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Social implications of readmissions of veteran patients to Shaughnessy Hospital, D.V.A Clohosey, Mary Edward Annie 1954

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SOCIAL IMPLICATIONS OF READMISSIONS OF VETERAN PATIENTS TO SHAUGHNESSY HOSPITAL. D. V. A  by MARY EDWARD ANNIE BRADLEY ELIZABETH CLOHOSEY  T h e s i s Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree o f MASTER OF SOCIAL WORK i n the S c h o o l o f S o c i a l Work  A c c e p t e d as conforming to the s t a n d a r d r e q u i r e d f o r the degree of Master o f S o c i a l Work  School o f S o c i a l Work  1954 The U n i v e r s i t y o f B r i t i s h  Columbia  iv ABSTRACT E s s e n t i a l l y , the s u b j e c t of t h i s t h e s i s i s the problem of m u l t i p l e h o s p i t a l admissions, and the p o s s i b l e p s y c h o s o c i a l e t i o l o g y of these admissions. Chronic r e a d m i s s i o n s to h o s p i t a l are of concern to s o c i a l workers, to h o s p i t a l p e r s o n n e l , and to the w i d e r community, i n view of the numerous and v a r i e d concommitant problems which may i n v o l v e not o n l y the p a t i e n t , but any number o f o t h e r persons o r p r o j e c t s i n the community. A survey of the s e v e r a l hundred r e f e r r a l s made to the M e d i c a l S o c i a l S e r v i c e Department a t Shaughnessy Hospi t a l , Vancouver, d a r i n g the f i s c a l y e a r s t u d i e d (1952-53) p o i n t s up the f a c t t h a t more than h a l f of t h i s r e f e r r a l group c o n s t i t u t e s p a t i e n t readmissions, and that a t l e a s t one-quarter o f the readmitted group might be c o n s i d e r e d as h a v i n g a c h r o n i c readmission p a t t e r n . The manner i n which t h i s p r e s e n t study i s approached i s through d e t a i l e d - e x a m i n a t i o n o f data on d i s t r i c t o f f i c e f i l e s and medical s o c i a l s e r v i c e case r e c o r d s , r e l a t i v e to a group o f f i f t y - o n e v e t e r a n p a t i e n t s w i t h a c h r o n i c r e a d m i s s i o n p a t t e r n , r e f e r r e d to the M e d i c a l S o c i a l S e r v i c e Department a t Shaughnessy, f o r v a r i e d m e d i c a l - s o c i a l problems. F i n d i n g s o f t h i s study i n d i c a t e t h a t p s y c h o s o c i a l f a c t o r s , a t l e a s t among the group s e l e c t e d , weigh h e a v i l y i n a p a t t e r n of c h r o n i c h o s p i t a l readmissions. Judging from the r e t a r d e d r e f e r r a l s , there does not seem to be a s u f f i c i e n t awareness, on the p a r t of a number of h o s p i t a l p e r s o n n e l , t h a t the admission p a t t e r n o f many v e t e r a n s c o n t a i n s a s u b s t a n t i a l p s y c h o s o c i a l element, and/or i f such i s r e a l i z e d , t h a t medical s o c i a l s e r v i c e s might be b e n e f i c i a l i n r e h a b i l i t a t i n g the p a t i e n t s concerned. The onus f o r remedyi n g t h i s s i t u a t i o n l i e s not o n l y w i t h the s t a f f of the Medic a l S o c i a l S e r v i c e Department a t Shaughnessy, but w i t h adm i n i s t r a t i o n , w i t h the medical s t a f f , and w i t h a l l DVA p e r s o n n e l i n t e r e s t e d i n h e l p i n g the v e t e r a n to f u n c t i o n adequately o u t s i d e the h o s p i t a l s e t t i n g .  V  ACKNOWLEDGEMENTS I am p l e a s e d to extend my s i n c e r e a p p r e c i a t i o n to a l l those who have g i v e n o f t h e i r time and e f f o r t i n a s s i s t i n g t h i s study. E s p e c i a l l y , I wish to thank Dr. K.S. R i t c h i e , A s s i s tant S u p e r i n t e n d e n t , Shaughnessy H o s p i t a l ; my f i e l d a d v i s o r , M i s s C e c i l Hay-Shaw, Head o f the M e d i c a l S o c i a l S e r v i c e Department; and each member o f the M e d i c a l S o c i a l S e r v i c e Department at Shaughnessy, f o r t h e i r i n t e r e s t i n , and s u g g e s t i o n s towards h e l p i n g me to develop t h i s t h e s i s on the s o c i a l problems of readmitted p a t i e n t s . I wish to thank a l s o , Dr. Leonard C. Marsh, Mr. Wm. G. Dixon, and Mrs. Joan Grant o f the School o f S o c i a l Work, U n i v e r s i t y o f B r i t i s h Columbia, and Mrs. Mary Tadych, my content a d v i s o r , f o r t h e i r c o n s i d e r a t i o n and d i r e c t i o n throughout the v a r i o u s phases o f t h i s study.  ii  TABLE OP CONTENTS Chapter 1.  Treatment F a c i l i t i e s f o r the Veteran  Veterans l e g i s l a t i o n . Treatment r i g h t s and t r e a t ment f a c i l i t i e s . H i s t o r y o f Shaughnessy H o s p i t a l . Reh a b i l i t a t i v e p r o v i s i o n s . Development o f medical s o c i a l s e r v i c e . E s t a b l i s h m e n t o f M e d i c a l S o c i a l S e r v i c e Department. Welfare O f f i c e r s . Purpose and method o f study.......  Page  1  Chapter 2.  The R e l a t i o n s h i p o f P s y c h o s o c i a l to P a t i e n t Admissions  Problems  Incidence o f readmissions r e f l e c t e d i n MSSD r e f e r r a l s . Unique c h a r a c t e r i s t i c s o f DVA p a t i e n t s . M e d i c a l s o c i a l s e r vice referrals: source, and i n c i d e n c e i n r e l a t i o n to medic a l diagnosis., F e a t u r e s o f the " s p e c i a l group" o f r e a d m i t t e d p a t i e n t s . Admissions i n r e l a t i o n to e m p l o y a b i l i t y and dependents. P s y c h o s o c i a l problems o f the MSSD c l i e n t ele. Major.and secondary problem-picture o f the " s p e c i a l group." Ma^pr problems i n r e l a t i o n t o e m p l o y a b i l i t y . I n f l u e n c e o f p s y c h o s o c i a l problems on h o s p i t a l admissions. Case i l l u s t r a t i o n s . . Chapter 3.  20.  The Role o f the H e d i c a l S o c i a l Worker, and the S e r v i c e s Rendered  Dynamics o f i l l n e s s . Treatment team. Role o f the s o c i a l worker as a - member, of the team — s p e c i a l r e s p o n s i bilities. M e d i c a l s o c i a l s e r v i c e s rendered. Illustrations Chapter 4.  1.  43.  Recommendations f o r Improved P a t i e n t - S e r v i c e  R e c a p i t u l a t i o n . S o c i a l s i g n i f i c a n c e and s o c i a l consequences o f repeated h o s p i t a l admissions. Implications and recommendations f o r improved medical s o c i a l s e r v i c e s . Conclusion.  64.  Appendices: A. DVA H o s p i t a l s and I n s t i t u t i o n s B. DVA Treatment C a t e g o r i e s 1 C. (1) Case A n a l y s i s Form C. (2) Legend f o r Case A n a l y s i s Form D. P r i n c i p l e s o f S o c i a l Case Work B. Bibliography  80. 81. 82. 83. 85. 86.  iii  TABLES, CHARTS. AND PICTURES IN THE TEXT (a) Tables  Page  Table A.  Patient readmissions related to MSSD r e f e r r a l s . . . 21.  Table B.  Comparison of MSSD c l i e n t e l e , with and without p r i o r hospital admissions, by medical diagnosis.. 27.  Table C. Source of MSSD r e f e r r a l s  29.  Table D. Major and secondary psychosocial problems among MSSD r e f e r r a l s Table E. Relationship between major problems and employability  37.  Table P.  52.  D i s t r i b u t i o n of medical s o c i a l services  38.  (b) Charts and Photographs Figure l . ( a ) Main Entrance, Shaughnessy Hospital  7a.  Figure l . ( b ) A e r i a l view, main hospital area, Shaughnessy Hospital  7a.  Figure 2.  Position of MSSD i n DVA Organization  14a.  vi  SOCIAL IMPLICATIONS OF READMISSIONS OF VETERAN PATIENTS TO SHAUGHNESSY HOSPITAL, D. V. A.  vii  INTRODUCTION The  M e d i c a l S o c i a l S e r v i c e Department a t Shaughnessy  H o s p i t a l , Vancouver, has f o r the p a s t y e a r been p u r s u i n g  topics  of s o c i a l s i g n i f i c a n c e i n an e f f o r t t o g a i n a b e t t e r understanding of c e r t a i n influences  such as a v a i l a b l e  treatment,  p e n s i o n s , community r e s o u r c e s , e t c e t e r a , on the r e h a b i l i t a t i o n o f v e t e r a n s and o t h e r persons r e f e r r e d t o the M e d i c a l S o c i a l Service  Department.  These t o p i c s were u s u a l l y c o n s i d e r e d i n a  s e r i e s o f weekly i l l u s t r a t i v e  case c o n f e r e n c e s .  In October, 1953, when the present study was undertaken, one  o f the proposed t o p i c s f o r c o n s i d e r a t i o n  by medical s o c i a l  s e r v i c e was the s o c i a l i m p l i c a t i o n s and s o c i a l consequences o f multiple  p a t i e n t admissions to Shaughnessy H o s p i t a l .  was t h e r e f o r e  picked  This  topic  up and developed i n t o the p r e s e n t t h e s i s ,  e n t i t l e d : "Social, Implications  o f Readmissions o f Veteran P a t -  i e n t s to Shaughnessy H o s p i t a l , D.V.A.," completed i n June, 1954. The  study, to f a c i l i t a t e a n a l y s i s , i s based on s o c i a l  f a c t o r s r e l a t i v e to the numerous h o s p i t a l admissions o f a s e l e c t e d group o f 51 v e t e r a n p a t i e n t s r e f e r r e d to the M e d i c a l S o c i a l S e r v i c e Department a t Shaughnessy H o s p i t a l most r e c e n t 1953.  during the  complete f i s c a l y e a r (1952-53) p r i o r to October,  CHAPTER 1 TREATMENT FACILITIES FOR THE VETERAN Veterans' L e g i s l a t i o n Veterans  1  have been o f f i c i a l l y recognized as unique  c i t i z e n s with unique problems, thereby requiring s p e c i a l l e g i s lation.  P r i o r to World War I , however, payment of pensions  f o r d i s a b i l i t i e s d i r e c t i y attributable to active service was the  only form of r e s p o n s i b i l i t y assumed by the Canadian Gov-  ernment on behalf of veterans. In 1915, a M i l i t a r y Hospitals Commission was formed to provide hospital accommodation and convalescent homes i n Canada f o r i n v a l i d e d o f f i c e r s and men of the Canadian Expeditionary Forces, and to a s s i s t them i n securing employment.  In 1916, a Board of Pension Commissioners  was established to handle pensioning of disabled veterans. The Department of S o l d i e r s  1  C i v i l Re-establishment  was created, February, 1918, to administer the a f f a i r s of the two e x i s t i n g commissions ( M i l i t a r y Hospitals Commission and Pension Commission). 1  Services undertaken by the Department of  A veteran, as defined i n the Statutes of Canada, 1945, i s : ( l ) a person who has been on active service i n the Canadian forces or i n receipt of active service rates of pay from such forces during the war ... w  (11) A person domiciled i n Canada who served i n the forces of (His) Majesty other than the Canadian forces and was so domiciled at the time he joined any such forces f o r the purpose of war, and who has been discharged from such services."  2 S o l d i e r s C i v i l Re-establishment  were c a t e g o r i z e d as m e d i c a l ;  p e r s o n a l ; o r t h o p a e d i c and s u r g i c a l a p p l i a n c e s ; v o c a t i o n a l ; and i n f o r m a t i o n and s e r v i c e . The Department o f Pensions and N a t i o n a l H e a l t h r e p l a c e d the Department o f S o l d i e r s ' C i v i l Re-establishment i n 1928.  As i t became e v i d e n t t h a t e x i s t i n g l e g i s l a t i o n d i d not  p r o v i d e adequate coverage f o r the v e t e r a n s became more apparent  as the time passed,  s i o n s were c r e a t e d , and a c t s were passed,  1  d i s a b i l i t i e s , which  bureaus and commist o meet s p e c i f i c  needs o f v e t e r a n s i n t h e i r e f f o r t s towards r e - e s t a b l i s h m e n t . L e g i s l a t i o n w i t h the broadest s i g n i f i c a n c e was the passage of the War V e t e r a n s ' Allowance A c t , 1930, t o p r o v i d e a minimum of support f o r veterans i n c a p a c i t a t e d due t o p h y s i c a l c o n d i t i o n o r age (War V e t e r a n s ' Allowance r e c i p i e n t s are e n t i t l e d t o f r e e treatment  i n DVA  1  h o s p i t a l s , r e g a r d l e s s of the nature  or cause o f t h e i r i l l n e s s ) ; the c r e a t i o n o f the V e t e r a n s ' Bureau i n the same y e a r f o r the purpose of a d v i s i n g veterans as t o t h e i r p e n s i o n r i g h t s ; and t h e establishment o f the Veterans A s s i s t a n c e Commission, 1936, t o i n v e s t i g a t e the extent o f u n e m p l o y a b i l i t y among employable v e t e r a n s .  T h i s Commission  r e a c t i v a t e d a program o f employment and r e h a b i l i t a t i o n . 1940,  In  a R e h a b i l i t a t i o n Branch was e s t a b l i s h e d w i t h i n the  Department of Pensions  and N a t i o n a l H e a l t h t o a d m i n i s t e r a l l  c i v i l r e - e s t a b l i s h m e n t s e r v i c e s o f the Department. 4  From here on, "Department* i s used i n t e r c h a n g e a b l y with "DVA and "Department o f V e t e r a n s ' A f f a i r s . " 0  3  World War  I I necessitated increased a c t i v i t i e s i n  the f i e l d of v e t e r a n s ' a f f a i r s , to the p o i n t where the e s t ablishment  of a s p e c i a l department f o r v e t e r a n s '  seemed expedient. was  I n 1944,  requirements  the Department of V e t e r a n s '  c r e a t e d by an A c t of Parliament  to a d m i n i s t e r , i n s o f a r as  possible, a l l veterans' l e g i s l a t i o n .  Heading the Department  i s the M i n i s t e r of V e t e r a n s ' A f f a i r s who mentary r e p r e s e n t a t i v e of DVA.  f u n c t i o n s as  Responsible  parlia-  The Deputy M i n i s t e r i s a  servant and f u n c t i o n s as e x e c u t i v e d i r e c t o r o f the tion.  Affairs  civil  organiza-  t o the Deputy M i n i s t e r f o r the performance  of the Department are the A s s i s t a n t Deputy M i n i s t e r , S e c r e t a r y , heads of the Departmental branches i n Ottawa, and  the  r e g i o n a l and d i s t r i c t a d m i n i s t r a t o r s . D e c e n t r a l i z e d a d m i n i s t r a t i o n has been  accomplished  by d i v i d i n g the country i n t o two major r e g i o n s , east and west of Winnipeg r e s p e c t i v e l y , w i t h i n which r e g i o n s s i x t e e n d i s t r i c t s and t h r e e s u b - d i s t r i c t s have been c r e a t e d . Treatment R i g h t s and Treatment F a c i l i t i e s The f i c treatment  v e t e r a n w i t h a m e d i c a l problem has c e r t a i n s p e c i r i g h t s and other b e n e f i t s d e l i n e a t e d i n the  Veterans' Charter.  1  Those e l i g i b l e f o r treatment  are c l a s s i f i e d under "The Treatment R e g u l a t i o n s "  and b e n e f i t s Veterans'  The V e t e r a n s ' Charter i s a c o m p i l a t i o n o f a l l the a c t s of the Canadian Parliament p e r t a i n i n g t o Canadian v e t e r a n s . 1  Appendix A l i s t s the DVA treatment c a t e g o r i e s under "The Treatment R e g u l a t i o n s , " V e t e r a n s ' C h a r t e r , and i n c l u d e s the number of the s e c t i o n c o n c e r n i n g each c a t e g o r y . 2  4  C h a r t e r , and i n c l u d e , mainly, former members: o f the f o r c e s s u f f e r i n g from d i s a b i l i t i e s a t t r i b u t a b l e to s e r v i c e due  to misconduct)  1  (and not  but may a l s o i n c l u d e such o t h e r persons  as a r e r e f e r r e d a t the r e q u e s t o f DVA o r a t the request and expense o f any o t h e r department o f the government o f Canada. The Department o f Veterans' A f f a i r s g r a d u a l l y e s t a b l i s h e d f a c i l i t i e s to implement the v e t e r a n s ' treatment needs in  the form o f h o s p i t a l accommodation and c o n v a l e s c e n t homes  i n v a r i o u s main c e n t r e s throughout  Canada.  A t the p r e s e n t  (June, 1954) t h e r e a r e , i n Canada, twelve a c t i v e  time  treatment  h o s p i t a l s owned and operated by DVA, w i t h an o p e r a t i n g capacity  3  o f s l i g h t l y more than 8,000.  I n a d d i t i o n to the a c t i v e  treatment h o s p i t a l s , s i x t e e n h o s p i t a l s and i n s t i t u t i o n s , w i t h an o p e r a t i n g c a p a c i t y o f approximately 1,900, a r e operated by the Department o f Veterans' A f f a i r s and are c a t e g o r i z e d as a c t i v e c o n v a l e s c e n t i n s t i t u t i o n s , s p e c i a l i n s t i t u t i o n s , and 4 v e t e r a n s ' care i n s t i t u t i o n s , r e s p e c t i v e l y . When DVA t r e a t D i s a b i l i t i e s a t t r i b u t a b l e to s e r v i c e i n c l u d e , f o r DVA purposes, those d i s a b i l i t i e s r e s u l t i n g from i n j u r y o r d i s e a s e i n c u r r e d d u r i n g m i l i t a r y s e r v i c e o r aggravated d u r i n g m i l i t a r y s e r v i c e , i n r e s p e c t o f which pension has been awarded o r ent i t l e m e n t conceded. 1  * Misconduct c o n s t i t u t e s w i l f u l d i s o b e d i e n c e o f o r d e r s , w i l f u l s e l f - i n f l i c t e d wounding and v i c i o u s o r c r i m i n a l conduct d u r i n g o r subsequent to m i l i t a r y s e r v i c e . The " o p e r a t i n g c a p a c i t y " i s the number o f beds the Department c o n s i d e r s n e c e s s a r y to handle the p a t i e n t l o a d i n a p a r t i cular institution. T h i s f i g u r e i s a matter o f e s t i m a t e d s t a n dards and i s s u b j e c t to change by Head O f f i c e a c c o r d i n g to the needs o f the Department. 