Being Prepared Can Lead to Better Care
Special to The Hawai‘i Herald
You’ve probably heard this before: A person is more than a diagnosis or a disease, even though the disease may be the focus of the visit to the doctor. In these days of increasingly specialized medicine, sometimes the idea of the patient as a “whole person” can get lost in the effort to treat a specific health problem. Lab tests can detect the presence of high cholesterol, high blood glucose and abnormal liver function, among many other conditions, but they don’t provide the full picture of the person.
That’s why a psychosocial assessment is often used to capture much more of whom the person really is — certainly not a full life story, but a broader understanding of the patient or client. It is an important narrative that is usually completed by someone in the helping professions — like a social worker, a nurse or a therapist — through a sit-down interview with the patient. It’s an opportunity for the helping professional to get to know the person needing care — his or her past, present and future.
Sometimes the person being interviewed cannot answer some, or any, of the questions due to memory problems or severe illness. That’s when caregivers can be helpful in filling in the gaps. The psychosocial assessment attempts to learn about the essential aspects of a person’s life history and current status. Anyone who works with the patient can glean important information and insights from this assessment, which can help in many different ways to plan for future care and assistance. For example, if an individual does not have any family members or friends who can help him or her after being discharged from the hospital, that information will affect the patient’s “discharge plan,” the recommended care plan after being discharged from the hospital.
There isn’t any one standard way of doing a psychosocial assessment. If you look at different examples of psychosocial assessments, they are not always the same length, nor do they necessarily address the exact same issues. The questions asked may be dictated by the organization collecting the information, such as a hospital, doctor’s office or a social service agency. Additionally, interviewers such as a social worker or a nurse may have their own particular style of interviewing. Some may conduct the assessment in a quick and somewhat formal manner. Others may take more time, gathering lots of details, asking follow-up questions, and having more of a conversation or a “talk story” than a formal interview. One approach is not necessarily better than the other. A lot of the differences between assessments can be explained by the interviewer’s personal style and training, as well as the institutional practices of the organization that employs the interviewer.
People with a history of medical problems, especially when they involve stays in the hospital, may already be familiar with the psychosocial assessment. In fact, they may have been interviewed multiple times. For others, the process may be new and might even seem invasive. Personal questions are often asked. This article will reveal some typical questions asked during an assessment. The more information a patient can provide to the interviewer during a psychosocial assessment, the more effective the overall health care plan will be. So, having the answers prepared ahead of time can make the interview go more smoothly and the information collected more accurate.
If a patient or client cannot provide the answers needed for the assessment, the primary caregiver is often asked to assist, which is helpful for patients who have dementia or other conditions that impair memory and communication.
As noted earlier, the assessment is often done during a hospital stay, although it might also be done in a long-term care facility or even during a home visit for social services. The assessment aids everyone on the patient’s care team in learning about the patient’s life and how to plan for future care.
A note on terminology: Many social workers and other helping professionals prefer to use the word “client” when working with someone outside of a hospital setting. The word “patient” is more commonly used in a hospital setting or a doctor’s office. In a nursing home or long-term care facility, the word “resident” is typically used. In this article, “patient” will be used for brevity’s sake.
Typical Parts of a Psychosocial Assessment
Let’s use a hypothetical hospital patient by the name of “Mrs. Sato.” (Her first name would also be listed in the assessment, but it is intentionally not included here to avoid giving the impression that Mrs. Sato is an actual person.)
The interviewer — let’s say a hospital social worker — would want to mention in the assessment why Mrs. Sato is in the hospital. This is referred to as a “presenting problem.” Mrs. Sato may have other ailments and conditions, but the intent is to find out the current problems that brought Mrs. Sato into the hospital, along with some basic identifying information, such as, “Mrs. (first name) Sato is an 85-year-old Japanese American woman who was admitted to this hospital on (date) after falling at home and complaining of severe pain in her left hip. After a physical exam and diagnostic imaging, ER physician concluded that Mrs. Sato had sustained a fracture in her left hip and was recommended for hospital admission and referral to orthopedic care.”
As mentioned earlier, there are different ways the interviewer might write up the assessment, but, in general, you want to capture something about Mrs. Sato beyond medical information, which is already in a patient’s medical chart. As such, the psychosocial assessment typically does not need to get into considerable detail about a person’s physical problems.
However, if the physical problems result in psychological and social issues, they should be mentioned. For example, if Mrs. Sato is diabetic and also has dementia, that combination of diseases will require family support, if she lives at home, to ensure that her nutritional and self-care needs are met. Also, health problems often result in severe stress and even depression, not only for the person suffering from the health problems but for family members and friends, as well. The emotional impact of a person’s physical disease or injury can be included in a psychosocial assessment, as well as the emotional and physical burden experienced by caregivers.
