional bivariate analyses (t-tests) explored the relationship between the two groups. Significant diffcrcnccs bctwccn thc non-targct and targct groups wcrc found in thc arcas of ( I ) number of appointments (t = 2.46; p = 0.015); (2) number of missed appointments (1 = 2.63; p = 0.009); and (3) number of prescription medications (t = 3.75; p = 0.0002). In each of these areas, the target group consislently reported a higher number than thc non-target group.

Mrrltivariate Analyses

Following bivariate analyses, a multiple regression analysis was per- formed. Specifically, multiple regression was used to analyze the relation- ship between unscheduled clinic w i t s and patient perception of health, number of prescnption medications and Nurse Talk. Self-pcrception of

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24 SOCIAL WORK IN HEALTH CARE

physical health and number of prescription medications account for 15% of the variance in unscheduled visits (F (4, 184) = 8.38; p < 0.001). Both variables significantly relate to unscheduled visits: patient perception of physical health (I = 2.32; p = 0.02) and number of prescribed medications (1 = 3.4R; p < 0.001). The model suggests lhose patients who view them- selves as less physically healthy, while controlling for number of medica- tions prescribed to them, request treatment more frequently from the am- bulatory triage clinic. Furthemorr, palienls who have a higher number of prescription medications are more likely to have a greater number of unscheduled clinic visits, while halding the effects of physical health constant.

Subsequent multiple regression equations were performed, separating target and non-target groups. Analyses of the target and non-target groups yielded direrent findings. The resulls from multiple regression indicates a stronger model (F (3, 103) = 15.059; p < 0.001) and a higher co-efficient of determination of (R2 = 0.29) than the analysis of the overall sample. As in the initial analysis, the same two vanahles reached statistical signifi- cance: patienl perceplion o f physical heallh (1 = 2.53; p = 0.01) and number or prescribed medicalions (1 = 3.90; p < 0.001). Comparing the unslandardired betas, the strength of lhe relalionship improved with the target group. For patient perception of physical health, the unshndardized beta increased from 1.14 lo 1.44. Regarding the number or medications prescribed, the unstandardized beta increased 0.08 units. While not stalls- tically significant in the initial analysis, patients’ reported use of Nurse Talk (a telephone tnage service provided by the VAh4C) has a modest relationship with unscheduled visits among the target group (t = - 1.91; p = 0.06).

The same set of variables were tested using multiple regression with the non-target group. The overall model was not significant (F (3 ,78) = 0.62; p C 0.60). No statistically significance occurred for the non-target group. Table 2 presents findings from this portion of the analysis.

As noted previously, patient needs were assessed in three areas (social, medical and psychiatric). Univariately, these variables, presented in Table 3, suggest needs exist in all three areas for the majority of respondents. However, analysis identified social needs as the highest area of need for both groups followed by medical and psychiatric needs.

When combined into a multiple regression model with patient perccp- tion of physical health, number of prescription medications and Nurse Talk, social needs reached statistical significance. Presented in Table 4, this model was tcstcd with thc overall samplc and the target and non-target groups. The only difference noted was in the target group. The overall

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VARIARLE

Intercept p = 0.004

Physical Health p=OOt7 Beta= 0.169 Beta = 0.222

Bela = 0.296 Beta - 0.359 Bela= -0.166

Nurse Talk p = 0 0 5 9

TOTAL SAMPLE NON.TARGET TARGETGROUP

R2 = .15 (n = 82) RZ = .29 (n = 189) GROUP (n = 107)

p = 0.w1 ns p E 0.001

TABLE 3. Descriplion of Type 01 Need (n = 194)

Psychiatric Need

VARIABLE I" = 194) In = 84) I n = l l O l

Medical Need

109 I54 5%) 42 (50.0%) 67 (609%)

model explained 3V/. of the variance in unscheduled visits (F (3, 103) = 15.06; p i 0.OOl). Among those veterans who rcported to the ambulatory triage clinic on two or more occasions in the past six months, social nccds significantly related to unscheduled visits when coiltrolling for the other variablts in the model (t = 2.40; p = 0.02). Those reporting at least one social need (using rhe Social Needs Checklist (Cook et al., 1996)) were more likely to request services from thc ambulatory triage clinic in the form of an unscheduled visit. While perception of physical health and number of prescription medications rcmaincd signiticanlly related to un- scheduled visits, the relationship between Nurse Talk and unscheduled visits no longer existed in this modcl. Givcn the modest relationship ini- tially repoffed, this finding is not surprising.