3  Appendix B i n c l u d e s a l i s t i n g o f DVA h o s p i t a l s and i n s t i t u t i o n s , w i t h t h e i r l o c a t i o n and o p e r a t i n g c a p a c i t y . 4  5  meat f a c i l i t i e s a r e not a v a i l a b l e t o a v e t e r a n e n t i t l e d t o , and r e q u i r i n g treatment, arrangements e x i s t whereby the v e t e r a n may be t r e a t e d i n s p e c i f i e d non-departmental  h o s p i t a l s a t the  expense of DVA. Shaughnessy H o s p i t a l and i t s a n c i l l a r y u n i t s , H y c r o f t , and George Derby H e a l t h and O c c u p a t i o n a l Centre, i n the Vancouver d i s t r i c t , a r e examples o f the Department's f a c i l i t i e s for  the treatment, convalescence, and care of v e t e r a n s .  H i s t o r y o f Shaughnessy H o s p i t a l The p r e s e n t Shaughnessy H o s p i t a l developed from an annex o f e i g h t wards, 250 beds, which was f i r s t  opened under  the a d m i n i s t r a t i o n o f Vancouver General H o s p i t a l f o r the treatment and accommodation o f m i l i t a r y p a t i e n t s o r war casualties.  During the f i r s t World War, a l l s u r g e r y was p e r -  formed a t the Vancouver General H o s p i t a l .  A t t h i s time, two  p r i v a t e s c h o o l s c l o s e d near the s i t e o f the present h o s p i t a l , and a l e a s e was taken up by the M i l i t a r y H o s p i t a l s Commission whereby these two p r o p e r t i e s , l a t e r named Shaughnessy H o s p i t a l and Fairmont H o s p i t a l , were o b t a i n e d f o r DVA treatment poses. and  Fairmont H o s p i t a l , opened i n May, 1919, f o r s h e l l  purshock  "nervous" p a t i e n t s , had 141 p a t i e n t s under treatment by  the end o f 1919.  I n t h i s same year when most o f the World War  I servicemen were being d e m o b i l i z e d , 202 a d d i t i o n a l v e t e r a n p a t i e n t s were d i s t r i b u t e d f o r treatment i n v a r i o u s c i v i c p i t a l s i n B r i t i s h Columbia,  o t h e r than i n Vancouver.  hos-  6  F i r e d e s t r o y e d the east wing of Shaughnessy H o s p i t a l September 20,  1919,  n e c e s s i t a t i n g a t r a n s f e r of p a t i e n t s  Fairmont H o s p i t a l , M i l i t a r y Annex, and  to  other h o s p i t a l s .  nessy H o s p i t a l re-opened February, 1920.  on  Shaugh-  I n the i n t e r i m , how-  e v e r , the North West Mounted P o l i c e ( l a t e r Royal Canadian Mounted P o l i c e ) o c c u p i e d the undamaged p o r t i o n of Shaughnessy H o s p i t a l and  upon i t s re-opening took over Fairmont H o s p i t a l .  Those v e t e r a n s under treatment i n v a r i o u s  c i v i c h o s p i t a l s out-  s i d e the Vancouver a r e a were t r a n s f e r r e d to Shaughnessy Hosp i t a l i n 1922, of the  which move i n c r e a s e d  l a t t e r h o s p i t a l t o 250.  time was  approximately 50*  Outpatient  I n 1922,  l i o n f o r t u b e r c u l o u s p a t i e n t s was main h o s p i t a l . Unit, replaced ients.  The  the i n - p a t i e n t  of the  P r i o r to the c o n s t r u c t i o n  the  accommodating 122  B u e l l wing was  observation  pat-  facilities  chest.  of the Chest U n i t , a  two-wing, f o u r - s t o r y main b u i l d i n g was  new,  o f f i c i a l l y opened,  constructed  of the main b u i l d i n g i n 1946.  graph of the new  this  Jean Matheson Memorial P a v i l i o n , o r Chest  were e s t a b l i s h e d f o r d i s e a s e s  c a s t end  at  b u i l t d i r e c t l y behind  t h i s s t r u c t u r e i n 1946,  The  strength  also, a thirty-bed pavi-  F u l l d i a g n o s t i c , treatment, and  J u l y 1, 1941.  strength  The  at the  south-  f r o n t view photd-  b u i l d i n g , ( F i g u r e l a ) g i v e s some i d e a of  s i z e and modern c o n s t r u c t i o n As World War  the  of the main b u i l d i n g .  I I p r o g r e s s e d the number of veterans  o t h e r persons r e q u i r i n g treatment i n DVA  hospitals  and  increased.  7 O l d e r h o s p i t a l b u i l d i n g s were re-opened t e m p o r a r i l y f o r p a t i e n t use, and temporary hutments were b u i l t to r e l i e v e i n the new  building.  In 1943,  congestion  " H y c r o f t , " a l a r g e Vancouver  e s t a t e donated by the l a t e Senator A. D. McRaey l o c a t e d o f f G r a n v i l l e S t r e e t a t S i x t e e n t h Avenue, was  opened by DVA  as a  more o r l e s s permanent home f o r e l d e r l y , male, ambulatory patients. The  " E x t e n s i o n , " f o r m e r l y Vancouver M i l i t a r y H o s p i t a l ,  l o c a t e d on Shaughnessy grounds, was  opened i n 1946  male v e t e r a n s r e q u i r i n g i n s t i t u t i o n a l n u r s i n g c a r e .  f o r aged A modern  s e v e n - s t o r y s t r u c t u r e , mainly f o r the treatment of those  pat-  i e n t s : now  the  i n the " E x t e n s i o n , " i s now  (1954) p r o j e c t e d on  p l a n n i n g boards and w i l l be the next major a d d i t i o n to ment f a c i l i t i e s o f DVA, b r i d g e the gap  Vancouver D i s t r i c t .  treat-  In an e f f o r t to  between h o s p i t a l i z a t i o n and f i n a l d i s c h a r g e ,  the George Derby H e a l t h and O c c u p a t i o n a l Centre, an a c t i v e conv a l e s c e n t e s t a b l i s h m e n t f o r Shaughnessy H o s p i t a l p a t i e n t s , was c o n s t r u c t e d i n A p r i l , 1947.  T h i s i n s t i t u t i o n , s i t u a t e d on  shores of Burnaby Lake, three m i l e s n o r t h o f New combines treatment  the  Westminster,  and t r a i n i n g f a c i l i t i e s to accomplish i t s  purpose. The  Regional a d m i n i s t r a t i v e department which moved  from the S h e l l y B u i l d i n g on Pender S t r e e t , to Shaughnessy H o s p i t a l grounds i n 1924,  was  of i t s p e r s o n n e l , to the new  moved again i n 1946, DVA  w i t h most  Regional Administration B u i l d -  7a  Figure 1 ( a ) . Main Entrance. Shaughnessy H o s p i t a l . Vancouver. B. C.  Figure 1 ( b ) . A e r i a l View. Main H o s p i t a l Area. Shaughnessy H o s p i t a l . Vancouver. B.C.  8  ing  on Haro S t r e e t i n Vancouver's West By January,  1948,  t r i c t f o r the treatment persons  DVA  End.  f a c i l i t i e s i n the Vancouver D i s -  and accommodation of veterans and  other  e l i g i b l e under "Treatment R e g u l a t i o n s " i n c l u d e d Shaugh-  nessy H o s p i t a l , main b u i l d i n g ; the E x t e n s i o n u n i t ; Chest U n i t ; the Annex; temporary hutments; H y c r o f t ; and George Derby H e a l t h and O c c u p a t i o n a l Centre, p r o v i d i n g a t o t a l bed c a p a c i t y of 1,350.  With the e x c e p t i o n of the Annex and the temporary  hutments, these b u i l d i n g s are s t i l l  (1954) i n p a t i e n t - u s e , and  have a t o t a l bed c a p a c i t y of approximately  1,300.*  The  aerial  photograph ( F i g u r e l b ) i n d i c a t e s q u i t e c l e a r l y the present l a y o u t and extent o f Shaughnessy H o s p i t a l ' s p h y s i c a l p l a n t , w i t h the e x c e p t i o n of H y c r o f t and George Derby H e a l t h and  Occu-  p a t i o n a l Centre which do not l i e w i t h i n the main h o s p i t a l a r e a . Rehabilitative Provisions Shaughnessy H o s p i t a l i s today equipped  to p r o v i d e a l l  m e d i c a l s e r v i c e s o t h e r than o b s t e t r i c s and p e d i a t r i c s .  The  p r o f e s s i o n a l work i n each medical department i s c a r r i e d  on  under s e p a r a t e d i r e c t o r s , who a d v i s o r y board.  together c o n s t i t u t e a medical  I n a d d i t i o n to medical s e r v i c e s , the  o f f e r s such adjunct s e r v i c e s as o c c u p a t i o n a l therapy,  hospital physio-  therapy, w e l f a r e s e r v i c e s , m e d i c a l s o c i a l s e r v i c e s , r e l i g i o u s guidance,  and i n s t i t u t i o n a l  training.  V i c t o r i a V e t e r a n s ' H o s p i t a l , V i c t o r i a , B. C., b u i l t i n 1948, i s i n c l u d e d w i t h i n the Vancouver D i s t r i c t , and p r o v i d e s a d d i t i o n a l accommodation f o r 300 p a t i e n t s . 1  9  The d e f i n i t i o n i o n a l Conference America,  of r e h a b i l i t a t i o n adopted a t the Nat-  on R e h a b i l i t a t i o n i n the U n i t e d S t a t e s o f  1946, and accepted by DVA as the g u i d i n g p r i n c i p l e  i n the r e h a b i l i t a t i o n o f the d i s a b l e d v e t e r a n i s : R e h a b i l i t a t i o n i s the r e s t o r a t i o n o f the d i s a b l e d t o the maximum p h y s i c a l , mental, s o c i a l , economic, and v o c a t i o n a l c a p a c i t y of. which they a r e c a p a b l e . The D i r e c t o r G e n e r a l o f Treatment  S e r v i c e s , DVA,  b e l i e v e s t h a t the DVA treatment program most c l o s e l y  approaches  i d e a l medical r e h a b i l i t a t i o n i n t h a t i t has a v a i l a b l e eminent s p e c i a l i s t s on a permanent, p a r t - t i m e , o r c o n s u l t a t i v e b a s i s t o s t a r t , and t o continue the s u p e r v i s i o n o f m e d i c a l r e h a b i l i t a t i o n ; p l u s an e f f i c i e n t team o f d o c t o r s , w e l f a r e o f f i c e r s , m e d i c a l s o c i a l workers, p h y s i o t h e r a p i s t s , and e d u c a t i o n o f f i c e r s t o c a r r y through the p r o c e s s i n i t i a t e d by the s p e c i a l i s t . I n Department h o s p i t a l s , as i n o t h e r m e d i c a l s e t t i n g s , the r e h a b i l i t a t i v e plain may o n l y be i n s t i g a t e d w i t h the a p p r o v a l of the d o c t o r i n charge o f the case. Development of M e d i c a l S o c i a l S e r v i c e s i n DVA M e d i c a l s o c i a l s e r v i c e i s but one o f many a v a i l a b l e s e r v i c e s i n a l a r g e scheme geared t o the e f f e c t i v e  treatment  and u l t i m a t e r e h a b i l i t a t i o n o f the p a t i e n t .  T h i s d e f i n i t i o n i s c i t e d by Dr. A. D. Temple, M e d i c a l Superintendent and C h i e f o f S e r v i c e , S t . Hyacinthe V e t e r a n s H o s p i t a l , S t . Hyacinthe, P. Q. i n h i s a r t i c l e : " R e h a b i l i t a t i o n as i t Concerns the P h y s i c i a n , " Treatment S e r v i c e s B u l l e t i n , Nov. 1950. V o l . V, Department o f V e t e r a n s ' A f f a i r s , Ottawa. 1  1  C o n s u l t a n t s i n c l u d e m e d i c a l p e r s o n n e l of the a s s o c i a t e d F a c u l t i e s o f Medicine i n the U n i v e r s i t i e s . 2  1G The v e t e r a n s ' need f o r s o c i a l s e r v i c e s was r e c o g n i z e d f o l l o w i n g World War I (although s o c i a l work as a p r o f e s s i o n was not r e c o g n i z e d ) and s t e p s were taken t o provide n u r s i n g s i s t e r s w i t h some t r a i n i n g problems.  t o enable them t o d e a l w i t h s o c i a l  The concept t h a t s o c i a l s e r v i c e s f o r h o s p i t a l  p a t i e n t s s h o u l d be handled by m e d i c a l p e r s o n n e l , p r e f e r a b l y w i t h some t r a i n i n g ,  facility,  o r "bent" f o r d e a l i n g with p e r -  s o n a l i t i e s , was not uncommon a t t h i s time.  The g e n e r i c con-  cept t h a t medical s o c i a l work i s d i s t i n g u i s h e d from o t h e r f i e l d s of s o c i a l work by s e t t i n g  a l o n e , and r e q u i r e s the s e r -  v i c e s o f a p r o f e s s i o n a l s o c i a l caseworker,  w i t h a working  knowledge o f m e d i c a l symptomatology, was not y e t accepted. Subsequently, i n the summer o f 1919, the Department o f S o l d i e r s ' C i v i l Re-establishment  s e l e c t e d a group of Canadian  e x - s e r v i c e nurses t o a t t e n d a two-month e x t e n s i o n course i n p s y c h i a t r i c s o c i a l work a t the U n i v e r s i t y of Toronto.  Each  m e d i c a l d i s t r i c t under the Department of S o l d i e r s ' C i v i l Ree s t a b l i s h m e n t sent r e p r e s e n t a t i v e s t o t h i s c o u r s e , sponsored by the Canadian  Committee of Mental Hygiene,  and the Canadian  Government p a i d the expenses o f these r e p r e s e n t a t i v e s . n u r s i n g s i s t e r s from B r i t i s h Columbia  Four  attended the course and  upon t h e i r r e t u r n two were a s s i g n e d t o the Department's subo f f i c e i n V i c t o r i a , two t o the main o f f i c e i n Vancouver. D u t i e s o f these s o c i a l s e r v i c e nurses i n v o l v e d f o l l o w up o f o u t p a t i e n t s o f the h o s p i t a l ,  o f t u b e r c u l o u s cases on leave  11  from s a n i t a r i a , and of mental p a t i e n t s on p r o b a t i o n , i n o r d e r to a s c e r t a i n t h a t the p r e s c r i b e d m e d i c a l treatment was to and t h a t the home environment was The v e t e r a n s  1  conducive  F l o r e n c e Clayden, i n her t h e s i s D i v i s i o n , DVA,  to recovery.  f a m i l i e s were worked with i n an attempt  cure t h e i r c o - o p e r a t i o n i n the v e t e r a n s *  adhered  to p r o -  treatment. on the S o c i a l S e r v i c e  states;  Other d u t i e s of the ' s o c i a l worker' i n c l u d e d the i n v e s t i g a t i o n of the circumstances o f the dependents of v e t e r a n s , t o see t h a t these dependents a c t u a l l y e x i s t e d ; a c t i n g as a d v i s o r s to the v e t e r a n s ' f a m i l i e s who needed encouragement or a s s i s t a n c e ; s e c u r i n g c o n f i d e n t i a l i n f o r m a t i o n r e q u i r e d by the A s s i s t a n t D i r e c t o r of the Department, the R e p r e s e n t a t i v e of the I n f o r m a t i o n and S e r v i c e Branch, the D i s t r i c t V o c a t i o n a l O f f i c e r , or the U n i t H e d i c a l D i r e c t o r ; and c a r r y i n g out n u r s i n g or o t h e r d u t i e s which the U n i t H e d i c a l D i r e c t o r might a d v i s e . I n the c a r r y i n g out of t h i s work, precedence was g i v e n t o cases of d i s t r e s s , f i n a n c i a l hardship, o r medical emergency. I t i s i n t e r e s t i n g t o note t h a t i n the Department's  2 Annual Report, 1920,  s o c i a l s e r v i c e i s d e s c r i b e d as a  "spec-  i a l i z e d n u r s i n g a c t i v i t y , " and the s o c i a l s e r v i c e nurse i s r e f e r r e d t o as an attendent upon the s i c k , an educator, and a reformer.  As the number of h o s p i t a l i z e d v e t e r a n s r e q u i r i n g  s o c i a l s e r v i c e s i n c r e a s e d , the s o c i a l s e r v i c e nurses were  unable  to cope w i t h the p e r s i s t e n t demand f o r work with persons i n the Clayden, F l o r e n c e , The S o c i a l S e r v i c e D i v i s i o n of the Department of V e t e r a n s ' A f f a i r s ; I t s O r i g i n , S e t t i n g , and F u n c t i o n s .. a study based on the D i v i s i o n i n the B r i t i s h Columbia D i s t r i c t . 1950. Master's of S o c i a l Work t h e s i s , U n i v e r s i t y of B r i t i s h Columbia. ^ Canada, Department of S o l d i e r s ' C i v i l Re-establishment, Annual Report. (1920). 1921; King's P r i n t e r , Ottawa.  12  community.  Consequently, some o f t h e community t a s k s o f  the s o c i a l s e r v i c e n u r s e s , such as study o f home c o n d i t i o n s , and f o l l o w - u p work w i t h p a t i e n t s and t h e i r f a m i l i e s , were absorbed by male departmental i n v e s t i g a t o r s and by nondepartmental p r o v i n c i a l workers, I n 1945,  respectively.  a survey o f the v e t e r a n s ' s o c i a l  service  requirements was undertaken by the D i r e c t o r o f S o c i a l S c i e n c e at N a t i o n a l Defence Headquarters a t the request o f the Department o f V e t e r a n s ' A f f a i r s ,  R e s u l t a n t t o the recommenda-  t i o n s o f t h i s survey a S o c i a l S e r v i c e D i r e c t o r a t e was e s t a b l i s h e d w i t h i n t h e V e t e r a n s ' Welfare S e r v i c e Branch, DVA, and was  made r e s p o n s i b l e t o the D i r e c t o r G e n e r a l o f V e t e r a n s ' Wel-  fare Services.  A medical s o c i a l s e r v i c e unit functioned w i t h i n  the S o c i a l S e r v i c e D i v i s i o n u n t i l May, 1947. E s t a b l i s h m e n t o f M e d i c a l S o c i a l S e r v i c e Department So t h a t a l l m e d i c a l l y o r i e n t a t e d d i s c i p l i n e s w i t h i n DVA  would be f o l l o w i n g a s i m i l a r c h a i n o f r e s p o n s i b i l i t y , an  a d m i n i s t r a t i v e o r d e r was i s s u e d i n the S p r i n g o f 1947, sepa r a t i n g the m e d i c a l s o c i a l s e r v i c e u n i t from Welfare Service,  Social  The Department o f M e d i c a l S o c i a l S e r v i c e was o f f i -  c i a l l y e s t a b l i s h e d on May 1, 1947, and made r e s p o n s i b l e t o the D i r e c t o r General o f Treatment A circular letter  1  Services,  on M e d i c a l S o c i a l S e r v i c e , General  C i r c u l a r L e t t e r , 1947 - 138, December 6, 1947, M e d i c a l S o c i a l S e r v i c e - General P o l i c y , r e f e r t o C.L. 1927 - 122, October 21, 1947. x  13 P o l i c y , s t i p u l a t e d t h a t M e d i c a l S o c i a l S e r v i c e was an i n t e g r a l p a r t of the h o s p i t a l s e t - u p , responsible  administratively  d i r e c t l y t o the h o s p i t a l s u p e r i n t e n d e n t .  