Social work biopsychosocial assessment example

Biopsychosocial Assessment

Throughout the MSW curriculum, you have learned how to conduct biopsychosocial assessments. In this Week’s Assignment, you apply what you learned to a medical context where you share assessment and intervention with an interdisciplinary team. As the medical social worker charged with a client’s care, you consider the nature and progression of their illness and integrate the macro and micro issues that influence their experience. You also monitor the nature and progression of their illness or disability to ensure they have the supports and resources needed. By examining medical social work roles, responsibilities, scope of practice and practice skills, and ethics, you understand how the medical social work profession contributes to the health care system and patient care.

To Prepare: Choose one of the following biopsychosocial assessment tools to analyze for this assignment (Pick one of the three tools attached). Select the tool you might be most likely to use in your preferred healthcare work setting. (FYI: the case study is just any example of a case, but the assessment tool is being measured in the assignment).

Home Care Example: http://www.matrixhomecare.com/Forms/Medical%20Social%20Work%20Assessment.pdf

Nursing Home Example: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Archive-Draft-of-the-MDS-30-Nursing-Home-Comprehensive-NC-Version-1140.pdf

Hospice Example: https://www.nhpco.org/sites/default/files/public/nchpp/SWAT_Information_Booklet.pdf

In a 3-4 page paper:

· Assess the overall tool you selected to analyze for this assignment. In your assessment, explain whether you believe there are questions that were not addressed and why you think that may be important.

· Explain whether or not the assessment is strengths-based.

· Identify other professionals in healthcare who may have input into the assessment.

· Identify any sections of the assessment tool that are best completed by other healthcare professionals and explain why.

· Consider the implications of various professionals disagreeing over the assessment content and discuss how would you mitigate those challenges.

· Explain how psychosocial issues (including policy and legal issues) might impact the patient’s medical care and/or health outcomes and the role of the social worker in assessing and addressing those issues on an interdisciplinary healthcare team.

Support your Assignment with specific references to resources, using appropriate APA format and style. You are asked to provide a reference list for all resources, including those in the resources for this course.

Name of Responsible Person: Relationship: Phone: PT/CL Name: Date:

Address:

Person to Contact in Emergency: Relationship: Phone: City, State, Zip:

Phone: D.O.B Sex M F

Prior Medical Social Work Service Referral Source/Date

Frequency/Duration of Visit

Rehabilitation Potential Physician Phone

Diagnosis Date of Onset AGENCY/SNF: Dates of Stay:

Primary

Secondary AGENCY/SNF: Dates of Stay:

SPECIFIC INFORMATION DESIRED ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

I. PERSONAL, PSYCHOSOCIAL AND FAMILY FUNCTIONING AND FINANCIAL INFORMATION: A. HOUSEHOLD MEMBERS SIGNIFICANT OTHERS COMMENTS (names and relationships) (names and relationships) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ B. BEHAVIOR INDICATORS/PSYCHOSOCIAL FUNCTIONING. Key PT = Patient PCP = Primary Care Person

GOOD FAIR POOR COMMENTS PT PCP PT PCP PT PCP

Functional Ability

Memory

Comprehension

Judgement/Decision Making

Communciation Ability

Knowledge of Health Problems

Motivation to Resolve Needs

Compliance with Treatment

Ability to Accept Help

C. Significant psycho/social/emotional factors/needs for counseling: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Refer to Case Manager: _____________________ Psych Nurse: ____________________ MHMR:____________________ Other:__________________

Client/Designee: I certify that the Matrix Home Cae Employee listed on this time slip worked the times indicated and the owrk was performed in a satisfavory manner. I agree to the times regarding this time slip.

Employee Signature: _________________________________

Patient/Client Signature: ______________________________

PT/CL NAME: _____________________________________

ADDRESS: _______________________________________

CITY, STATE, ZIP: __________________________________

VISIT DATE: ____________________________________________

TIME IN:__________________ TIME OUT: ______________

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MATRIX HOME CARE MEDICAL SOCIAL WORK ASSESSMENT

MATRIX HOME CARE MEDICAL SOCIAL WORK ASSESSMENT Patient/Client Name: _______________________________________________ Date: _____________________________

II. ASSESMENT SUMMARY:

III. LONG-TERM CARE PLANNING: ______ Access community resourse utiliztion on ongoing basis ______ Provide information, referral consultation & collateral contacts as needed ______ Counsel/teach re: appropriate community resourse utilization ______ Instruct pt/family to call Care Team if assistance needed after discharge

IV. Problem Areas/Reasons: Indentify factors which are impeding patients ability to achieve maximal health potential/compliance with treatment plan.

HOUSING: Adequate YES NO Due to: Crowing Santitation Structural deficiency Neighborhood Dysfunctional utilities

Other: _____________________

EQUIPMENT/SUPPLIES/INFORMATION: Adequate YES NO Due to: Knowledge deficit Income deficit

Other: _____________________

INCOME: Adequate YES NO Due to: No income resource Disproportionate living or medical expenses Poor financial planning/ decision making

Other: _____________________

SAFETY: Adequate YES NO Due to: Lack of supervision Abuse/neglect Poor judgement Environment Alcohol/substance abuse Prome to falls or medical emergencies

Other: _____________________

TRANSPORATION: Adequate YES NO Due to: Unable to drive Unable to ride in car Driver no available Can’t afford Inaccessibility

Other: _____________________

PERSONAL CARE/HOUSEKEEPING: Adequate YES NO Due to: Lives alone Elderly/ill PCP Extreme dependency of pt. Employed PCP Refuses to accept help Cannot afford to hire

Other: _____________________

FOOD MEALS: Adequate YES NO Due to: Pt/PCP unable to prepare meals Inadequate income Inability to shop for groceries

Other: _____________________

OTHER: __________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________

Comments: ________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature: ________________________________________________________ Date: ___________________________

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