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26 SOCIAL WORK In HEALTH CARE

TABLE 4. Multivariate Analysis-Model 2 (n = 189)

VARIABLE

TOTAL SAMPLE NON.TARGET TARGET GROUP (n = 189) GROUP (n = 107) R2.0.15 In = 82) RZ = .30 p c 0.001 ns p < 0.001

Intercept p = 0.004

Physical Heallh p=O.O17 Beta = 0 169 Beta=O.l73

Bela = 0 2% Beta = 0.394 p<o.oot

Beta = 0.201 Social Needs NIA p = 0.018

DISCUSSION

This exploratory study cxamined factors associated with frequent use by veterans of the ambulatory care services of a large, metropolitan Veter- ans Aduunistration Medical Center (VAMC). The findings suggested that this primarily middlc-aged male populatlon has multiple and complex health and social needs. Three factors related to moderately high levels of amhulalory care service usage by the respondents in the target groupself- perception of physical health, number of prescription medications and sclf-perceived social needs.

As notcd, this research highlights three factors related to the number of patients’ unschedulcd visits. Each factor warrants individual examination regarding the impact it has on the delivery ofhealth care services, panicu- larly social work services. First, the patient’s self-perception of physical health rclatcs to the pahent’s use of the ambulatory care triage services. Those respondents who visitcd thc triage clinic at least twice in the past six months and who also perccivcd thcmsclvcs to bc in poor health were more likely to make unscheduled visits. In other words, vetcrans who think they are unhealthy, regardless oftheir social needs or numbcr of mcdications, place a greater strain on the limited resources available. This finding suppons thc carlicr work of Freeborn and colleagues (1990) in which patient perception of hcalth rclatcd to higher use of health care services. As length of patient hospitalization stays continucs to decrease and pa- tients return home “quickcr-and-sickcr” (Kosccoff ct al., 1990), the de- mands for outpatient services will also continue to risc. Again, this trend

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may place unrealistic expectations on thc outpaticnt health care team to serve larger numbers of sicker (perccivcd and rcalistic) patients with fewer resources.

Besides the obvious indication that a physically ill patient requires medical care, does thc paticnt’s pcrception of illness suggest the presence of emotional invokcmcnt? This study noted a moderately high level or depression in the respondents that suggests exploration of a linkage between psychiatric and physical illness, Prwious research suggests a relationship between both psychiatric and medical illness and increased outpatient visits (Massad, West & Friedman, 1993; Durancc, Gibson, Davis-Sacks & Floman, 1992). Massad and colleagues (1993) further provide a connec- tion hehveen psychiatric hospitalization and iiicreased need for medical care.

Second, the moderatcly high number of medications prescribed to the patients in this sample related to the frcqucncy of clinic use. A related fuiding of this study was the ovcnvhelming numbcr of patient visits (12142.4%) reported by the nursing staff to be medically unnecessary. Nurses assessed 39 (35.5%) of the visits made by the target group as medically unnecessary, while 34 (40.5%) of the non-target @up visits were not medical necessities. The majority of these visits (63186.3% of those with reasons cikd) were primarily for prescription refill only and could have been managed over the lelephone.

For thc target group, the nurse report indicated that 33 of 39 patient visits (84.6% of those cases with a reason cited) were appropriate for telephone management. For the noo-target group, telephone management wds appropriate for 30 of 34 patient visits (88.2% of those cases with a reason cited). Thcse fmdiiigs, along with the previously reported relation- ship hehveen number of medicatiobs and unscheduled visib, raise ques- tions regarding monitoring of medications, patient education and com- pliance. Fearing that by the time hefshe is able Lo see the pnmary care physician the mcdicationr wdl be gone, might a patient request unsched- uled services?

Lastly, having at least one sccial need is significantly related to the number of unscheduled visits made to the VAMC by the veteran. This finding suggests that patients may request services from the VAMC for reasons other than requiring medical attention. As noted by McCoy and colleagues (1992), a patient may feel he/she has to report a physical symptom to “legitimately” use the VAMC services. Could early identifi- cation of the presence of perceived social needs enable practitioners to target interventions to address these concerns?

Of interest is the finding that Nurse Talk use did not rctain statistical

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significance in thc fmal analyses. A possible explanation For this finding may be that paticnts who are frequent users of the triage clinic and who also report having social needs would not take advantage oPan opportuni- ty for a telephone contact when they can go to the clinic for a personal visit.