t h a t p o i n t , the c h a i n  of r e s p o n s i b i l i t y was  Prom  1  to be the same  as f o r o t h e r p e r s o n n e l i n treatment s e r v i c e s . and  t o become  Por  technical  p r o f e s s i o n a l guidance, however, the M e d i c a l S o c i a l S e r -  v i c e Department has  a d i r e c t l i n e of communication on a con-  s u l t a t i v e b a s i s w i t h the D i r e c t o r of M e d i c a l S o c i a l  Services,  Ottawa. The  a c t u a l p r o c e s s of becoming "an i n t e g r a l p a r t  the h o s p i t a l s e t - u p " was  and  s t i l l i s gradual.  As i n  of  any  r e c e n t l y p r o f e s s i o n a l i z e d s e r v i c e , continuous i n t e r p r e t a t i v e measures t o g e t h e r w i t h c o n s i s t e n t  demonstrable a b i l i t y  n e c e s s a r y i n e x t e n d i n g the s e r v i c e t o a l l who  may  are  benefit;  t h i s i s e s p e c i a l l y t r u e i n s e t t i n g s such as Shaughnessy Hosp i t a l where r e f e r r a l s must be approved by another d i s c i p l i n e . The  D i r e c t o r General of Treatment S e r v i c e s , DVA,  issues  p e r i o d i c treatment i n s t r u c t i o n l e t t e r s c o n c e r n i n g the t i o n and  scope of s e r v i c e s r e s p o n s i b l e  to Departmental p o l i c y . dated January 5, 1949  2  One  t o him  with  func-  reference  such treatment i n s t r u c t i o n l e t t e r  a d v i s e d t h a t the f u n c t i o n of the medi-  The h o s p i t a l s u p e r i n t e n d e n t at Shaughnessy i s a q u a l i f i e d m e d i c a l p r a c t i t i o n e r , and f u n c t i o n s as S e n i o r Treatment M e d i c a l O f f i c e r f o r the Vancouver D i s t r i c t . 1  o  Treatment I n s t r u c t i o n L e t t e r , 1949 P o l i c y - F u n c t i o n of the S e r v i c e .  - 1, J a n t a r y 5,  1949,  14 c a l s o c i a l worker w i t h i n DVA was t o provide  s o c i a l casework  s e r v i c e s t o i n d i v i d u a l p a t i e n t s as a member o f the m e d i c a l team headed by the doctor; t o p r o v i d e m e d i c a l s o c i a l  consul-  t a t i o n s e r v i c e t o other d i s c i p l i n e s s e r v i c i n g the p a t i e n t ; t o a s s i s t the development of community understanding w i t h the g o a l o f f u r t h e r i n g a i d t o the s i c k and d i s a b l e d who must r e t u r n t o the community; and t o a s s i s t r e s e a r c h p r o j e c t s  having  medical s o c i a l i m p l i c a t i o n s . H e d i c a l S o c i a l S e r v i c e i n Shaughnessy H o s p i t a l , o r any DVA h o s p i t a l , i s one of the seven d i v i s i o n s w i t h i n H e d i c a l S e r v i c e s , a d m i n i s t r a t i v e l y r e s p o n s i b l e to the h o s p i t a l s u p e r i n tendent.  These seven d i v i s i o n s a r e : i n t e r n a l medicine;  tuber-  c u l o s i s ; dermatology; neurology; p s y c h i a t r y ; p h y s i c a l medicine; and m e d i c a l s o c i a l s e r v i c e . The p o s i t i o n of the H e d i c a l S o c i a l S e r v i c e Department w i t h i n the o r g a n i z a t i o n o f the Department of Veterans  1  A f f a i r s g e n e r a l l y , and w i t h i n Shaughnessy H o s p i t a l  s p e c i f i c a l l y , i s i l l u s t r a t e d diagrammatically  i n F i g u r e 2.  It  s h o u l d be noted t h a t F i g u r e 2 i s a p a r t i a l o r g a n i z a t i o n a l c h a r t o n l y and does not i l l u s t r a t e the c h a i n of r e s p o n s i b i l i t y f o r a l l s e r v i c e s r e s p o n s i b l e t o the S e n i o r Treatment H e d i c a l c e r ; nor does i t i n d i c a t e D i s t r i c t or R e g i o n a l  Offi-  responsibility.  As p r e v i o u s l y noted i n t h i s s t u d y , the H e d i c a l S o c i a l S e r v i c e Department, now under the D i r e c t o r General of T r e a t ment S e r v i c e s , o r i g i n a l l y f u n c t i o n e d as a u n i t w i t h i n the S o c i a l S e r v i c e D i v i s i o n under the D i r e c t o r General of V e t e r a n s  1  14a M i n i s t e r of Veterans' A f f a i r s  Deputy M i n i s t e r A s s i s t a n t Deputy M i n i s t e r s Director M e d i c a l Soci a l Services  D i r e c t o r General Treatment S e r v i c e s O T T A W A  S H A U G H N E S S Y  H O S P I T A L  S e n i o r Treatment Medical O f f i c e r ( H o s p i t a l Superintendent)  Business Administration  Education Research  A s s i s t a n t H o s p i t a l Superintendent 1  C L I N I C A L  Otolaryn gology & Surgery Ophthalmology  Internal Medicine  Tuberculosis  F i g u r e 2.  S E R V I C E S  Dentristry  Dermatology  Auxiliary Services  Neurology  Pathology  Anaesthesia  Physical edicine  Medicine  Medical Social Services  The P o s i t i o n of the M e d i c a l S o c i a l S e r v i c e Department i n the DVA O r g a n i z a t i o n .  15 Welfare S e r v i c e s .  I t i s t h e r e f o r e important  to p o i n t out the  d i s t i n c t i v e areas o f s e r v i c e o f the M e d i c a l S o c i a l S e r v i c e Department and the S o c i a l S e r v i c e D i v i s i o n which l e a d to a d m i n i s t r a t i v e s e p a r a t i o n o f these two s o c i a l s e r v i c e r e sources.  The fundamental d i s t i n c t i o n l i e s i n the f a c t t h a t  the M e d i c a l S o c i a l S e r v i c e Department i s a u t h o r i z e d to p r o v i d e s o c i a l s e r v i c e s f o r v e t e r a n s under DVA medical c a r e , whereas the S o c i a l S e r v i c e D i v i s i o n i s a u t h o r i z e d to o f f e r s o c i a l s e r v i c e s to those v e t e r a n s r e q u i r i n g a s s i s t a n c e w i t h s o c i a l p r o blems, who a r e n o t under DVA medical c a r e . Both the S o c i a l S e r v i c e D i v i s i o n and the M e d i c a l S o c i a l S e r v i c e Department have employed q u a l i f i e d p e r s o n n e l  1  s i n c e t h e i r e s t a b l i s h m e n t on a p r o f e s s i o n a l b a s i s i n 1945. I n 2 the Vancouver D i s t r i c t ,  Welfare S o c i a l S e r v i c e operates w i t h i n  the DVA d i s t r i c t and s u b - d i s t r i c t o f f i c e s , and medical  social  s e r v i c e operates i n Shaughnessy H o s p i t a l and i n V i c t o r i a V e t erans' H o s p i t a l .  Although  q u a r t e r e d i n the main b u i l d i n g ,  Shaughnessy H o s p i t a l , the M e d i c a l S o c i a l S e r v i c e Department s e r v i c e s the h o s p i t a l ' s a n c i l l a r y u n i t s :  also  H y c r o f t , and George  Derby H e a l t h and O c c u p a t i o n a l C e n t r e . Minimum academic requirements: B a c h e l o r o f S o c i a l Work (Master o f S o c i a l Work f o r M e d i c a l S o c i a l S e r v i c e Department a t present time). 1  The Vancouver ( o r "VA") D i s t r i c t i n c l u d e s a l l o f B r i t i s h Columbia. The s o c i a l worker a t t a c h e d to V i c t o r i a Veterans' H o s p i t a l i s w i t h i n the establishment o f the M e d i c a l S o c i a l S e r v i c e Department, Shaughnessy H o s p i t a l . 3  16  Welfare  Officers In  Veterans workers.  1  both the a d m i n i s t r a t i v e and the m e d i c a l s e t t i n g s ,  Welfare O f f i c e r s are employed i n a d d i t i o n t o s o c i a l There are t h r e e c l a s s i f i c a t i o n s of Veterans* Wel-  f a r e O f f i c e r s depending ate:  upon the s e t t i n g i n which they oper-  General W e l f a r e O f f i c e r s , who  operate from the adminis-  t r a t i v e s e t t i n g ; F i e l d Welfare O f f i c e r s ; and C a s u a l t y Welfare O f f i c e r s , who  operate w i t h i n the h o s p i t a l s e t t i n g .  the three c a t e g o r i e s were merged i n an attempt  In  1951,  to e s t a b l i s h  g e n e r i c t r a i n i n g f o r the Welfare O f f i c e r s , which would enable an i n t e r c h a n g e of workers i n the d i f f e r e n t s e t t i n g s . s h o r t p e r i o d , however, t h i s scheme was  After a  regarded as unworkable  under e x i s t i n g c i r c u m s t a n c e s , and the o r i g i n a l  classifications  were r e - i n s t a t e d . I t i s necessary that the m e d i c a l s o c i a l worker be aware of the d e f i n e d f u n c t i o n s of the Welfare O f f i c e r s s i n c e c e r t a i n areas w i t h i n the s o c i a l s i t u a t i o n , such as housing, employment, and, on o c c a s i o n , f i n a n c e s , are d e a l t w i t h by the Welfare O f f i c e r s i n DVA  settings.  P a r t of the Welfare  Offi-  c e r ' s f u n c t i o n i s t o h e l p h o s p i t a l i z e d or o u t p a t i e n t v e t e r a n s s o l v e problems,  the nature of which problems do not a f f e c t the  veteran*s treatment.  I n the C a s u a l t y Welfare O f f i c e r s * Manual,  the f o l l o w i n g statement i s made:  1  I n s t a n c e s w i l l occur where v e t e r a n s undergoing treatment p l a c e before Welfare O f f i c e r s problems which the s o l v i n g of w i l l b e t t e r the v e t e r a n ' s l o t , but w i l l C a s u a l t y W e l f a r e O f f i c e r s ' Manual (mimeographed); page 44.  17  i n no way a f f e c t h i s treatment. On the other hand, when veterans r e c e i v i n g D.V.A. m e d i c a l care c o n f r o n t Welfare O f f i c e r s with s i t u a t i o n s which may a f f e c t t h e i r treatment, these s h o u l d not be f u r t h e r e d u n t i l d i s c u s s e d w i t h the Doctor, who w i l l then i n s t r u c t the Welfare O f f i c e r to proceed, e i t h e r alone or i n c o - o p e r a t i o n w i t h the M e d i c a l S o c i a l S e r v i c e , or may decide t h a t the matter i s one to be d e a l t w i t h e n t i r e l y by M e d i c a l Soci a l Service. The  v a s t amount of l e g i s l a t i v e d e t a i l s u r r o u n d i n g  the  h o s p i t a l i z a t i o n and r e h a b i l i t a t i o n of v e t e r a n s , and the s p e c i a l problems encountered  i n effecting satisfactory  rehabilitation,  make i t e s s e n t i a l t h a t Welfare O f f i c e r s as w e l l as medical s o c i a l workers are employed t o d e a l w i t h the v a r i o u s problems which a r i s e . h o s p i t a l s , who  U n l i k e the medical s o c i a l workers w i t h i n  DVA  approach o n l y those veterans s p e c i f i c a l l y r e -  f e r r e d f o r s o c i a l s e r v i c e s , the C a s u a l t y Welfare  Officers  have a r e s p o n s i b i l i t y to c o n t a c t a l l veterans admitted t o h o s p i t a l i n o r d e r t o a s c e r t a i n that these veterans are aware of the b e n e f i t s to which they are e n t i t l e d under DVA  legis-  lation. Where necessary, the C a s u a l t y Welfare O f f i c e r s are o b l i g e d t o make known t o the proper a u t h o r i t i e s those v e t erans who  are not r e c e i v i n g b e n e f i t s f o r which they have  entitlement.  A f t e r t h i s i n i t i a l c o n t a c t , the veteran's  s t a t u s i s determined  as " r e g i s t r a n t  0  or " n o n - r e g i s t r a n t . "  R e g i s t r a n t s t a t u s i n d i c a t e s that the v e t e r a n i s probably employable but w i l l have some r e s i d u a l p h y s i c a l a f t e r treatment.  The  disability  C a s u a l t y Welfare O f f i c e r ' s most concen-  18  t r a t e d a c t i v i t y i s w i t h the r e g i s t r a n t f o r whom s u i t a b l e employment i s a paramount aim. Purpose and Method of Present  Study  A l l h o s p i t a l p e r s o n n e l are n e c e s s a r i l y concerned  with  p a t i e n t admissions, whether these be i n i t i a l admissions o r r e admissions.  I n o r d e r to determine  the f e a s i b i l i t y ,  insofar  as M e d i c a l S o c i a l S e r v i c e i s concerned, of making a s p e c i a l study of v e t e r a n s r e a d m i t t e d t o Shaughnessy H o s p i t a l i t was necessary t o determine  the i n c i d e n c e of v e t e r a n p a t i e n t s r e -  admitted t o h o s p i t a l i n r e l a t i o n t o the number of r e f e r r a l s made t o the M e d i c a l S o c i a l S e r v i c e Department w i t h i n a g i v e n period. Upon making a survey of the 756 r e f e r r a l s r e c o r d e d i n the M e d i c a l S o c i a l S e r v i c e Department's case r e g i s t e r 1952-53 f i s c a l y e a r ( A p r i l 1, 1952,  t o March 31, 1953)  1  i n the  i t was  noted that s l i g h t l y more than h a l f of a l l the veterans r e f e r r e d f o r s o c i a l s e r v i c e s d u r i n g t h i s p e r i o d had had a t l e a s t  one  p r e v i o u s admission t o Shaughnessy H o s p i t a l , or i f o u t p a t i e n t s at the time of the present r e f e r r a l , had had at l e a s t one p i t a l admission.  Approximately  hos-  one-quarter o f these r e a d m i t t e d  p a t i e n t s had been i n Shaughnessy H o s p i t a l more than t h r e e times, the v e t e r a n among t h i s group w i t h the g r e a t e s t number of readmLs-  A c t u a l l y 1,100 r e f e r r a l s were made t o the M e d i c a l S o c i a l S e r v i c e Department a t Shaughnessy H o s p i t a l d u r i n g the 1952-53 f i s c a l y e a r , but due t o c e r t a i n i n a c c u r a c i e s i n keeping the case r e g i s t e r , f i g u r e s on monthly r e t u r n s do not t a l l y with t o t a l s i n the case r e g i s t e r . 1  19  s i o n s having been i n t h i s h o s p i t a l on 18 p r e v i o u s o c c a s i o n s * The i n c i d e n c e of readmissions service r e f e r r a l s i s considered high.  among medical  There are c e r t a i n r e -  c o g n i z e d reasons, i n c l u d i n g age, c h r o n i c i t y , and e n t i t l e m e n t , f o r a h i g h e r percentage  social  treatment  of readmissions  among  the t o t a l p a t i e n t group i n a v e t e r a n s ' h o s p i t a l than among the p a t i e n t group of a c i v i l i a n  o r g e n e r a l h o s p i t a l , which would  apply t o the group under study.  I n a d d i t i o n to these  factors,  i t i s remembered that the group of r e a d m i t t e d v e t e r a n p a t i e n t s under study have e x h i b i t e d some s o c i a l problem or problems, r e c o g n i z e d by themselves,  by t h e i r d o c t o r , o r by some other  person. The  q u e s t i o n r a i s e d i s whether or not the v e t e r a n s '  s o c i a l problems are i n some measure r e s p o n s i b l e f o r t h e i r h o s p i t a l admissions,  and i f such i s the case, c o u l d the  inci-  dence of r e a d m i t t e d p a t i e n t s be l e s s e n e d by s o c i a l work s e r vices? ters.  T h i s theme i s e l a b o r a t e d upon i n the f o l l o w i n g chap-  CHAPTER 2 THE RELATIONSHIP OP PSYCHOSOCIAL PROBLEMS TO PATIENT ADMISSIONS In l i n e w i t h the i n c r e a s i n g emphasis on p r e v e n t i o n among treatment p e r s o n n e l i n a l l f i e l d s , s o c i a l workers are n a t u r a l l y i n t e r e s t e d i n ways and means of keeping people f u n c t i o n i n g a t t h e i r optimum l e v e l .  I t i s important, t h e r e f o r e , to  determine the reasons behind repeated h o s p i t a l admissions. Are these persons who  are c o n s t a n t l y readmitted to h o s p i t a l making  the b e s t p o s s i b l e adjustment to t h e i r l i f e  situation?  What are  the s p e c i a l f a c t o r s o p e r a t i n g w i t h r e f e r e n c e to v e t e r a n p a t i e n t s ? More s p e c i f i c a l l y , what are the f a c t o r s o p e r a t i n g w i t h r e f e r ence to a s e l e c t e d group o f 51 readmitted p a t i e n t s among the medical s o c i a l s e r v i c e r e f e r r a l s , that c o n t r i b u t e to readmissions? A cross-comparison o f p a t i e n t s r e f e r r e d to medical s o c i a l s e r v i c e s d u r i n g the 1952-53 f i s c a l year, by medical diagnosis' ' and by number of h o s p i t a l admissions 1  (Table B), i n -  d i c a t e s t h a t s l i g h t l y more than h a l f (51$) of the p a t i e n t s r e f e r r e d have had p r e v i o u s admissions to Shaughnessy H o s p i t a l . As s t a t e d e a r l i e r i n t h i s study (Chapter 1) t h i s f i n d i n g p r o v i d e d one  of the s t r o n g e s t reasons f o r c o n s i d e r i n g the study  F o r purposes of t h i s study, medical d i a g n o s i s i s d e t e r mined by the p a t i e n t ' s l o c a t i o n on a ward d e s i g n a t e d as g e n e r a l medicine, s u r g e r y , p s y c h i a t r y , t u b e r c u l o s i s , e t c e t e r a . 1  21 o f the s o c i a l a s p e c t s o f h o s p i t a l readmissions  feasible.  Incidence o f Readmissions R e f l e c t e d i n MSSD R e f e r r a l s 1  A breakdown o f p a t i e n t readmissions i n r e l a t i o n t o M e d i c a l S o c i a l S e r v i c e Department r e f e r r a l s (Table A ) shows t h a t o f 386 readmitted v e t e r a n s r e f e r r e d , 226 v e t e r a n s ( a p p r o x i mately  59% o f the readmitted r e f e r r a l group, and 30% o f the  t o t a l r e f e r r a l group) have had more than one p r e v i o u s  admission  to Shaughnessy, and 101 o f these v e t e r a n s have been admitted to  Table A.  Month  P a t i e n t Readmissions Related_to MSSD R e f e r r a l s 1952-53 " F i s c a l Year  Referrals  April May June July August Sept. Oct. Nov. Dec. Jan. Feb. March .  