Managing Caregiver Stress through Psychosocial Enhancement in Discharge Planning Lim Lutin1, Eunice Chin1, Prabha TM1, J Selvi1, Daryl Ng1, Linda Marican1 1 Medical Social Services Department BACKGROUND Family caregivers are instrumental in caring and enabling their loved ones to cope and age in place in the community. However, they often experience caregiving stress that impact their well-being, family relationships, hospital readmissions and length of stay. Using the validated Modified Caregiver Strain Index (M-CSI), BVH’s Medical Social Services (MSS) surveyed 20 family caregivers of inpatients undergoing rehabilitation. Results showed that 19 of them (95%) reported high stress (score ≥ 8). This indicates a strong need to provide caregiver support at the hospital level. PDCA 2: Counselling caregivers to better cope with stress With the awareness of the pain points identified through the M-CSI tool, the social worker is better able to incorporate counselling as an approach to address the psychosocial needs of caregivers. During the counselling session, the social worker helps the caregiver develop awareness, discuss possible management options and empower him or her towards change. The workflows of discharge planning pre and post project are summarized in Figure 3. OLD WORKFLOW NEW WORKFLOW PDSA 1: Tool: M-CSI (1) Assessment (1) Assessment PROJECT AIM At least 50% of BVH caregivers will achieve a sense of self-efficacy about planning for patients’ discharge and long term care. Psychosocial Assessment Psychosocial Assessment Genogram Genogram Administer M-CSI Tool ANALYSIS The team used the cause & effect tool and identified 29 causes of caregiver stress as shown in the Ishikawa diagram in Figure 1. After conducting multivoting and Pareto analysis, the causes of caregiver stress were narrowed down to two main ones below: 1. Don’t know where / how to get help 2. An emotionally lonely journey (2) Coordination (2) Coordination Care Planning Care Planning Multi-Disciplinary Multi-Disciplinary Meeting Meeting Case Discussion / HUMAN FAMILY SYSTEM Filial piety = caregiving SOCIOCULTURAL BELIEFS Institutional care is unacceptable Members with own Poor Loosely commitments knit family relationship Consultation Consultation Family Conference LACK FAMILY SUPPORT Family Conference Poor communication Family conflicts Emotionally Heavy care Other family lonely Poor healthdemands commitments Nuclear/ Poor communication single child family patterns Members living apart / overseas Poor relationship with patient Sandwiched generation Lifestyle change Unmanaged expectations of patients No/inaccessible Non-disabled amenities and friendly steps/kerbs, transport facilities no lift Insufficient Other financial Burden of long government funding obligations term bills FINANCIAL STRAIN (3) Linkages Why are Caregivers Stressed UNCONDUCIVE SURROUNDING Develop awareness Discuss options Empower caregiver towards change Linkage to community resources / services Unfriendly structural design Space constraint, & layout: steps, kerbs, many occupants narrow toilet Don’t know No proper training where to get or education help provided UNCONDUCIVE HOME SETTING (4) Linkages Cluttered – many bulky furniture & fittings Demand > Supply LACK/INACCESSIBLE COMMUNITY SUPPORT SERVICES RESOURCES PDSA 2: New Counselling (3) Caregiver Counselling CAREGIVER CAN’T COPE UNSTABLE FAMILY STRUCTURE LACK CAREGIVING KNOWLEDGE & SKILLS Case Discussion / Linkage to community resources / services ENVIRONMENT Figure 3: Enhanced Discharge Planning Workflow Figure 1: Causes of Caregiver Stress SOLUTION Discharge planning is primarily undertaken by Medical Social Workers in BVH who typically perform tasks such as assessment, coordination and linkages. Counselling to address the psychosocial needs of caregivers enhances discharge planning as a therapeutic intervention. Therefore, Enhanced Discharge Planning becomes an intervention technique to support patients’ transition to home with the provision of counselling to caregivers. PROJECT’S IMPACT A post-intervention survey was conducted on 20 caregivers to assess their own perceived levels of self-efficacy. The results showed that 90% of the respondents were happy with the counselling interventions and between 70% to 80% feeling less stressed and know how to cope with caregiving better (Figure 4). 100 90 80 Discharge Planning Enhanced Discharge Planning Percentage 70 60 50 40 30 20 10 Counselling 0 Satisfied with service Figure 2: Enhanced Discharge Planning PDCA 1 : Implementation of M-CSI tool The team trialed the use of the Modified Caregiver Strain Index (M-CSI) tool to identify the key psychosocial issues that the caregivers are currently facing. This is done during the assessment stage whereby the social worker will perform a psychosocial assessment and mapping of the patient’s genogram. The key issues identified through the M-CSI tool were: 1. Feeling completely overwhelmed 2. Caregiving is confining Upon identifying these psychosocial issues, the social worker can better address them through the provision of counselling. Know where to get more information Feel less stressed Able to cope better More confident and hopeful Figure 4: Survey of caregivers post-intervention (n=20) SUSTAINABILITY & SPREAD BVH’s psychosocial enhancement to performing discharge planning is a helpful therapeutic intervention for caregivers who experience caregiver stress in coping with the care of their loved ones. This project has raised awareness of caregiver stress and its causes. Psychosocial concerns of caregivers can be identified and attended to during discharge planning. M-CSI is easy to administer by healthcare staff and helps alert staff to caregivers in need. The project can be extended to working with caregivers in Palliative Care and Chronic Sick Units at BVH and other hospitals.
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