A frequent user profile evolves when considering these three ractors together with the level of unscheduled visits to the ambulatory care clinic. Specifically, thesc data suggest that a patient who may he a candidate for frequent clinic usage is one who has a high numher or medications pre- scribed to hinlnier, perceives himilierself lo he in poor physical hrdlth, and reports having at least one social need.

Conceptualiziiig these k l o r s for a user profile may enable health care providcrs to develop criteria by which to assess ambulatory care clinic paticnts. Targeting this group of veterans who are frequent users of the clinic scrvices iiiay provide the hralth care team with mfumtion in devel- oping early andor more appropriate interventions. As access to needed resources within the VAMC systcms continucs to hccomc more restrictive and as patient needs increase (Kizer, 19961, health care providcrs and social workers in particular need strategies and techniques to identify and serve veteran needs more effectively and efficiently. The ability to idcntify a group of patients who may be potentlal "over-users" of an already over-burdened health care system certainly warrants further examination by those engaged in providing services, developing policy and conducting research.

The social work practice implications are considered for the three fac- tors related to thc frequency of ambulatory care triage clinic use, Gaining insight into the patient's self-perception of hisher physical health may aid in developing mure relevant social work interventions. Developing assess- ment criteria by incorporating the frequent user profile described above may allow social workers to identify individual high-risk areas (patient pcrception ofhealth, medication usage and social needs) which may bene- fit from a targeted intervention. Further, providing appropriate treatment carlier inay lead tu savings in overall health care cost.

From a policy and program development perspective, the implications of this research are threefold. First, it is feasible to consider that a social work case manager should conduct an assessment of each patient who meets the criteria for high utilization using the profile developed in this research. As this research indicates, this group of patients has multiplc medical and social needs and can benefit from a proactive assessment and intervention effort. Second, the social workcr may thcn serve as the prima- ry case manager. The social worker may function as the patient's point of

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contact with thc hcalth care systcm and a liaison for services within the health cam dclivcry system as wcll as with thc community. Casc managc- mcnt scrviccs arc suggested elsewhere as a stratcgy for addressing prob- lcms of frequent inpatient VAMC admission (Pankratz & Jackson, 1994). Lastly, incorporating an educational component into patient assessment and interventions regarding indication usage, reactions and prescription refills along with appropriate use of a telephone information and triage service may bc considered as well. In an effort to document the effective- ness of a proactive assessment, intervention and educational effort, patient use of out-patient services may be tracked.

Iuiplications of this study for research may first be considered for the identified limitations that relate primarily to areas of measurement. Specif- ically, a more objective measure of the patient’s physical health may provide increased sensilivily when interpreting any relationship between physical health and unscheduled visits. The inclusion of additional data regarding the patienr’s psychiahic and substance usdabuse history may also yield greater understanding of the relationship between psychiatric illness, substance use/abuse and health care utilization. A longitudmal study (as opposed to cross-sectional data collection) may provide insight into the long-term patterns of usage of this population.

Additional research implications relate to examining specific subsets of this population. For instance, investigating the potential relationships be- tween the depressed and non-depressed patient in regard to service utiliza- tion may yield data to aid in program development. Designing an inquiry into the actual cust expenditures associated with a social work case man- agement model versus specialty treatment may also he of Interest.

While no1 found to he significantly related to unschedulrd \*isits in this study, the issue of race may he an area of further study. Because African- Americans use unscheduled visils ralher than primary care more frequent- ly than their Caucasian counterparts, services are more etTective when targeted a1 h e health, functional and socioeconomic slatus of the group and the group’s expectations (Damn-Rodriguez, Wallace & Kington, 1994, p. 55). Additionally, minority elders use services less frequently than Caucasian elders ( U S . Commission on Civil Rights, 1982). As noted by Keith and Jones (1990, p. 84). studies of African-Americans’ use of VAMC services may include measures of “qualily as well a5 quantity.” Building on the suggestions of Damron-Rodriguez and colleagues (1994), further inquiry into veterans’ needs and expectations by demographic groupings may provide data to enhance accessibility and acceptability of services.

In sum, this rescarch cffon serves to idcntify scvcral factors to aid

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social work and other practitioners to better understand patients' ambula- tory care utilization patterns. This data may be used in planning social work interventions in a time of increasing resource constraints. As impor- tantly, however, this rescarch has raised a number of issues that may serve as thc basis for future investigation.

Original Manuscript Received: 12/03/96 Accepled/ar Publication: 02/06/97

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