36 42 57 52 38 40 85 85 76 85 77 83  TOTALS 756  P a t i e n t Readmissions No. %  Novo t P n.or Admissions 1 2 3 Over 3  23 24 31 30 16 23 31 46 41 33 38 50  63.9 57.1 54.4 57.7 42.1 57.5 36.5 54.1 53.9 38.8 49.4 60.2  11 9 12 13 5 7 18 19 15 19 14 18  386  51  150  h o s p i t a l more than three times p r e v i o u s l y . admission  4 5 3 5 5 8 2 7 6 7 12 9 73  3 3 6 4 1 4 3 9 4 2 5 8 52  5 7 10 8 5 4 8 11 16 5 7 15 101  This multiple  group, (mainly e x c l u d i n g those oyer 70 y e a r s o f  MSSD i s used i n t e r c h a n g e a b l y w i t h M e d i c a l S o c i a l S e r v i c e Department from here on.  22 age i n o r d e r t h a t g e r i a t r i c c o n s i d e r a t i o n s should not weigh the f i n d i n g s ) forms the n u c l e u s of the present study.  The  s p e c i a l group s t u d i e d , comprising 51 persons, i n c l u d e s 48 v e t erans under seventy years of age, and 3 v e t e r a n s o v e r years of The  seventy  age.  Veteran The v e t e r a n  1  v o l u n t e e r e d o r was  c o n s c r i p t e d to serve  i n the armed f o r c e s i n defence o f h i s country, d i d so, and d i s c h a r g e d from the f o r c e s .  By v i r t u e of h i s s e r v i c e , he  have earned l e s s than he might have had he remained a he may  was may  civilian;  have l o s t c e r t a i n employment o p p o r t u n i t i e s ; aged p r e -  maturely; o r , s u f f e r e d any number o f o t h e r s o c i a l , economic, p h y s i c a l , o r mental d i s a b i l i t i e s . i n c u r r e d , i t i s reasonable  I f such d i s a b i l i t i e s were  to expect t h a t some compensation be  o f f e r e d these v e t e r a n s by the government.  Compensation i n the  form of c e r t a i n l e g i s l a t i v e b e n e f i t s i s o u t l i n e d i n the V e t erans* C h a r t e r .  I t i s not the purpose of t h i s study to d e t -  ermine the a p p r o p r i a t e n e s s o r adequacy of these b e n e f i t s .  It  i s merely p o i n t e d out, i n s o f a r as i t a f f e c t s t h i s study, that h o s p i t a l i z a t i o n and treatment are among the compensatory p r o v i s i o n s under the V e t e r a n s ' C h a r t e r o f Canada. V e t e r a n P a t i e n t s a t Shaughnessy Admissions  to a v e t e r a n s ' h o s p i t a l c o u l d be  a t t r i b u t a b l e to any one o r a combination  of i n t r i n s i c  partially and  The term "veteran'* i s d e f i n e d and e l a b o r a t e d upon i n Chapter 1 of t h i s t h e s i s . 1  23 e x t r i n s i c f a c t o r s i n a d d i t i o n to the a c t u a l i l l n e s s .  Among  these are such f e a t u r e s as p e r s o n a l i t y make-up, age,  employ-  ment s t a t u s , f a m i l y r e l a t i o n s h i p s , l i v i n g accommodation, and income.  These broad c a u s a l f a c t o r s , i n t u r n , are o f t e n a t t r i -  butable to more s u b t l e i n f l u e n c e s , i n c l u d i n g e a r l y developmental h i s t o r y , p a s t e d u c a t i o n a l o p p o r t u n i t i e s , and p r e s e n t f a m i l y t i e s and  responsibilities.  "Income" to the v e t e r a n may o r d i n a r y c i v i l i a n income s o u r c e s , War 2 a d i s a b i l i t y pension.  mean, i n a d d i t i o n to 1 Veterans' Allowance or  In t h i s p a r t i c u l a r a n a l y s i s , 70% of  the MSSD r e f e r r a l s a t Shaughnessy w i t h three o r more h o s p i t a l admissions were i n r e c e i p t of d i s a b i l i t y pensions (8 v e t e r a n s were i n r e c e i p t of 100$ d i s a b i l i t y p e n s i o n s ) ; an a d d i t i o n a l  10%  Those e l i g i b l e f o r War Veterans' Allowance (WVA) under the WVA A c t of 1930, a r e : (a) male v e t e r a n s who have a t t a i n e d the age of 60 y e a r s , and female v e t e r a n s who have a t t a i n e d the age o f 55 y e a r s ; (b) v e t e r a n s of any age who because of d i s a b i l i t i e s are permanently unemployable; ( c ) v e t e r a n s who w h i l e unable to q u a l i f y under (a) o r (b) are c o n s i d e r e d i n c a p a b l e and u n l i k e l y to become capable of maintenance because of p h y s i c a l o r mental d i s a b i l i t y combined w i t h economic handicaps. WVA i s a l s o a v a i l a b l e f o r widows and orphans o f such v e t e r a n s , but no p r o v i s i o n i s made f o r dependent c h i l d r e n i f both p a r e n t s are l i v i n g . This i s a defi n i t e l a g i n Canadian l e g i s l a t i o n . (There are an estimated 1,200 dependent c h i l d r e n i n the Vancouver DVA d i s t r i c t alone whose p a r ents are i n r e c e i p t o f WVA). WVA p r o v i d e s f o r payment of f i f t y o r s i x t y d o l l a r s p e r month to a s i n g l e v e t e r a n and n i n e t y o r one hundred d o l l a r s monthly to a m a r r i e d v e t e r a n , on a means t e s t basis. 1  2 Under the p r o v i s i o n s o f the Pension A c t (Chapter 157 o f the Revised S t a t u t e s of Canada, 1927, and amended to date) d i s a b i l i t y pensions are awarded by the Canadian Pension Commission i n a c c o r d ance w i t h the degree of s e r v i c e disablement found on m e d i c a l examination, without r e f e r e n c e to the f i n a n c i a l circumstances and o c c u p a t i o n o f a p e n s i o n e r p r i o r to h i s e n l i s t m e n t and subsequent to h i s d i s c h a r g e . Rates are governed by the extent to which such s e r v i c e disablement c o n s t i t u t e s a v o c a t i o n a l handicap. Veterans' dependents are p r o v i d e d f o r through an a d d i t i o n a l monthly sum.  24  were e n t i t l e d to treatment f o r s e r v i c e d i s a b i l i t i e s not  con-  s t ! t o t i n g a v o c a t i o n a l handicap; and approximately 40% were 1 r e c e i v i n g WVA.  , (Many of the men  i n receipt of small d i s a b i l -  i t y pensions were a l s o r e c e i v i n g WVA, to the WVA  b r i n g i n g t h e i r income  c e i l i n g of f i f t y , s i x t y , n i n e t y , o r one hundred  d o l l a r s , depending  upon t h e i r m a r i t a l s t a t u s and economic c i r -  cumstances). Briefly, WVA  the f a c t that a v e t e r a n i s i n r e c e i p t of  i n d i c a t e s t h a t he i s i n a low income b r a c k e t , whereas a  v e t e r a n r e c e i v i n g a d i s a b i l i t y pension may low income b r a c k e t , depending sources of income, i f any.  o r may n o t be i n a  upon h i s p e n s i o n r a t e and o t h e r  While h o s p i t a l i z e d f o r h i s p e n s i o n -  a b l e d i s a b i l i t y , a p e n s i o n e r r e c e i v e s an allowance e q u i v a l e n t to a 100$ pension ($125.00 monthly f o r a s i n g l e man w i t h no dependents) l e s s $15.00 maintenance. Unique C h a r a c t e r i s t i c s o f DVA P a t i e n t s F o r a b e t t e r understanding of the p a r t i c u l a r group o f p a t i e n t s under study, i t i s h e l p f u l to c o n s i d e r the t o t a l v e t e r a n group, and  the v e t e r a n p a t i e n t  group.  H o s p i t a l f a c i l i t i e s of the Department of Veterans* A f f a i r s are d i s c u s s e d e a r l i e r i n t h i s study.  The v e t e r a n may be 2 h o s p i t a l i z e d under a number of treatment c a t e g o r i e s , i n c l u d i n g WVA and War Veterans* Allowance from here on. 1  2  Treatment  are used i n t e r c h a n g e a b l y  c a t e g o r i e s are l i s t e d i n Appendix B.  25 e x a c e r b a t i o n o f h i s pensionable d i s a b i l i t y , emergency t r e a t ment, non-committable and non-pensionable  neuropsychiatric d i s -  a b i l i t i e s , o b s e r v a t i o n , and r e s e a r c h purposes, and as War Veterans* Allowance treatment.  r e c i p i e n t s r e q u i r i n g a c t i v e remedial  The i l l n e s s may o r may n o t be r e l a t e d to war s e r -  vice. 1  A study of DVA i n - p a t i e n t s  f o r the 1951-52 f i s c a l  y e a r (immediately p r i o r to the p r e s e n t study o f readmissions) p o i n t s up some o f the c h a r a c t e r i s t i c s of h o s p i t a l i z e d v e t e r a n p a t i e n t s under DVA r e s p o n s i b i l i t y .  Because those h o s p i t a l i z e d  are mostly World War I and World War I I v e t e r a n s , the average age of DVA p a t i e n t s i s probably h i g h e r than t h a t f o r the g e n e r a l o r c i v i l i a n h o s p i t a l p o p u l a t i o n , and the d i s e a s e s a s s o c i a t e d w i t h the aged are t h e r e f o r e l i k e l y to be found i n g r e a t e r p r o p o r t i o n i n DVA h o s p i t a l s .  The ages f o r DVA p a t i e n t s i n the 1951-  52 f i s c a l y e a r ranged from 17 to 97, w i t h an average age o f 55, and a median age o f 58.  The average age o f DVA p a t i e n t s has  i n c r e a s e d g r a d u a l l y o v e r the p a s t few y e a r s , and t h i s t r e n d i s expected to continue w i t h some minor f l u c t u a t i o n s a t t r i b u t a b l e to the d e m o b i l i z a t i o n o f the Korean S p e c i a l F o r c e .  I t i s of  i n t e r e s t to note t h a t , a c c o r d i n g to t h i s study, 70$ o f the t o t a l number o f DVA i n - p a t i e n t s were h o s p i t a l i z e d up to one year, and 30$ were h o s p i t a l i z e d f o r more than one y e a r . —-T  ~  ;  T h i s would seem ;  T h i s study was undertaken by D r . G.A. W i n f i e l d , D i r e c t o r of M e d i c a l Research, S t a t i s t i c s , Development and P l a n n i n g , DVA, and M i s s L. Wellwood, M e d i c a l S t a t i s t i c i a n , DVA, and appeared i n the DVA Treatment S e r v i c e B u l l e t i n , November, 1953.  26 to indicate that personnel concerned  with the veterans' rehab-  i l i t a t i o n (including medical s o c i a l workers) would, i n many i n stances, have an extended period during which to employ rehabi l i t a t i v e measures.  However, since these percentages take into  account psychotic and tuberculous patients, who often remain i n hospital f o r a number of years, i t does not follow that the gene r a l patient-group i s available for treatment or services over such an extended period (although the average patient days stay i s longer than that i n c i v i l i a n h o s p i t a l s ) .  The figures regard-  ing age-range and length of h o s p i t a l i z a t i o n at Shaughnessy Hospi t a l are not s i g n i f i c a n t l y d i f f e r e n t from the general DVA i n patient pattern. Incidence of Referrals i n Relation to Medical Diagnosis One method of viewing the source of medical s o c i a l service r e f e r r a l s i s by medical diagnosis (ward designation) indicated i n Table B.  Certain f a c t o r s , such as the admission  of patients f o r quarters and rations f o r observation or awaiting pensions medical examination, and the location of a l l women patients on a ward designated as a medical ward, plus the fact that patients under certain services are covered routinely, render the findings approximate only. However, general medicine and surgery wards, whose patients together comprise nearly half of the t o t a l in-patient strength of Shaughnessy H o s p i t a l , and have only a s l i g h t l y unequal d i s t r i b u t i o n of patients (5 medicine to 4 surgery) are sources of a v a s t l y unequal number of r e f e r r a l s to the Medical  27 T a b l e B.  Comparison o f MSSD C l i e n t e l e , w i t h and without P r i o r H o s p i t a l Admissions. by M e d i c a l Diagnoses  D i a g n o s t i c Group General Medicine Psychiatry Surgery Chest U n i t Institutional & Convalescent Outpatients & non-patients Other  No P r i o r H o s p i t a l Admissions No. %  Total  152 29 36 31  41.1 7.9 9.7 8.4  173 27 49 25  44.9 7.0 12.8 6.5  24  6.5  37  9.6  87 11  23.5 2.9  65 10  16.6 2.6  370  Total  Readmissions No. %  386  100  S o c i a l S e r v i c e Department (4 medicine  100  756  to 1 s u r g e r y ) .  This d i s  crepancy i s a p a t t e r n o v e r the years r a t h e r than a phenomenon of  the p a r t i c u l a r y e a r under study, and r a i s e s the q u e s t i o n as  to whether the surgeons are aware of the f u n c t i o n and  availa-  b i l i t y of medical s o c i a l s e r v i c e s f o r t h e i r p a t i e n t s , to the same extent as a r e the p e r s o n n e l on g e n e r a l medicine wards. Medical S o c i a l Service Referrals In  t h i s p a r t of the study, medical s o c i a l  service  r e f e r r a l s have been examined w i t h r e f e r e n c e to the person r e f e r r i n g the case; the medical d i a g n o s i s and p r o g n o s i s o f the person r e f e r r e d ; age; e d u c a t i o n ; employment r e c o r d ; m a r i t a l s t a t u s and number of dependents; employment p o t e n t i a l ; p a t t e r n o f p s y c h o s o c i a l problems. to f a c i l i t a t e  and  Such a coverage i s i n t e n d e d  an understanding of the group and of the  v i d u a l s w i t h i n the group r e f e r r e d to medical s o c i a l  indi-  service;  28 to p o i n t up the p s y c h o s o c i a l problems c a r r i e d by those r e f e r r e d ; and  to i n d i c a t e the r e l a t i o n s h i p , where e v i d e n t , between the  p a t i e n t ' s v a r i o u s problems and h i s h o s p i t a l  admissions.  Satiree o f R e f e r r a l An  examination o f the t o t a l r e f e r r a l s (Table 6) to the  M e d i c a l S o c i a l S e r v i c e Department d u r i n g the 1952-53 f i s c a l y e a r , shows a monthly average o f 91.6 r e f e r r a l s made to the department from a l l s o u r c e s .  Routine r e f e r r a l s account f o r an  average o f 14.8 r e f e r r a l s monthly; 10.7 and 10.4 average monthly r e f e r r a l s o r i g i n a t e w i t h the p a t i e n t and w i t h h o s p i t a l s t a f f o t h e r than d o c t o r s , r e s p e c t i v e l y ; 5.9 and 4.5 monthly r e f e r r a l s come from the community and from r e l a t i v e s , r e s p e c t i v e l y ; an average o f 3.8 r e f e r r a l s i s made by non-medical DVA s t a f f w i t h i n the Vancouver D i s t r i c t ; and an average o f o n l y 1 monthly r e f e r r a l i s made by persons i n o i l i e r DVA h o s p i t a l s o r o t h e r DVA d i s t r i c t offices.  By f a r the g r e a t e s t p r o p o r t i o n o f r e f e r r a l s (40.5  average monthly r e f e r r a l s ) however, i s made by d o c t o r s . Immediately the M e d i c a l S o c i a l S e r v i c e Department i s reminded t h a t i t i s l a r g e l y dependent upon the d o c t o r ' s  recogni-  t i o n o f s o c i a l f a c t o r s as p a r t o f the c o n s t e l l a t i o n o f problems c o n f r o n t i n g the h o s p i t a l i z e d v e t e r a n , f o r an o p p o r t u n i t y to o f f e r s o c i a l work s e r v i c e s to p a t i e n t s .  Even among those r e -  f e r r a l s o r i g i n a t i n g from o t h e r sources, such as the community, r e l a t i v e s , o t h e r h o s p i t a l s t a f f , and the p a t i e n t h i m s e l f , the s o c i a l worker must o b t a i n the d o c t o r ' s permission i n g the s i t u a t i o n .  before  enter-  29 1  1952-53 F i s c a l  Doctor 19 21 22 31 33 32 Other H o s p i tal Staff 7 4 11 9 11 8 Other DVA Hospital or District 1 1 1 _ _ Other DVA P e r sonnel 3 7 2 3 1 5 Patient 15 11 5 10 5 7 Relatives 8 3 5 2 2 4 Community 8 3 7 4 3 9 Routine 38 26 28 9 5 13 Total  March  Feb.  Dec.  Nov.  Oct.  ei s> <!  Sept.  July  & X  June  April  Source  Jan.  I  Source o f MSSD R e f e r r a l s .  1  T a b l e G.  Year  Average No. o f T o t - Monthly al Referrals  52 62 55 62 48 49  486  40.5  14 13 13 14  124  10.4  1  12  1.0  5 3 5 2 7 3 8 9 12 17 12 17 3 5 5 6 6 5 6 5 9 2 9 6 15 10 4 10 6 13  46 128 54 71 177  3.9 10.7 4.5 5.9 14.8  99 77 81 69 60 78 103 107 305 317 99 305  1100  91.6  • _  -. 2  4  9 11 2  Monthly average no. o f r e f e r r a l s f o r the 1952-53 f i s c a l year  Source: MSSD Annual Report, 1952-53 F i s c a l Year.  The procedure o f o b t a i n i n g the d o c t o r ' s s a n c t i o n  prior  to i n i t i a t i n g s o c i a l s e r v i c e s i s e n t i r e l y d e s i r a b l e from the p o i n t o f view o f the p a t i e n t ' s w e l f a r e and the c o - o r d i n a t i o n o f e f f o r t on h i s b e h a l f , b u t i t does underscore the p e r e n n i a l n e c e s s i t y o f i n t e r p r e t i n g medical s o c i a l s e r v i c e s through demonstrative  a b i l i t y , and through more f o r m a l i z e d channels ( d i s c u s s e d  i n f i n a l c h a p t e r ) t o the medical s t a f f a s w e l l as to the c l i e n t e l e .  The number o f r e f e r r a l s (1,100) o b t a i n e d from the MSSD Annual Report i s a c c u r a t e f o r the t o t a l group; the t o t a l o f 756 r e c o r d e d i n the Case R e g i s t e r , approximates the number o f new ' r e f e r r a l s t o MSSD.  30 Certain p a t i e n t s are interviewed  r o u t i n e l y by the medi-  c a l s o c i a l s e r v i c e s t a f f upon admission to Shaughnessy H o s p i t a l ( f o r example, a l l persons r e f e r r e d f o r p s y c h i a t r i c treatment o r assessment, and a l l tuberculous Unit).  They are reviewed as to need, wishes, and s u i t a b i l i t y  f o r continued two  p a t i e n t s admitted to the Chest  casework s e r v i c e s .  I t i s o n l y w i t h i n the past  o r three y e a r s that s p e c i f i e d groups o f p a t i e n t s have been  covered r o u t i n e l y by the M e d i c a l r e f l e c t s administrative  S o c i a l S e r v i c e s t a f f , and i t  r e c o g n i t i o n t h a t the m a j o r i t y o f p a t i e n t s ,  o r the f a m i l i e s o f p a t i e n t s w i t h p s y c h i a t r i c o r tuberculous  ill-  nesses, have accompanying s o c i a l problems which have e i t h e r cont r i b u t e d to the i l l n e s s , o r may accrue from such i l l n e s s . J u s t o v e r 15% o f the M e d i c a l new and re-opened cases d u r i n g of these r o u t i n e r e f e r r a l s .  