The assessment will involve finding out about personal status (single, married, divorced, widowed, etc.), living arrangement (who the patient lives with, if not alone), other significant relationships and whether there is a social support system in place. There may be questions that come across as being personally invasive, such as drug history and current use, substance abuse and treatment history, tobacco use, legal history (e.g., criminal background) and sexual abuse. Honest answers to these questions can help the care team put together a more effective treatment plan. The psychosocial assessment is not meant to be like a prison interrogation, however. If a person feels uncomfortable answering a personal question, she or he can say, “I don’t want to answer that question right now.” Other questions may relate to education, employment, roles and responsibilities, social and recreational activities, as well as religious and spiritual involvement.
The interviewer will likely ask about family relationships and whether there are people in the patient’s life who can assist with care after leaving the hospital. If the interview is to determine the need for social services, the interviewer will be particularly interested in whether a patient is able to perform what are called “activities of daily living” — ADLs, or “instrumental activities of daily living,” or IADLs. ADLs are bathing, dressing, eating, transferring (able to walk or move from bed to wheelchair, for example), continence (able to control bowels and bladder) and toileting (able to use the toilet). IADLs include using the telephone, managing medications, preparing meals, maintaining the house, shopping, managing finances and using transportation (e.g., driving or using buses or taxis to get to appointments, etc.).
It is important to accurately report what ADLs and IADLs a patient or client can do because it may affect the level of social services available to that individual. A caregiver may need to be consulted to verify responses from the patient.
The interviewer will also want to get a sense of the patient’s readiness for treatment. What concerns do the patient and loved ones have about treatment? What are their preferences?
Through this questioning process, the interviewer should be able to get a sense of the patient’s strengths and limitations. An example of a strength could be a strong family support system and a motivation to participate in self-care recommendations. Examples of limitations are a lack of family support and a poor memory. The interviewer will try to determine what capacities and resources the patient has for self-care and work with the health care team to develop an effective treatment plan.
A mental status exam of some kind may be part of a psychosocial assessment, too. This would usually involve a short test to evaluate a patient’s memory and thinking abilities. If the results signal a problem, additional tests may be needed. The end of a psychosocial assessment usually consists of a list of goals and a plan for helping the patient to get well, seek additional services, or cope with current circumstances to the best of his or her abilities. In our hypothetical case above, after her psychosocial assessment is done, Mrs. Sato’s care team would be in a much better situation to recommend treatment and care after discharge.
Preparing for a Psychosocial Assessment
Just as it is advisable that you prepare yourself with information before going to a new doctor, it is likewise advisable that you prepare for a psychosocial assessment. Details are important. For example, a caregiver might say, “Mom hasn’t been able to feed herself for a long time.” That is useful information, but it could be more specific. This is more helpful for assessment purposes: “Mom hasn’t been able to feed herself for about two years, but if I hand-feed her soft food in small amounts, about half a tablespoon, she can chew on her own and swallow.”
Having information ready is a good policy, even though you don’t know exactly what you will be asked. In a hospital, the interviewer may ask more medical-related questions than someone who is interviewing you for social services.
What kind of information should you have on hand, in addition to what was mentioned previously? Here is a partial list:
- The names, addresses, and phone numbers of current and previous physicians, and for what they are or were being seen.
- An updated list of all medications, including dosages, prescribing physician and the reason for the medications.
- Any allergies (food, medications, etc.).
- Marital status (single, married, divorced, widowed, other).
- What kind of exercise, if any, do you do?
- Are you on a special diet — and, if so, what kind of diet?
- Any diseases that seem to run in your family?
- When did you last see your current physician(s)?
- Any hospitalizations in the past? If yes, when and for what purpose?
- Others: What in your life is causing you stress? What positive things are going on in your life? Do you socialize? Who helps you when you need help? What social services are you currently receiving? What kind of help do you need that you are not currently receiving?
A person can write his or her own life story as part of the preparation for a psychosocial assessment. Or, primary caregivers can do their best to write one up, just as a way of having this information close at hand when it is needed. It can begin: “I was born on Jan. 24, 1948, in Wailuku on the island of Maui. My father died in 1988 at age 70 of lung cancer, and my mother . . .” In the end, you will have a personal narrative — most likely at least several pages long — that captures much more of your life story than a current description of your diagnosis or disease.
Occasionally, a family member will tell a health care provider, “I wish you knew Mom before she got sick. She had such an interesting life when she was younger.” The psychosocial assessment can give the fuller picture.
Believe it or not, health care providers often enjoy reading them because they, too, may be curious about what someone like Mrs. Sato was like before her current health care problems. And, preparing for a psychosocial assessment can be an interesting experience for both patients and their loved ones as they try to reconstruct their life’s journey — good, bad and indifferent. When these individual pieces of a person’s life are joined together, they often have a meaning and significance that were not evident beforehand, which is why reminiscence (remembering and talking about one’s life history) is actually a form of psychotherapy, too. The memories need not be all good — even memories about difficult circumstances in one’s past can be therapeutic, because a person can look back on his or her life and conclude: “Wow. I really overcame a lot in my life. I’m a survivor!” But we’ll discuss reminiscence therapy in another article.
Kevin Kawamoto is a longtime contributor to The Hawai‘i Herald.