S o c i a l S e r v i c e Department's  the 1952-53 f i s c a l y e a r c o n s i s t e d  The remainder o f the cases com-  p r i s e d a r e l a t i v e l y s m a l l percentage of r e f e r r a l s from the community, r e l a t i v e s , and DVA non-medical  personnel.  F e a t u r e s o f the " S p e c i a l Group" o f Readmitted P a t i e n t s The  group o f 51 readmitted  patients selected f o r special  c o n s i d e r a t i o n are grouped f o r e a s i e r a n a l y s i s i n t o three  cate-  g o r i e s on the b a s i s o f e m p l o y a b i l i t y o r employment p o t e n t i a l . The  d i s t r i c t f i l e f o r each case was s t u d i e d i n d e t a i l , and  according  to the f a c t u a l i n f o r m a t i o n  and the comments o f the  medical s t a f f , the s o c i a l workers, and o t h e r persons concerned w i t h the v e t e r a n s i n q u e s t i o n , t r a r i l y designated  the v e t e r a n  i n each case was a r b i -  as having (A) poor o r n i l ,  (B) f a i r , and  31 (C) good employment p o t e n t i a l .  (A case a n a l y s i s form i s i n s e r t e d  a t Appendix C ) . U s i n g these c r i t e r i a , approximately 60% of the s p e c i a l group ( o r 30 v e t e r a n s ) were c l a s s i f i e d as h a v i n g o r n i l " employment p o t e n t i a l , 25% (13 v e t e r a n s ) a s having  "poor "fair"  employment p o t e n t i a l , and o n l y 15% (8 v e t e r a n s ) as having good employment  potentialities. In t h i s s e t t i n g , the Welfare O f f i c e r s have a s p e c i a l  i n t e r e s t i n , and f a c i l i t i e s f o r o f f e r i n g v o c a t i o n a l  counselling  and v o c a t i o n a l t r a i n i n g , and have as w e l l , the s e r v i c e s o f a s p e c i a l v e t e r a n s ' placement Service.  o f f i c e r a t the N a t i o n a l Employment  C o n s i d e r i n g these added r e s o u r c e s , some of the v e t e r -  ans who would p o s s i b l y be r a t e d as having o n l y f a i r employment p o t e n t i a l when compared w i t h the g e n e r a l p o p u l a t i o n , c o u l d be r a t e d as h a v i n g good employment p o t e n t i a l f o r purposes o f t h i s study.  To i l l u s t r a t e  this situation:  a young v e t e r a n r e c e i v i n g  100$ d i s a b i l i t y p e n s i o n f o r a b r a i n tumour would have a d i f f i c u l t , i f n o t i m p o s s i b l e time competing  i n the g e n e r a l employment  market w i t h non-handicapped persons, but t h i s v e t e r a n i s s t e a d i l y employed and performing adequately i n a s h e l t e r e d s e t t i n g , and is  t h e r e f o r e i n c l u d e d w i t h i n the group h a v i n g good employment  potential. O b j e c t i v e D e t a i l s Concerning the S p e c i a l Group (age; h e a l t h ; e d u c a t i o n ; employment record") A c u r s o r y review o f the s p e c i f i c o b j e c t i v e f a c t s (as r e c o r d e d on d i s t r i c t o f f i c e f i l e s and MSSD f i l e s ) p e r t a i n i n g to each o f the employment p o t e n t i a l groups h i g h l i g h t s the main reasons f o r the i n c l u s i o n o f persons under one o r another c a t e gory.  32 In group (A) (poor o r n i l employment p o t e n t i a l ) one h a l f of the v e t e r a n s are 61 y e a r s of age o r over, i n c l u d i n g the o n l y three v e t e r a n s among the 51 who age,  are more than 70 y e a r s of  and l e s s than 15% of the group ( o n l y 4 v e t e r a n s ) are  y e a r s of age o r younger.  40  Group (B) has an approximately equal  p r o p o r t i o n o f v e t e r a n s on e i t h e r s i d e o f middle age  (40 y e a r s )  and i n group (C) 75% of the p a t i e n t s are i n the 40-and-under age  group. More than h a l f of the v e t e r a n s i n group (A) have phy-  sical  o r mental d i s a b i l i t i e s of a s e r i o u s enough nature to p r e -  clude any attempt a t steady employment w i t h o r without  the  f u r t h e r burden o f d i s a b l i n g p s y c h o s o c i a l problems; whereas  B5%  of  15%  (or  group (B) are c o n s i d e r e d m e d i c a l l y f i t f o r work and  the  2 v e t e r a n s ) c o n s i d e r e d u n f i t ( i n f e c t i o u s pulmonary t u b e r -  c u l o s i s ) are working a s o c i a l hazard.  d e s p i t e medical d i s a p p r o v a l , thus c r e a t i n g  A l l the men  i n group (C) are m e d i c a l l y f i t f o r  some type of employment. Lack of e d u c a t i o n , o r inadequate e d u c a t i o n , can  con-  s t i t u t e a r e a l v o c a t i o n a l handicap, e s p e c i a l l y when p h y s i c a l i n f i r m i t y p r e c l u d e s heavy manual l a b o u r .  (The p r e v i o u s work  experience f o r approximately h a l f o f the group o f 51 i s u n s k i l l e d l a b o u r , w i t h a d i s t r i b u t i o n of 50% u n s k i l l e d i n group (C) and j u s t o v e r 65% u n s k i l l e d i n groups (A) and (B) combined).  Fewer  than o n e - s i x t h o f the v e t e r a n s i n group (A) r e c e i v e d s c h o o l i n g above the elementary university trained —  l e v e l (2 v e t e r a n s among the e x c e p t i o n s were one had a d e t e r i o r a t i n g o r g a n i c  d i s e a s e , the o t h e r had a c h r o n i c , severe a l l e r g i c  mental  condition),  33 whereas h a l f of group reached o r completed  ( B ) , and t h r e e - q u a r t e r s of group  (C)  secondary s c h o o l .  The employment h i s t o r y of j u s t o v e r h a l f of the v e t e r a n s i n group (A) r e f l e c t s i n s t a b i l i t y , w h i l e o n e - t h i r d o f the v e t erans i n t h i s group have good r e c o r d s and the remainder have a t l e a s t a f a i r employment p a t t e r n .  The v e t e r a n s w i t h i n  groups  (B) and ( C ) , however, have more f a v o r a b l e employment h i s t o r i e s . On the b a s i s of the number of jobs h e l d , and the average g r e a t e s t l e n g t h of time spent a t any one  job —  or  both f a c t o r s  r e l a t i v e to the age of the p a t i e n t and the nature o f the employment —  h a l f o f the v e t e r a n s i n groups  (B) and (C) p r e v i o u s l y  had a good employment r e c o r d , and o n l y 1 o r 2 v e t e r a n s i n each of these c a t e g o r i e s a c t u a l l y had a poor r e c o r d . Admissions i n R e l a t i o n to E m p l o y a b i l i t y and Dependents The group o f 51 v e t e r a n s under s p e c i a l study r e p r e s e n t s a t o t a l of 361 admissions to Shaughnessy H o s p i t a l : t h i s means an approximate  average of 7 admissions per v e t e r a n .  a t o t a l of 88 admissions, h o l d s to the average.  Group ( B ) , w i t h Group ( A ) ,  r e p r e s e n t i n g 226 h o s p i t a l admissions, averages 8 admissions p e r person, and group  ( C ) , w i t h the h i g h e s t e m p l o y a b i l i t y p o t e n t i a l ,  t o t a l s 47 admissions, and averages 6 admissions per p a t i e n t . The younger v e t e r a n s , group ( C ) , have the l a r g e s t average number of dependents p e r person ( 3 ) , the o l d e r v e t e r a n s , group  ( A ) , have the l e a s t number of dependents per person ( 1 ) ,  and group  (B) f i l l s  per veteran.  the u s u a l middle r o l e , w i t h 2 dependents  Most of the dependents are c l u s t e r e d around the  married v e t e r a n s , who  c o n s t i t u t e j u s t under 65$ of the  total  34  group of 51.  (Many of t h e s i n g l e men among the group l i v e i n  s m a l l , unpleasant rooms i n u n d e s i r a b l e areas o f town, have no one  to care f o r them upon d i s c h a r g e , and a r e t h e r e f o r e l i a b l e  to r e t u r n t o h o s p i t a l f r e q u e n t l y , o r t o be kept i n h o s p i t a l l o n g e r than would o r d i n a r i l y be n e c e s s a r y ) . I n c l u d i n g the v e t e r a n s and t h e i r dependents, 133 persons (50 c h i l d r e n ) a r e d i r e c t l y and v a r i o u s l y a f f e c t e d by the v e t e r a n s ' h o s p i t a l admissions.  T h i s f i n d i n g would seem  to be o f s u f f i c i e n t s o c i a l s i g n i f i c a n c e to warrant  further  p e r u s a l o f the reasons f o r these h o s p i t a l admissions.  I s there  any b a s i s f o r c o r r e l a t i n g p s y c h o s o c i a l problems and repeated hospital  admissions?  P s y c h o s o c i a l Problems o f the MSSD C l i e n t e l e Each o f the v e t e r a n s w i t h i n t h i s s e l e c t i o n o f 51 MSSD r e f e r r a l s has some p s y c h o s o c i a l problem.  A proportion  of these men have problems which a r e deep-rooted  and so i n t e r -  twined w i t h t h e i r p e r s o n a l i t y s t r u c t u r e that t h e i r a b i l i t y to a d j u s t t o t h e i r e x i s t i n g environment environment  i s q u e s t i o n a b l e , b u t the  might be m o d i f i a b l e to the e x t e n t of i n c l u d i n g  these s o c i a l l y maladjusted people more c o m f o r t a b l y w i t h i n i t . Others a r e i n need o f the a s s i s t a n c e o f an o b j e c t i v e and s k i l ful  t h i r d p a r t y to e n t e r the s i t u a t i o n , o f f e r the a p p r o p r i a t e  s e r v i c e r s ) , and, i f the c l i e n t i s amenable to s o c i a l work s e r v i c e s , thereby enable him to steady h i m s e l f and to pursue a more s t a b l e course.  35 A f t e r an examination  o f the c o n s t e l l a t i o n o f problems  e x i s t i n g among the p a t i e n t s r e f e r r e d to MSSD, a problem c a t i o n was evolved to f a c i l i t a t e revealed. I.  classifi-  the i n c l u s i o n o f a l l the problems  F i v e broad c a t e g o r i e s were d e r i v e d , a s f o l l o w s : 1  V o c a t i o n a l — t h i s c a t e g o r y i n c l u d e s such problems a s : need o f a j o b o r change of job, perhaps coupled w i t h r e l u c t a n c e to a c c e p t such j o b o r j o b change; d i f f i c u l t y w i t h employer o r f e l l o w employees; i n s u f f i c i e n t v o c a t i o n a l t r a i n i n g o r education to h o l d a j o b which i s p h y s i c a l l y s u i t a b l e ; p h y s i c a l h a n d i cap r e q u i r i n g s h e l t e r e d employment.  II.  M a t e r i a l — t h i s c a t e g o r y i n c l u d e s problems such as i n s u f f i c i e n t funds o r b i l l s o u t s t a n d i n g ; inadequate, u n s u i t a b l e , o r n o n - e x i s t e n t housing accommodation; l a c k of medical n e c e s s i t i e s f o r p a t i e n t s ' f a m i l i e s ; absence o f f a m i l y o r f r i e n d s to p r o v i d e care f o r d i s a b l e d v e t e r a n s ; l a c k of necessary care o r housekeepi n g s e r v i c e s f o r f a m i l i e s of h o s p i t a l i z e d v e t e r a n s .  III.  F a m i l y R e l a t i o n s h i p s — i n c l u d e d w i t h i n t h i s category are problems of marTtal o r o t h e r f a m i l y d i s c o r d , and u n w i l l i n g n e s s of f a m i l i e s f o r the v e t e r a n s ' r e t u r n to the home.  IV.  V.  F a i l u r e to Respond to and/or to Co-operate i n T r e a t ment (on A p p a r e n t l y Non-medical Grounds) — w i t h i n t h i s c a t e g o r y are i n c l u d e d problems r e l a t i n g to misunderstanding o r f e a r o f treatment; i n a b i l i t y to accept the medical d i a g n o s i s and i t s i m p l i c a t i o n s ; i n a b i l i t y o r u n w i l l i n g n e s s to f o r e g o d e t r i m e n t a l p r a c t i c e s ( f o r example: d r i n k i n g l i q u o r ; smoking; eating prohibited foods). P e r s o n a l i t y o r Mental A b e r r a t i o n s -- diagnosed cond i t i o n s of p s y c h o s i s , severe p s y c h o n e u r o s i s , and severe psychopathology are i n c l u d e d w i t h i n t h i s category.!  Major and Secondary  Problem-Picture  A c r o s s - c l a s s i f i c a t i o n o f major and secondary  problems  (Table D) c o n t r i b u t e s to a b e t t e r understanding o f the i n d i v i d u a l s ,  These c a t e g o r i e s are n o t standard c r i t e r i a f o r a n a l y s i s of p s y c h o s o c i a l problems; they are merely a convenient frame o f r e f e r e n c e f o r t h i s p a r t i c u l a r study. Boundaries are not r i g i d and some o v e r l a p p i n g i s i n e v i t a b l e .  36 and the problems  o f the i n d i v i d u a l s , among the s e l e c t e d  group  of MSSD r e f e r r a l s , and p o i n t s t o a c o n c e n t r a t i o n o f major o r primary p s y c h o s o c i a l problems almost e q u a l l y d i s t r i b u t e d b e t ween the areas o f m a t e r i a l l a c k s and f a m i l y r e l a t i o n s h i p s . Secondary problems*" a r e g e n e r a l l y s c a t t e r e d . A f u r t h e r breakdown o f the p r o b l e m - p i c t u r e i n d i c a t e s t h a t problems of v o c a t i o n and o f p e r s o n a l i t y o r mental  defects  t o g e t h e r c o n s t i t u t e approximately 30% o f the t o t a l p i c t u r e , and have equal w e i g h t i n g .  F a i l u r e t o respond t o , o r l a c k o f c o -  o p e r a t i o n i n the treatment p l a n (on a p p a r e n t l y non-medical grounds) i n c o r p o r a t e s the l e a s t number o f major problems.  Of  the v e t e r a n s (6) whose major problem i s i n t h i s a r e a , however, h a l f have u n s a t i s f a c t o r y f a m i l y r e l a t i o n s h i p s .  Table D shows  that problems o f f a m i l y r e l a t i o n s h i p s and o f m a t e r i a l  need  t o g e t h e r , and p r o p o r t i o n a t e l y , c o n s t i t u t e 75% o f the secondary concerns o f v e t e r a n s w i t h mental o r p e r s o n a l i t y d e f e c t s .  How-  ever, the t o t a l s of o n l y 6 and 8 v e t e r a n s r e s p e c t i v e l y , i n the l a t t e r two groups does n o t p e r m i t v a l i d d i s t i n c t i o n s o r gene r a l i t i e s t o be made i n c i t i n g psychosocial  the i n c i d e n c e of t h e i r secondary  problems.  Less than 30% o f those whose major problem i s materi a l i n n a t u r e have secondary v o c a t i o n a l problems.  Of those  v e t e r a n s whose primary problem i s v o c a t i o n a l , however, more than h a l f have secondary problems  o f a m a t e r i a l nature —  an expected  Only the problem next i n s e v e r i t y to the major problem i s i n c l u d e d , although some of the v e t e r a n s have two o r more p r o blems i n a d d i t i o n to the major problem. 1  37  Table D.  Major and Secondary P s y c h o s o c i a l Problems among MSSD R e f e r r a l s . 1952-53 F i s c a l Year  Major Problems  Secondary Problems I IV Total III II V Vocat. M a t e r i a l F a m i l y T r e a t . P e r s . None 5  I Vocational 4  II Material I I I Family R e l a tionships  4  IV Lack Response o r Cooperation i n Treatment V Personality o r Menjal Total  5  1  1  m»  1  8  1  6  2  1  14  -  6  -  15  x  2  3  1  3  3  -  9  15  8  7  6  1  9  Source: Compiled from DVA Vancouver D i s t r i c t O f f i c e and from MSSD Case Records.  1  8  3  51  files,  p a t t e r n , s i n c e unemployment, which i n t h i s a n a l y s i s i s the major v o c a t i o n a l concern, u s u a l l y connotes  l a c k o f money and o f the  goods and s e r v i c e s t h a t money can buy. Major Problems i n R e l a t i o n to E m p l o y a b i l i t y A study of the major p s y c h o s o c i a l problems o f the 51 v e t e r a n s i n the c h r o n i c readmission group r e f e r r e d to MSSD, i n r e l a t i o n t o the employment p o t e n t i a l of these men (Table E ) , r e f l e c t s a c l u s t e r o f problems concerning f a m i l y r e l a t i o n s h i p s and m a t e r i a l n e c e s s i t y among v e t e r a n s w i t h poor o r n i l employment potential.  ( T h i s i s the same problem-concentration  r e l a t i v e to  the t o t a l group of 51 v e t e r a n s , p o i n t e d up i n Table D ) .  It is  38  Table E. Relationship Between Major Problems and Employability  Employability  I Vocat.  Major Problems III IV II Family Treat. Material  V Pers.  Total  A Poor o r n i l  1  10  9  4  6  30  B Pair  4  3  3  1  2  13  C Good  3  1  3  1  -  8  8  14  15  6  8  51  Total  Source: Assessed and compiled from Information i n D i s t r i c t Office F i l e s and MSSD Case Records.  true that veterans with poor o r n i l employment p o t e n t i a l cons t i t u t e the largest number of i n d i v i d u a l s within t h i s group of 51, but t h i s i s c h a r a c t e r i s t i c of the t o t a l chronic readmission r e f e r r a l group, i f not of the entire MSSD r e f e r r a l group. A c t u a l l y , veterans with poor or n i l employment pote n t i a l carry a s l i g h t l y greater weighting of the s o c i a l problems i n the remaining areas, with the exception of vocational problems.  Major problems among those with f a i r o r good employ-  ment p o t e n t i a l are scattered.  In the hospital s e t t i n g , many o f  those with material needs are dealt with by MSSD i n a r e l a t i v e l y short period.  The l i n g e r i n g problem-area,  of family r e l a t i o n s h i p s .  therefore, i s that  39  I n f l u e n c e o f P s y c h o s o c i a l Problems on H o s p i t a l Admissions Although the g e n e r a l s o c i a l problem c o n s t i t u e n t o f the s p e c i a l group o f 51 readmitted  p a t i e n t s has been  covered  b r i e f l y , some o f these s o c i a l problems c o u l d be reviewed i n r e l a t i o n to t h e i r e f f e c t on the p a t i e n t s ' h o s p i t a l Two o r more i l l u s t r a t i o n s from each e m p l o y a b i l i t y are s u f f i c i e n t to strengthen  the c o n t e n t i o n  admissions. grouping  t h a t the s o c i a l  m i l i e u i n many i n s t a n c e s c o n t r i b u t e s t o , o r d e t r a c t s from, a persons*s a b i l i t y to f u n c t i o n adequately  o u t s i d e the h o s p i t a l .  ( I l l u s t r a t i o n s are i n terms o f problems o n l y ; no attempt i s made to give a complete p i c t u r e o f the s i t u a t i o n ) . Group (A) - Poor o r N i l Employment P o t e n t i a l (1) C o n t r i b u t i n g t o one e l d e r l y p a t i e n t ' s h o s p i t a l admissions was h i s a c t u a l i n c a p a c i t y to care f o r h i m s e l f due to mental d e t e r i o r a t i o n ( s e n i l e p s y c h o s i s ) and h i s u n w i l l i n g ness to l i v e w i t h h i s c h i l d r e n , p l u s l a c k o f funds to f i n a n c e accommodation i n a n u r s i n g home. He was f i n a l l y admitted to Shaughnessy H o s p i t a l f o r i n s t i t u t i o n a l c a r e . (2) Another p a t i e n t admitted to Shaughnessy H o s p i t a l f i f t e e n times f o r h i s h e a r t c o n d i t i o n , s t a t e d d u r i n g h i s l a t e s t admission that he had r e q u e s t e d h o s p i t a l i z a t i o n as a WVA r e c i p i e n t mainly because he was d i s c o n t e n t e d w i t h the home situation. I t was a l s o determined t h a t h i s w i f e was i l l and the c h i l d r e n , w i l l i n g to tend t h e i r mother, were not w i l l i n g to care f o r t h e i r f a t h e r , whom they d e s c r i b e d as r e s t l e s s , i l l - t e m p e r e d , and i m p o s s i b l e to p l e a s e . (3) A skid-row i n h a b i t a n t admitted nine times f o r h i s pensionable d i s a b i l i t y ( d i a b e t e s ) aggravated by an improper regime ( t o o much a l c o h o l and too l i t t l e food) thought he c o u l d manage o u t s i d e the h o s p i t a l i f s u i t a b l e housing i n a "temp e r a t e " environment c o u l d be l o c a t e d . T h i s same p a t i e n t was r e c e i v i n g Old Age A s s i s t a n c e p l u s a 100$ d i s a b i l i t y pension so he d i d n o t g a i n much f i n a n c i a l l y through h i s admissions to hospital.  40 (4) A young married World War I I veteran, unemployable and completely destitute, had a 5$ d i s a b i l i t y pension f o r a knee injury but was admitted to hospital f i v e times f o r an asthmatic condition under the f i n a n c i a l section (Section 13). Both the patient and h i s wife were thought to be b a s i c a l l y dependent persons, and not finding i n each other a resource upon which to lean, had separated at the time of the patient's l a t e s t admission. The patient was caught i n the proverbial vicious c i r c l e wherein he had an i l l n e s s , possibly attributable to early childhood influences, which prevented his holding a job; and h i s unemployed state coupled with h i s unmet personality needs and a disappointed, immature wife, caused exacerbation of h i s i l l n e s s . (5) A dual war veteran admitted alternately f o r h i s pensionable d i s a b i l i t y (recurrent bronchitis — 30$) and f o r his diabetic condition and dermatitis, had run into debt, was upset by h i s daughter's "wild" behavior and was generally d i f f i c u l t to l i v e with. When hospitalized f o r h i s pensionable d i s a b i l i t y he was able to gain approximately sixty dollars per month, and he and his wife were admittedly crusading f o r a raise i n the veteran's pension assessment, possibly on quite j u s t i f i a b l e grounds. (6) A 35-year-old patient admitted f i f t e e n times f o r an asthmatic condition, thought by the doctors to be l a r g e l y psychological, mentioned i l l n e s s i n the home as one of the reasons f o r his present admission to h o s p i t a l , explaining that the s l i g h t e s t upsetting incident causes him to panic and u l t i mately leads to an asthmatic attack and subsequent h o s p i t a l i z a t i o n . On a previous occasion the patient's wife stated that her husband would just have to come back to the hospital to c o l l e c t the hospital allowance i f DVA would not give the family enough on which to l i v e . (This man was an 85$ pensioner and was hospitalized f o r h i s pensionable d i s a b i l i t y , thus receiving 100% pension during h o s p i t a l i z a t i o n ) . (7) Another dual war veteran, aged 62, had a 5% pension f o r o t i t i s externa and had treatment entitlement f o r ulcers, but his f i v e hospital admissions, under WVA, were f o r dermatitis. A notation on the medical f i l e indicated that the patient's medical condition was secondary and that the dermatitis f l a r e d when the man was unemployed. Group (B) - F a i r Employment Potential (1) A 65-year-old single World War I veteran with a high school and business school education had eight hospital admissions under the WVA section f o r asthma, bronchitis, alcoholism, and malnutrition, and the medical notes on record concerning the veteran's l a t e s t admission ( f o r alcoholism)  41 confirmed the f a c t t h a t h i s problems were more s o c i a l than m e d i c a l . From the f i l e s i t was noted t h a t h i s s o c i a l p r o blems i n c l u d e d mismanagement of h i s f i n a n c e s (used up funds d u r i n g f i r s t p a r t o f month on a l c o h o l , e t c e t e r a , and towards the end of the month he had no money f o r f o o d , hence malnutrition). (2) A WVA r e c i p i e n t , aged 63, married f o r the t h i r d time f i v e years ago had s i x h o s p i t a l admissions f o r v a r y i n g c o n d i t i o n s such as u l c e r s , p l e u r i s y , a r t h r i t i s , p s y c h o n e u r o s i s , o s t e o a r t h r i t i s , and f r a c t u r e s , and was admitted t h i s s i x t h time f o r a r t h r i t i s . A s u c c e s s i o n o f d o c t o r s were of the o p i n i o n t h a t many of t h i s man's i l l n e s s e s i n c l u d e d a psychogenic element. Upon r e f e r r a l to MSSD he s a i d that he was w o r r i e d about h i s w i f e f o r whom he was unable to p r o v i d e medical a t t e n t i o n . Upon r e v i e w i n g t h i s p a t i e n t ' s h o s p i t a l f i l e a p a t t e r n of dependency was e v i d e n t and the q u e s t i o n was r a i s e d as to whether t h i s man was t r a n s f e r r i n g some of h i s dependency to the h o s p i t a l w h i l e h i s w i f e was unwell and t h e r e f o r e unable to g i v e him as much a t t e n t i o n as he seemed to r e q u i r e . Group (C) - Good Employment P o t e n t i a l (1) One of the v e t e r a n s w i t h i n t h i s employment p o t e n t i a l grouping had f o u r admissions to h o s p i t a l f o r h i s pens i o n a b l e d i s a b i l i t y , duodenal u l c e r . The medical r e c o r d s show t h a t the p a t i e n t ' s u l c e r c o n d i t i o n remains c o n t r o l l e d u n l e s s the man i s under p h y s i c a l o r emotional s t r e s s . An examination of p o s s i b l e areas of s t r e s s p o i n t s up a p e r s o n a l need f o r an i n c e n t i v e to s t r i v e , admitted by the v e t e r a n . The v e t e r a n ' s w i f e , l a c k i n g o v e r t warmth and a f f e c t i o n , f a i l s to p r o v i d e t h i s i n c e n t i v e , and c o n t r i b u t e s to the v e t e r a n ' s emotional s t r e s s . E x a c e r b a t i o n of the p a t i e n t ' s u l c e r symptoms f o l l o w s . (2) A young v e t e r a n w i t h two dependent c h i l d r e n was admitted to h o s p i t a l f i v e times f o r v a r i o u s i n j u r i e s r e l a t e d to h i s pensionable d i s a b i l i t y ( f r a c t u r e and subsequent s h o r t e n i n g of the l e g ) . The d o c t o r suggested that the young man c o u l d guard h i s l e g more c a r e f u l l y through such measures as a r a i s e d boot h e e l and a c q u i s i t i o n of a l i g h t e r j o b . A t the time o f t h i s v e t e r a n ' s l a t e s t h o s p i t a l admission he had not attempted e i t h e r remedy. From the i n f o r m a t i o n o b t a i n e d c o n c e r n i n g the p a t i e n t ' s e a r l y c h i l d h o o d ( p a r e n t s d i e d and the boy was p l a c e d i n a s e r i e s of u n s a t i s f a c t o r y f o s t e r homes, from which he r e p e a t e d l y f l e d ) and p r e s e n t p a t t e r n and una s a t i s f a c t o r y home l i f e , the p o s s i b i l i t y was r a i s e d that t h i s young man was u n c o n s c i o u s l y seeking a t t e n t i o n ( v i a h o s p i t a l i z a t i o n ) i n l i e u of the a f f e c t i o n o r p o s i t i v e a t t e n t i o n l a c k i n g i n h i s e a r l y background and i n h i s present home s i t uation.  42 Summary Chapter 2 b r i e f l y r e c a p i t u l a t e s the reasons  that a  survey o f p a t i e n t readmissions i n r e l a t i o n to M e d i c a l S o c i a l S e r v i c e Department r e f e r r a l s was c o n s i d e r e d f e a s i b l e . Through a g e n e r a l survey o f the 756 cases r e c o r d e d i n the M e d i c a l S o c i a l S e r v i c e case r e g i s t e r , c u l m i n a t i n g i n an a n a l y s i s o f a s p e c i a l group o f v e t e r a n p a t i e n t s (51 personsj 48 men under seventy y e a r s of age and 3 men o v e r seventy years o f age, chosen from a group o f 100 persons r e f e r r e d to MSSD who had had more than three admissions  to h o s p i t a l p r i o r to r e f e r r a l  d u r i n g the 1952-53 f i s c a l y e a r ) a g r a d u a l p i c t u r e  evolved  which i n d i c a t e d that i n many, although c e r t a i n l y not i n a l l i n s t a n c e s , p s y c h o s o c i a l f a c t o r s e i t h e r predominated o r cont r i b u t e d measurably to the p a t i e n t s ' h o s p i t a l C e r t a i n unique  admissions.  f a c t o r s concerning DVA p a t i e n t s such  as treatment e n t i t l e m e n t and o t h e r l e g i s l a t i v e b e n e f i t s were o u t l i n e d i n r e l a t i o n t o the p o s s i b l e i n f l u e n c e o f these t o r s on the v e t e r a n s ' h o s p i t a l admissions  fac-  and i n an e f f o r t to  p o r t r a y a c l e a r e r p i c t u r e o f the v e t e r a n as a person and as a patient.  F i n a l l y , c h a r a c t e r i s t i c s of Medical S o c i a l Service  Department r e f e r r a l s were d e t a i l e d and i l l u s t r a t e d w i t h emphasis on the p s y c h o s o c i a l p r o b l e m - p i c t u r e and the employment p o t e n t i a l o f each v e t e r a n .  CHAPTER 3 THE  ROLE OF THE MEDICAL SOCIAL WORKER, AND THE SERVICES RENDERED  Chapter 3 i s i n t e n d e d to be a f o l l o w - t h r o u g h from the problems found and o u t l i n e d i n Chapter 2 to the s e r v i c e s r e n dered by p r o f e s s i o n a l s o c i a l caseworkers g e n e r a l l y , and by the M e d i c a l S o c i a l S e r v i c e Department p e r s o n n e l with r e f e r e n c e to the s p e c i a l group o f 51 readmitted p a t i e n t s s t u d i e d , i n p a r ticular.  Case i l l u s t r a t i o n s are i n c l u d e d , p l u s background mat-  e r i a l on the dynamics o f i l l n e s s , and the nature o f s o c i a l work i n a medical  setting.  Dynamics of I l l n e s s An understanding  o f i l l n e s s might b e s t be approached  through a d e f i n i t i o n o f h e a l t h  1  adopted  by the World H e a l t h  O r g a n i z a t i o n , a s p e c i a l i z e d agency o f the U n i t e d N a t i o n s : H e a l t h i s a s t a t e of complete p h y s i c a l , mental, and s o c i a l w e l l - b e i n g , and not merely the absence o f disease o r i n f i r m i t y . I l l n e s s , o f course, e x i s t s when the d e f i n e d s t a t e of w e l l - b e i n g does n o t e x i s t . I l l n e s s , o r a p a r t i c u l a r i l l n e s s , means many t h i n g s to as many people, a s does any l i f e experience.  I l l n e s s may have a  d i f f e r e n t meaning to the same person a t d i f f e r e n t  times.  A state  Chisholm, Brock, " O r g a n i z a t i o n f o r World H e a l t h , " Mental Hygiene. J u l y , 1948. V. 32. pp. 364-371. 1  44 o f i l l - h e a l t h r e p r e s e n t s c e r t a i n t h i n g s to a person, dependi n g upon the nature and s e v e r i t y o f the i l l n e s s ,  the e n v i r o n -  mental s i t u a t i o n , and the person's p e r s o n a l i t y s t r u c t u r e . A c c o r d i n g to the person and the s i t u a t i o n , then, i l l n e s s might r e p r e s e n t l o s s o f s t a t u s , l o s s o f income, o r c o n v e r s e l y , (and e s p e c i a l l y i n a v e t e r a n s ' h o s p i t a l s e t t i n g ) , i n c r e a s e d s t a t u s and income.  I t might e n t a i l l e n g t h y and unwelcome sep-  a r a t i o n from f a m i l y and f r i e n d s , o r refuge from a t r y i n g home situation.  I l l n e s s might mean permanent o r temporary  cessation  o f p l e a s u r a b l e a c t i v i t i e s , o r i t might mean escape from unpleasant r e a l i t y pressures.  Everyone  does not possess comparable f a c u l -  t i e s f o r meeting a d v e r s i t y o r f o r t o l e r a t i n g f r u s t r a t i o n s .  When  p r e s s u r e s mount to a c e r t a i n p o i n t , the i n d i v i d u a l may be f o r c e d to employ defences, one of which c o u l d be i l l n e s s , i n o r d e r to maintain some measure o f e q u i l i b r i u m . I f a person i s u s i n g i l l n e s s as a defence o r as a r e l e a s e mechanism, i t i s important to c o n s i d e r t h a t i l l n e s s may be the b e s t adjustment  to h i s l i f e  a t the p a r t i c u l a r time.  s i t u a t i o n t h a t the person can make  F o r example, r e l e a s e i n t o some r e l a -  t i v e l y m i l d i n d i s p o s i t i o n , i f i t permits a person to escape p e r manently  a dreaded  t a s k , through such a s o c i a l l y a c c e p t a b l e means  as i l l n e s s , may prevent a much more s e r i o u s c o l l a p s e . i l l n e s s o r d i s e a s e cannot be s t r i c t l y l o c a l i z e d ; a p e r s o n a l i t y involvement; there are always  I n any case,  there i s always  feelings.  I t i s n e c e s s a r y f o r whomever i s d e a l i n g with a person who i s i l l ,  to make every e f f o r t  to understand the person w i t h the  45 i l l n e s s i n terms of the accompanying f e e l i n g s , i n i t i a t e d  or  r e a c t i v a t e d by i l l n e s s , o r p r e d i s p o s i n g the i l l n e s s . I s the p a t i e n t s t r u g g l i n g w i t h f e e l i n g s of anger and b i t t e r n e s s a t h i s lot?  I s he bewildered  by the medical procedures;  treatment  and of the prognosis?  punished,  o r ashamed on account of h i s i l l n e s s ?  r e l i e v e d , r e s i g n e d , and  f e a r f u l of the  Does the p a t i e n t f e e l  depressed,  Or does he  feel  content w i t h h i s i n d i s p o s i t i o n ? What  are the dynamic f a c t o r s o p e r a t i n g w i t h r e f e r e n c e to the k i n d l y , but w o r r i e d - l o o k i n g o l d v e t e r a n , i n h o s p i t a l again w i t h  an  e x a c e r b a t i o n o f h i s h e a r t c o n d i t i o n ; o r the tense, young, Korean v e t e r a n who treatment  responds o n l y i n monosyllables?  What i s the  best  p l a n f o r each p a t i e n t ?  Treatment Team In a l a r g e s e t t i n g s t a f f e d with s p e c i a l i s t s , such as Shaughnessy H o s p i t a l , many d i f f e r e n t persons are i n v o l v e d i n c a r r y i n g out  the treatment  p r e s c r i b e d f o r each p a t i e n t .  s i t u a t i o n enables a teamwork approach, but the f a c t specialists  t r e a t the p a t i e n t does not  Such a  that various  i t s e l f connote teamwork.  S k i l l e d , c o - o r d i n a t e d e f f o r t towards the p a t i e n t ' s optimum r e c o v e r y , based on a knowledge of the t o t a l needs and c a p a b i l i t i e s o f the p a t i e n t , i s the keynote of an team approach.  In a medical  s e t t i n g , the d o c t o r , who  paramount r e s p o n s i b i l i t y f o r the p a t i e n t , and who one  enlightened has  the  i s the o n l y  competent to make d e c i s i o n s r e g a r d i n g the p h y s i c a l , mental,  o r emotional  c a p a c i t i e s of the person  under h i s care  i n t o c e r t a i n p a r t s of a p r o j e c t e d treatment the l e a d e r o f the treatment  team.  to e n t e r  p l a n , f u n c t i o n s as  The d o c t o r , t h e r e f o r e , i s i n  46 a v i t a l p o s i t i o n to u t i l i z e  the v a r i o u s  treatment s e r v i c e s on  b e h a l f o f the p a t i e n t ; and the p a t i e n t , i n turn, has a r i g h t to expect f u l l  use to be made o f a v a i l a b l e  The  facilities.  p r o f e s s i o n a l h o s p i t a l o r medical team may comprise  d o c t o r , nurse, s o c i a l worker, p s y c h o l o g i s t , and  various  technicians,  i n DVA h o s p i t a l s , Veterans' Welfare O f f i c e r , each with  t i n c t i v e , but complementary f u n c t i o n s .  dis-  I n a d d i t i o n to the  i n c l u s i o n of p r o f e s s i o n a l p e r s o n n e l i n the d i a g n o s t i c and t r e a t ment p r o c e s s , i t i s important to i n c l u d e  the p a t i e n t , and when  p r a c t i c a l , r e l a t i v e s , i n the treatment p l a n . operation,  In t h i s way, c o -  r a t h e r than r e s i s t a n c e , may be f o s t e r e d .  of the treatment team i n i t i a t e s s e r v i c e s on behalf  No member o f the p a t i e n t  w i t h o u t the knowledge and approval o f the d o c t o r i n charge o f the case. Role o f the S o c i a l Worker as a Member o f the Team — R e s p o n s i b i l i ties"^  Special ~  P r o f e s s i o n a l s o c i a l casework, which i s the s o c i a l work method employed i n a medical s e t t i n g , and i n any s e t t i n g i n which the s o c i a l worker d e a l s w i t h one i n d i v i d u a l a t one time, r a t h e r than w i t h a group o f i n d i v i d u a l s a t one time, has been and  described  the y e a r s .  defined  numerous times by s o c i a l work p r a c t i t i o n e r s o v e r  A concise  d e f i n i t i o n f o r m u l a t e d by Swithun Bowers i s : 1  ... an a r t i n which knowledge o f the s c i e n c e o f human r e l a t i o n s and s k i l l i n r e l a t i o n s h i p a r e used to m o b i l i z e c a p a c i t i e s i n the i n d i v i d u a l and r e s o u r c e s i n the community, a p p r o p r i a t e f o r b e t t e r adjustment between the c l i e n t and a l l o r any p a r t o f h i s t o t a l environment.  Bowers^ Swithun, "The Nature and D e f i n i t i o n o f S o c i a l Casework." Journal o f S o c i a l Casework. XXX (October, 1949), 311-17.  The  philosophy  47 and p r a c t i c e of s o c i a l work are based on  c e r t a i n p r i n c i p l e s * such as s o c i e t y ' s r e s p o n s i b i l i t y f o r p r o v i d i n g the means f o r meeting b a s i c dependency needs; a b e l i e f each person i s unique, and t h e r e f o r e , should  receive  treatment; a b e l i e f t h a t every i n d i v i d u a l has worth, o f h i s c a p a c i t y to c o n t r i b u t e  that  differential regardless  to s o c i e t y ; and r e c o g n i t i o n o f a  person's r i g h t to manage h i s own a f f a i r s , unless  intervention i s  necessary to prevent i n j u r y to the person concerned o r to o t h e r s . The  extent  and k i n d o f h e l p which the s o c i a l worker i s enabled  to o f f e r i s governed by what the c u l t u r e sees as the purpose i n life,  and what the c u l t u r e sees as the worth o f the i n d i v i d u a l . In Shaughnessy H o s p i t a l , the s o c i a l caseworker, o r  medical s o c i a l worker, operates as a member o f the treatment team, o n l y upon r e f e r r a l o f a case s i t u a t i o n f o r MSSD a t t e n t i o n .  About  1 i n 6 o r 7 p a t i e n t s admitted to Shatrghnessy H o s p i t a l i n the course of a y e a r a r e r e f e r r e d to MSSD a t some p o i n t i n t h e i r treatment. B r i e f l y , the g o a l o f the s o c i a l worker i n a medical s e t t i n g i s , t o f a c i l i t a t e medical c a r e , thus c o n t r i b u t i n g to the p a t i e n t ' s r e s t o r a t i o n t o , and continuance i n h e a l t h i f t h i s i s to be r e a l i z e d , through techniques such as i n t e r p r e t a t i o n , supp o r t i v e h e l p , and m a t e r i a l a i d ( d e s c r i b e d l a t e r i n t h i s  study).  In s i t u a t i o n s o f t e r m i n a l o r c h r o n i c i l l n e s s , i t i s e s p e c i a l l y necessary to h e l p  the p a t i e n t and/or h i s f a m i l y to accept the  See Appendix D f o r L i n t o n B. S w i f t ' s creed of s o c i a l work p r i n c i p l e s .  case-  48 diagnosis and prognosis.  Gordon Hamilton  1  c i t e s the main con-  t r i b u t i o n of the professional s o c i a l caseworker on the medical team as "accenting the psychosocial, i n t e r - f a m i l i a l component in study and treatment." The defined function of medical s o c i a l workers at Shaughnessy Hospital (or any DVA  hospital) i s outlined i n Treat-  ment Instruction Letters and d i r e c t i v e s , issued from time to time, by the Director General of Treatment Services, Ottawa. 2 One such Letter contains a f a i r l y i n c l u s i v e description of the work to be engaged i n by DVA medical s o c i a l workers: Individualized service, (including casework with the patient and/or his family, preparation of s o c i a l h i s t o r i e s , securing of other pertinent information, ref e r r a l to the community f o r service) may be given, under medical d i r e c t i o n , to ... any patient, veteran or nonveteran, under departmental medical care i n h o s p i t a l or as an outpatient, whose personal and s o c i a l problems are related to h i s i l l n e s s or d i s a b i l i t y .... i t i s understood that the medical s o c i a l worker w i l l c a l l on the assistance of other departmental and community services i n meeting the needs of the patient and h i s doctor, when, i n the opinion of the doctor concerned, the value of the requested service w i l l not be materially lessened by channelling through someone else, and, the service requested i s i n l i n e with the p o l i c y and function of the departmental or community service to whom the request i s made .... Within  this defined framework, e f f e c t i v e s o c i a l case-  work practice i s possible at Shaughnessy H o s p i t a l , but certain factors sometimes operate against i t s optimum e f f i c a c y . These factors include late r e f e r r a l , non-referral, short-term  treat-  ment, occasional lack of co-ordination of the services of 1 Hamilton, Gordon, Theory and Practice of S o c i a l Casework. Columbia University Press, New York, 1951. Canada, Department of Veterans A f f a i r s , Treatment Instruction L e t t e r , No. 1-49: P o l i c y - Function of the Service. 1949. 2  1  49 various personnel,  p l u s the f a c t that the p a t i e n t o r c l i e n t , i n  most cases, does n o t i n i t i a t e the request l a t t e r s i t u a t i o n might preclude  f o rservice.  This  s o c i a l s e r v i c e s to c e r t a i n  persons i f the time i s s h o r t , and the c l i e n t i s understanda b l y r e l u c t a n t , o r has l i t t l e  self-awareness.  With the concepts, f u n c t i o n , g o a l s , and l i m i t a t i o n s o f medical s o c i a l work i n mind, i t should be p o s s i b l e to evaluate o r to e x p l o r e  the a c t u a l medical s o c i a l s e r v i c e s rendered on  b e h a l f o f , and i n c o - o p e r a t i o n f a m i l i e s represented in  with,  the v e t e r a n s  and v e t e r a n s '  i n the 51 s e l e c t e d case s t u d i e s  discussed  t h i s paper.  M e d i c a l S o c i a l S e r v i c e s Rendered The  nature o f the s o c i a l s e r v i c e s rendered i n r e l a -  t i o n to the p a r t i c u l a r s e t t i n g and the p a r t i c u l a r group under study may be i n c l u d e d w i t h i n seven broad categories*" which are as f o l l o w s : (a) R e f e r r a l — i n c l u d e s d i r e c t i o n o f c l i e n t s to an a p p r o p r i a t e r e s o u r c e , which may be w i t h i n Shaughnessy H o s p i t a l o r some o t h e r DVA s e t t i n g , o r i n the community. In t h i s s e t t i n g the V e t e r a n s ' Welfare O f f i c e r s are o f t e n the o b j e c t o f r e f e r r a l i n view o f t h e i r d e f i n e d f u n c t i o n and ready f a c i l i t i e s f o r a t t e n d i n g to l e g i s l a t i v e b e n e f i t s , job placement, and housing accommodation. (b) Supportive Help — t h i s type of s e r v i c e i s an attempt to s u s t a i n the " s t a t u s quo" o r the c u r r e n t l e v e l of p e r s o n a l i t y f u n c t i o n i n g o f the v e t e r a n and/or h i s f a m i l y through p s y c h o l o g i c a l and p r a c t i c a l support. Frequently, s u p p o r t i v e h e l p i s the extent o f the d i r e c t casework o f f e r e d to c h r o n i c neurotic p a t i e n t s , f o r example, although many v a r i a t i o n s o f i n d i r e c t help may be g i v e n . To a c e r t a i n degree, s u p p o r t i v e h e l p i s o f f e r e d i n each casesituation.  C a t e g o r i e s b, c, d, and g, are p r e c i s e l y d e f i n e d and have g e n e r a l a p p l i c a b i l i t y i n s o c i a l work p r a c t i c e ; c a t e g o r i e s a, e, and f , r e p r e s e n t g e n e r a l p r a c t i c e but the e x p l a n a t i o n of these c a t e g o r i e s i s adapted to MSSD p r a c t i c e a t Shaughnessy H o s p i t a l .  50 ( c ) I n t e r p r e t a t i o n — i n c l u d e s e x p l a n a t i o n o f the outward o r o v e r t a s p e c t s o f a problem-; c l a r i f i c a t i o n o f a t t i t u d e s , i s s u e s , and f e e l i n g s ; d i s t i n g u i s h i n g between f a c t s and f e e l i n g s ; p o i n t i n g out o f behavior p a t t e r n s ; and i n r a r e i n s t a n c e s , e x p l a n a t i o n of m o t i v a t i o n s . I n t e r p r e t a t i o n w i t h i n t h i s study was o f f e r e d to p a t i e n t s , r e l a t i v e s , d o c t o r s , o r o t h e r persons i n v o l v e d i n the situations. (d) S o c i a l H i s t o r y Taking — The end product o f s o c i a l h i s t o r y t a k i n g i s a r e c o r d o f the present problems i t u a t i o n , p l u s r e l e v a n t background data, i n c l u d i n g f a c t s , and the way people f e e l about the f a c t s . The process o f s o c i a l h i s t o r y t a k i n g should be r e c i p r o c a l , and where poss i b l e , l e a d to a g r e a t e r understanding of the p a t i e n t o r c l i e n t , both by the treatment team, and by the p a t i e n t himself. S k i l f u l s o c i a l h i s t o r y t a k i n g i s dependent upon the s o c i a l worker's a b i l i t y to r e l a t e q u e r i e s to the main theme, as seen by the p a t i e n t . I t i s o f t e n d i f f i c u l t , and sometimes unwise, to procure a l l the f a c t s i n one i n t e r v i e w . (e) E x p l a n a t i o n and O f f e r o f S e r v i c e s Only — N a t u r a l l y , i n a l l case s i t u a t i o n s , a b r i e f , p r e l i m i n a r y explanat i o n i s made o f the type o f help MSSD i s able to o f f e r . In some i n s t a n c e s o f r o u t i n e s c r e e n i n g , however, o r r e f e r r a l to MSSD without the p a t i e n t ' s knowledge, the p a t i e n t i s not i n need o f , o r not w i l l i n g to accept the s e r v i c e s of MSSD, and f u r t h e r c o n t a c t i s l e f t to the p a t i e n t ' s i n i t i a tive . No s e r v i c e rendered — U n f o r t u n a t e l y , a few r e f e r r a l s do not reach the MSSD u n t i l a f t e r the p a t i e n t ' s d i s c h a r g e , o r so l a t e i n the course o f the p a t i e n t ' s h o s p i t a l i z a t i o n , that the s o c i a l worker i s unable to c o n t a c t the person r e f e r r e d , p r i o r to h i s d i s c h a r g e . ( f ) M a t e r i a l A i d — F o r purposes o f t h i s study, mate r i a l a i d r e f e r s to the a c t u a l p r o c u r i n g o f goods o r funds, by MSSD, on behalf o f the p a t i e n t , and i n c l u d e s o b t a i n i n g c l o t h i n g from the h o s p i t a l s t o r e s ; money from the S u p e r i n tendent's A s s i s t a n c e Fund, which enables MSSD to make a grant o r a l o a n n o t exceeding ten d o l l a r s ; o r money from the Christmas Cheer Fund. D i r e c t i o n o f the p a t i e n t to another resource f o r m a t e r i a l a i d i s i n c l u d e d under ( a ) above. (g) S o c i a l Assessment — c o n s t i t u t e s an a p p r a i s a l of f a c t o r s w i t h i n the p a t i e n t ' s environment, such as the phys i c a l c o n d i t i o n o f h i s home, and the composition and a t t i tude o f the p a t i e n t ' s f a m i l y o r f r i e n d s , o r whomever i s concerned w i t h the p a t i e n t ' s l i v i n g accommodation. S u i t a b i l i t y o f o t h e r a v a i l a b l e sources o f care w i t h i n the community may a l s o be assessed.  51 Within  the group o f 51 p a t i e n t s s t u d i e d , more than one  type o f s e r v i c e i s rendered  by MSSD i n most o f the s i t u a t i o n s .  In o n l y three out o f ten i n s t a n c e s , f o r example, was s o c i a l t o r y t a k i n g the o n l y medical  s o c i a l s e r v i c e undertaken.  than 10G s e r v i c e s were rendered  his-  More  i n c o o p e r a t i o n with o t h e r mem-  bers o f the treatment team on b e h a l f o f the f i f t y - o n e p a t i e n t s under study.  In 16 i n s t a n c e s , o n l y one s e r v i c e was o f f e r e d ,  and i n two s i t u a t i o n s , the p a t i e n t was d i s c h a r g e d  before any  s o c i a l work s e r v i c e s c o u l d be i n i t i a t e d . Table F (showing the d i s t r i b u t i o n of medical s e r v i c e s rendered,  i n r e l a t i o n to the veterans*  social  employment  p o t e n t i a l as e s t a b l i s h e d i n Chapter 2) p i n p o i n t s " r e f e r r a l " as the s e r v i c e most f r e q u e n t l y employed by MSSD. o c c a s i o n , however, was r e f e r r a l Within and  On n o t one  the o n l y form o f a s s i s t a n c e .  the employment p o t e n t i a l c a t e g o r i e s o f "poor o r n i l "  " f a i r , " r e s p e c t i v e l y , r e f e r r a l was o f f e r e d most f r e q u e n t l y ,  and i n the "good" employment p o t e n t i a l group, r e f e r r a l was o f f e r e d w i t h o n l y s l i g h t l y l e s s frequency  than was s u p p o r t i v e  help. Supportive  h e l p f o l l o w s r e f e r r a l as the most f r e -  quent s e r v i c e o f f e r e d to the t o t a l group, and i s i n t u r n , f o l l o w e d by i n t e r p r e t a t i o n , s o c i a l assessment, s o c i a l h i s t o r y t a k i n g , e x p l a n a t i o n and o f f e r of s e r v i c e s , and i n one i n s t a n c e only, material a i d .  The r e s p e c t i v e e m p l o y a b i l i t y c a t e g o r i e s  f o l l o w the t o t a l group p a t t e r n f a i r l y c l o s e l y with regard to r e f e r r a l and s u p p o r t i v e h e l p , but d i v e r g e from that p o i n t .  52 Table F. D i s t r i b u t i o n of M e d i c a l S o c i a l S e r v i c e s  Total M e d i c a l S o c i a l S e r v i c e s Rendered S er(e) (d) (f) 1 (g) Employa- (a) (b) (c) v i ces Ref Sup I n t e r p Soc.His E x p l Mat.Aid Soc .As bility (A) Poor or n i l  19  14  11  2  3  (B) F a i r  8  5  3  5  4  (C) Good  5  6  4  3  18  10  Total  32  25  1  15  2  -  -  9  1  15  Total Veterans  65  30  25  13  20  8  110  51  Source: MSSD Case Records  S o c i a l assessment and m a t e r i a l a i d were n o t d i r e c t l y at  undertaken  a l l w i t h v e t e r a n s i n the " f a i r " and "good" employment  poten-  t i a l c a t e g o r i e s , whereas, i n e x a c t l y h a l f o f the s i t u a t i o n s  con-  c e r n i n g v e t e r a n s i n the "poor o r n i l " e m p l o y a b i l i t y grouping, s o c i a l assessment was r e q u i r e d and o b t a i n e d , f r e q u e n t l y as a p r e l i m i n a r y to recommendation f o r d o m i c i l i a r y care ( S e c t i o n 2 9 ) . Complete, o r near complete,  s o c i a l h i s t o r i e s were  taken  i n o n l y a v e r y few i n s t a n c e s (2) among the group w i t h the l e a s t employment p o t e n t i a l , but were procured i n j u s t o v e r one t h i r d of  the c a s e - s i t u a t i o n s r e g a r d i n g v e t e r a n s i n both the " f a i r "  and the "good" employment p o t e n t i a l groupings.  Interpretation  and e x p l a n a t i o n and o f f e r o f s e r v i c e s were undertaken r e l a t i v e l y equal frequency among the b e t t e r employment  with poten-  t i a l groups, whereas, i n the l e a s t employable group, i n t e r -  53 p r e t a t i o n was  r e q u i r e d with approximately f o u r times the  fre-  quency t h a t e x p l a n a t i o n and o f f e r o f s e r v i c e s o n l y was r e q u i r e d . T h i s l a t t e r s i t u a t i o n i s p r o b a b l y r e s p o n s i b l e i n l a r g e measure, to the f a c t t h a t more v e t e r a n s i n the lowest e m p l o y a b i l i t y c a t e g o r y are i n need of d o m i c i l i a r y care o r constant care i f r e t u r n e d to t h e i r homes, and the reasons and the means f o r a d j u s t i n g to such a dependent s i t u a t i o n o f t e n r e q u i r e p a i n s t a k i n g i n t e r p r e t a t i o n , p l u s support, to h e l p the p a t i e n t and/or h i s f a m i l y to accept the n e c e s s i t y and r e s p o n s i b i l i t y f o r such an adjustment.  Of course, i n some i n s t a n c e s of s i n g l e o r lone  v e t e r a n s , d o m i c i l i a r y care i s sought, and r e f u s a l o f such  care  would n e c e s s i t a t e even more i n t e r p r e t a t i o n than would recommendation f o r i n s t i t u t i o n a l i z a t i o n . Illustrations Case i l l u s t r a t i o n s p r o v i d e a b e t t e r guage f o r determini n g the nature of the s o c i a l s e r v i c e rendered, and, where s i g n i f i c a n t , the e f f e c t of casework s e r v i c e s on the admission ture.  pic-  Case e x c e r p t s , i n d i s g u i s e d form, are i n c l u d e d under  the v a r i o u s c a t e g o r i e s of s e r v i c e s rendered. (a) R e f e r r a l (1) T h i s case, c o n c e r n i n g a 62-year-old World War v e t e r a n , married, and i n r e c e i p t of WVA,  was  I  p i c k e d up by the  worker r o u t i n e l y , f o l l o w i n g a p r e v i o u s r e f e r r a l to MSSD f o r a s s i s t a n c e w i t h the v e t e r a n ' s w i f e s medical treatment. 1  the p r e s e n t admission problem.  Upon  (6th) the p a t i e n t p r e s e n t e d a s i m i l a r  54 The s o c i a l worker r e c o r d e d : "Case re-opened on r e - a d m i s s i o n . P a t i e n t was v i s i t e d on the ward and he again expressed concern over h i s w i f e ' s poor h e a l t h , s t a t i n g t h a t she i s unable to work and unable to a f f o r d treatment. Two p o s s i b i l i t i e s were suggested to him — f i r s t t h a t he c o n t a c t the F i e l d S e r v i c e s R e p r e s e n t a t i v e (Welfare O f f i c e r ) , o r secondly, that he c o n t a c t the (community agency). P a t i e n t was q u i t e agreeable to t h i s p l a n . (Four days l a t e r ) : ... Welfare O f f i c e r c o n t a c t e d r e g a r d i n g p o s s i b l e l o c a l agencies i n the area. He suggested we cont a c t the (community agency) d i r e c t as he would have to have c o n t a c t w i t h that agency. L e t t e r to p a t i e n t , as he was d i s c h a r g e d before worker saw him a g a i n , s u g g e s t i n g c o n t a c t (copy to - ) . D u r i n g both r e f e r r a l s the veteran was  referred for f i n -  a n c i a l a s s i s t a n c e on behalf o f h i s w i f e , and s e r v i c e s were l i m i t e d to t h i s a r e a . was  During the l a t t e r admission,  the p a t i e n t  i n h o s p i t a l f o r 19 daysj he was not seen by the s o c i a l worker  u n t i l the 13th day, however, and d i s c h a r g e d before the worker had completed  his service.  There was  little  social  opportunity,  therefore, f o r further service. A review of the d i s t r i c t o f f i c e f i l e gave many l e a d s s u g g e s t i v e o f p s y c h o s o c i a l d i f f i c u l t i e s c o n t r i b u t i n g to hosp i t a l admissions.  The v e t e r a n was  m a r r i e d f o r the t h i r d  having d i v o r c e d h i s two p r e v i o u s wives. date of h i s l a s t d i v o r c e , p a t i e n t was  time,  C o i n c i d i n g with the  i n h o s p i t a l , and a doc-  t o r ' s summary i s e n t e r e d : " M a r i t a l d i f f i c u l t i e s , p r o f u s i o n of complaints, f u n c t i o n a l a s p e c t , r e l u c t a n t (The p a t i e n t was sequent  NOT  to l e a v e h o s p i t a l . "  r e f e r r e d to MSSD a t t h i s t i m e ) .  A sub-  medical note r e a d : "Large p s y c h i c and dependent f a c -  tor i n personality." good u n t i l 1 9 — .  He  This veteran stated that h i s health has had s e v e r a l readmissions  was  to Shaughnessy  H o s p i t a l f o r u l c e r f l a r e - u p s between.19— and 1951.  A note  filed  55 by an o r t h o p a e d i c  consultant  i n 1950 c o n t a i n s  remarks t o the  e f f e c t t h a t the p a t i e n t should n o t be so d i s a b l e d as he would appear t o be, on p h y s i c a l f i n d i n g s ; the c o n s u l t a n t  further  noted that the p a t i e n t ' s w i f e was e v i d e n t l y unable to leave the home w i t h o u t g e t t i n g someone to care f o r the v e t e r a n . consultant  The  remarks that t h i s seems t o be an unnecessary degree  of d i s a b i l i t y .  (The p a t i e n t was NOT r e f e r r e d to MSSD a t t h i s  time). S e v e r a l p o i n t s a r e apparent from t h i s b r i e f o f the case.  excerpt  F i r s t , the o r i g i n a l r e f e r r a l was f o r f i n a n c i a l  a s s i s t a n c e , and the p a t i e n t ' s expressed concern d u r i n g  sub-  sequent contact w i t h the s o c i a l worker was f i n a n c i a l need; f o l l o w i n g the casework p r i n c i p l e o f "meeting the c l i e n t where he i s , "  the s o c i a l worker's i n i t i a l  s e r v i c e s were c o r r e c t l y  d i r e c t e d towards meeting the expressed need. worker had i n s u f f i c i e n t time between i n i t i a l p a t i e n t , and the p a t i e n t ' s d i s c h a r g e , of more b a s i c d i f f i c u l t i e s . o r i g i n a l MSSD c o n t a c t  on the r e c o r d of the  t h a t the d i s t r i c t o f f i c e f i l e was n o t the p a t i e n t ' s  discharge;  a l l p r o b a b i l i t y , t h e r e f o r e , the worker was not aware o f the  p a t i e n t ' s admission p a t t e r n . opportunities in  c o n t a c t w i t h the  t o work towards d i s c u s s i o n  I t i s notated  a v a i l a b l e t o the s o c i a l worker before in  Secondly, the  (underlined)  T h i r d l y , a t l e a s t two g l a r i n g  f o r r e f e r r a l to MSSD were  the medical r e c o r d s , had the f u n c t i o n o f MSSD been  evident recognized,  y e t r e f e r r a l was n o t made u n t i l f i n a n c i a l need was expressed by the p a t i e n t . . M a t e r i a l a s s i s t a n c e  c o n s t i t u t e s an important  area  56 of  s o c i a l s e r v i c e , b u t i n Shaughnessy H o s p i t a l , m a t e r i a l a i d  i s o n l y a v e r y minor f u n c t i o n o f MSSD, and i n t h i s  situation,  d i r e c t f i n a n c i a l a i d from MSSD would n o t be s u f f i c i e n t to  (limited  $10.00). The  s p e c u l a t i o n i s v a l i d that e a r l i e r r e f e r r a l a l o n g the  course o f admissions ient's hospital  might have l e s s e n e d the number o f the p a t -  admissions.  (b) S u p p o r t i v e  Help  Instances o f s u p p o r t i v e h e l p a r e d i f f i c u l t t o i l l u s t r a t e mainly due to the c o n c i s e n e s s o f MSSD r e c o r d s , which, as a g e n e r a l r u l e , give the f a c t s requested,  p o i n t up trends  when apparent, and o f t e n g i v e the s o c i a l worker's of  impression  the s i t u a t i o n a l e t i o l o g y , but i n many i n s t a n c e s , do not  d e s c r i b e the casework p r o c e s s .  (The r e c o r d s a r e i n l i n e  with  the g e n e r a l p o l i c y of b r e v i t y , however, and w r i t t e n r e c o r d s are supplemented by d i s c u s s i o n w i t h the d o c t o r i n charge o f the case. see f i n a l  Some r e v i s i o n would be i n order, n e v e r t h e l e s s ,  —  chapter).  Another d i f f i c u l t y i n r e p r o d u c i n g examples o f support i v e h e l p i s the f a c t t h a t a s u p p o r t i v e , h a r d l y d i s c e r n i b l e t h r e a d may permeate the w o r k e r - p a t i e n t  c o n t a c t by a t t i t u d e ,  g e s t u r e s , f a c i a l e x p r e s s i o n , but v e r y few words.  Following  i s an excerpt from one c a s e - s i t u a t i o n which r e f l e c t s a b e g i n ning supportive  thread:  The v e t e r a n , d i v o r c e d , n e a r i n g 40 y e a r s of age, was admitted  to h o s p i t a l f o r the f i f t h  time w i t h p h l e b i t i s ( h i s  57 four previous arthritis).  admissions were e i t h e r f o r p h l e b i t i s o r S e v e r a l y e a r s ago  the v e t e r a n was  seen by Psy-  c h i a t r y , and no g r o s s p s y c h i a t r i c d i s a b i l i t y was The  p s y c h i a t r i s t s t a t e d t h a t the v e t e r a n  cal  d i s a b i l i t y , but p l a c e d a heavy w e i g h t i n g on s o c i a l f a c -  tors. and  The  p a t i e n t had  tended to d r i n k  had  apparent.  a real physi-  f i n a n c i a l and v o c a t i o n a l  difficulties,  excessively.  The s o c i a l worker recorded i n p a r t : "Dr. _ s t a t e s that p a t i e n t appears to l a c k the s e l f - d e t e r m i n a t i o n o r r e s p o n s i b i l i t y to care f o r h i m s e l f , and i s a p e r s o n a l i t y problem. On r e c e i p t of r e f e r r a l from Dr. noting t h a t he drew a t t e n t i o n to poor s o c i a l hygiene, a l c o h o l i s m , and f i g h t i n g , the d i s t r i c t o f f i c e f i l e was r e viewed and community sources c o n t a c t e d — - ( f i n d i n g s recorded). A review of h i s numerous admissions to hosp i t a l shows t h a t he has u s u a l l y come i n f o l l o w i n g a d r i n k i n g bout o r under the i n f l u e n c e of l i q u o r . The r e c u r r e n t p a i n and d i f f i c u l t y w i t h h i s l e g have undoubtedly ( c o n t r i b u t e d ) to h i s d r i n k i n g , and t h i s i n t u r n , has l e d to a way o f l i f e which has i n c r e a s e d the leg d i s a b i l i t y . P a t i e n t i n t e r v i e w e d i n ... o f f i c e and f r a n k l y admits h i s p a s t s o c i a l problems. He says he has maintained c o n t a c t w i t h AA s i n c e l a s t — . He was encouraged to keep i n touch w i t h them. He c l a i m s , w i t h c o n s i d e r a b l e s u p p o r t i v e d e t a i l ) , t h a t he does not d r i n k when i n steady work. He says that he has had to take heavy work u n s u i t e d to h i s d i s a b i l i t y , then l a y o f f because of p a i n . . . and i n consequence he has become d i s couraged and has been s i n k i n g ... to s k i d - r o a d l e v e l . He was urged to c o n t a c t ( s p e c i a l employment placement o f f i c e r ) re s u i t a b l e employment .... B  The  minimal g o a l i n t h i s s i t u a t i o n i s to keep the  p a t i e n t from " s i n k i n g , " to keep him quate, i f not admirable,  f u n c t i o n i n g a t an  ade  level.  (c) Interpretation (1) An another DVA  e n q u i r y was  made f r o m a s o c i a l worker i n  s e t t i n g on behalf of a p u b l i c h e a l t h nurse, as to  58 whether o r n o t the p a t i e n t ' s w i f e was aware of the v e t e r a n ' s medical d i a g n o s i s .  The v e t e r a n , 3 2 - y e a r s - o l d , was a w e l l  i n t e g r a t e d young man w i t h a 100$ d i s a b i l i t y pension f o r a d e t e r i o r a t i n g organic brain c o n d i t i o n . admissions  His five  hospital  ( f o u r o f them f o r h i s pensionable d i s a b i l i t y ) have  been on medical grounds.  H i s present admission was occasioned  by a b r o n c h i a l i n f e c t i o n . I n t e r p r e t a t i o n undertaken of  by MSSD was i n the nature  c l a r i f i c a t i o n of issues. The s o c i a l worker s t a t e s : "Miss _ ( s o c i a l worker) t e l e phoned s a y i n g she had e n q u i r y from M i s s _ ( P u b l i c H e a l t h Nurse) who p l a n s to v i s i t t h i s p a t i e n t ' s home. Miss _ wonders i f f a m i l y i s aware p a t i e n t has ( b r o n c h i a l i n f e c t i o n ) and wishes to have t h i s c l a r i f i e d w i t h p a t i e n t . S o c i a l worker requests t h a t we v i s i t p a t i e n t and inform Miss (Next d a y ) : P a t i e n t seen and f o r e g o i n g e x p l a i n e d . He has been employed i n department o f , and e v i d e n t l y p r e s e n t t r a n s f e r to U n i t a d v i s e d onT-Ray f i n d i n g s . Speaks s l o w l y and d e l i b e r a t e l y and i n answer to e n q u i r y s t a t e s h i s w i f e i s aware o f present d i a g n o s i s and has a c cepted i t v e r y w e l l . He p a i d t r i b u t e to h e r understanding and support .... P a t i e n t speaks w i t h p r i d e o f h i s two c h i l dren .... He w i l l inform h i s w i f e o f proposed v i s i t o f P u b l i c H e a l t h Nurse and understands why t h i s i s undertaken There do not appear to be any problems a t p r e s e n t , and p a t i e n t i s aware o f our i n t e r e s t should anyt h i n g a r i s e i n which we c o u l d be h e l p f u l . Gave Miss i n f o r m a t i o n as requested." ~~ (2) T h i s c a s e - s i t u a t i o n was p i c k e d up by the s o c i a l  worker d u r i n g the p a t i e n t ' s s i x t h h o s p i t a l admission f o r r e occurring (organic) trouble.  P r e v i o u s l y p a t i e n t had been r e -  ferred f o r vocational counselling.  Most readmissions were on  medical grounds, and e n t i r e l y n e c e s s a r y . L a t t e r l y , however, v e t e r a n requested d o m i c i l i a r y care, a s he s a i d he had n o t  59 s u f f i c i e n t funds (WVA, s i n g l e r a t e , o n l y ) and that h i s room was not s u i t a b l e . C l a r i f i c a t i o n o f a t t i t u d e s , i s s u e s , and f e e l i n g s , was accomplished through e x p l a n a t i o n  of r e g u l a t i o n s and a reminder  o f the reasons f o r the p a t i e n t ' s n o t r e c e i v i n g d o m i c i l i a r y care on a p r e v i o u s  occasion.  The s o c i a l worker's r e c o r d i s , i n p a r t : "Case re-opened. ... V i s i t e d on ward. Veteran f e e l i n g b e t t e r . He found i t d i f f i c u l t l i v i n g i n the robm behind the shop and would l i k e to g e t i n t o S e c t i o n 29 ( d o m i c i l i a r y c a r e ) a t , but understands t h a t t h i s might be a b i t d i f f i c u l t to arrange. S e c t i o n 29 p r o v i s i o n s e x p l a i n e d , the two b a s i c requirements being, p h y s i c a l d i s a b i l i t y and l a c k of a p l a c e to l i v e . I t was p o i n t e d out that a t the time o f h i s p r e v i o u s a p p l i c a t i o n he had n o t gone S e c t i o n 29, and not because o f the s t r i c t r e g u l a t i o n s , but because he had appeared able and w i l l i n g to t r y and get a l o n g on h i s own. There i s never any q u e s t i o n about g r a n t i n g S e c t i o n 29 when a v e t e r a n r e a l l y needs i t . V i s i t e d Veteran ( a g a i n ) . He had made i n q u i r i e s and h i s former accommodation was no l o n g e r a v a i l a b l e . He i s f i r m l y convinced t h a t he r e q u i r e s i n s t i t u t i o n a l care a t l e a s t f o r the w i n t e r and s t a t e d t h a t h i s doctor was r e commending i t . He p r e f e r s to go to _ . I t has not been p o s s i b l e to c o n t a c t B r . _ r e g a r d i n g v e t e r a n s ' s p h y s i c a l c o n d i t i o n but from what i s known, and i n view of h i s s o c i a l s i t u a t i o n , S e c t i o n 29 f o r the w i n t e r months would appear a d v i s a b l e . " The  veteran  r e c e i v e d d o m i c i l i a r y accommodation and  the case was c l o s e d w i t h the note that i t might be re-opened i n the S p r i n g , as the v e t e r a n  expected to go o u t again a t that  timej and h e l p would be given with discharge  planning i f  indicated. (d) S o c i a l H i s t o r y T a k i n g (and I n t e r p r e t a t i o n ) A young, unmarried p a t i e n t was admitted to Shaughnessy H o s p i t a l eleven  times f o r e p i l e p t i c s e i z u r e s (pensionable  dis-  60  a b i l i t y ) and was r e f e r r e d to MSSD on the eleventh admission f o r "aid  i n rehabilitation."  The s o c i a l worker, towards t h i s end,  obtained a s o c i a l h i s t o r y i n f o u r i n t e r v i e w s and made some attempt to i n t e r p r e t o r to p o i n t out to the veteran, h i s beh a v i o r p a t t e r n as evidenced i n h i s psychosocial development so far. The medical s o c i a l worker records i n p a r t : *This (young) p a t i e n t was r e f e r r e d today by Dr. for aid i n rehabilit a t i o n . He has been a p a t i e n t on f o r two months, h i s admission having followed an attack while he was w a i t i n g ... to v i s i t h i s f a t h e r . The man's h i s t o r y was d i s cussed ... with Dr. _ who has been h e l p i n g t h i s p a t i e n t to s e t t l e down. The present plan i s that Mr. A w i l l be t r a n s f e r r e d to ( d o m i c i l i a r y i n s t i t u t i o n ) and w i l l be seen by t h i s department (bi-weekly) i n an e f f o r t to help him understand why he has been unable to h o l d any work. ... has been seen by P s y c h i a t r y on 2 o r 3 occasions, hates h i s f a t h e r , apparently w i t h some j u s t i f i c a t i o n . He s t a r t e d i n business w i t h h i s brother, but t h i s business f a i l e d , and p a t i e n t f e e l s the business f a i l u r e i s the reason he cannot hold a job. ... i t i s i n an e f f o r t to u t i l i z e h i s present adjustment ( s e t t l e d down w e l l i n h o s p i t a l ) that f u r t h e r casework w i l l be undertaken." Within the s o c i a l h i s t o r y the s o c i a l worker s t a t e s h i s impression: "The traumatic e f f e c t on t h i s f a m i l y of (brother's) unfortunate accident (severe burn, n e c e s s i t a t i n g s e v e r a l years' h o s p i t a l i z a t i o n ) apparently robbed the p a t i e n t o f any f e e l i n g of being loved o r wanted ( p a t i e n t was w i t h h i s brother a t time of accident, although only 4-years-old, and t h i n k s f a m i l y blame him because he d i d not prevent the a c c i d e n t ) . He apparently i d e n t i f i e d s t r o n g l y w i t h h i s mother, who became an a l l good person, and he became the unworthy, unloved member of the f a m i l y . As a c h i l d he gave h i s young brother sweets, e t c e t e r a , and i n l a t e r years, money. Although he has no use whatsoever f o r h i s f a t h e r , he f e e l s that h i s f a t h e r i s o b l i g e d to care f o r him." The worker describes h i s contact w i t h the p a t i e n t : " I n t e r p r e t a t i o n regarding p a t i e n t ' s behavior has been l i m i t e d to s u p e r f i c i a l things such as h i s s a r c a s t i c response to any person who t r i e s to t e l l him how to do anything, h i s tendency to prejudge people, h i s f e e l i n g that he must succeed i n doing a job, and h i s f e e l i n g of i n f e r i o r i t y r e s u l t i n g from h i s i n a b i l i t y to support h i s f a m i l y as h i s o l d e r brothers d i d . "  61 Factors immediately apparent with reference to t h i s case-situation are that the patient's seizures are c e r t a i n l y s o c i a l l y and emotionally stimulated, i n that he often has a seizure when he contacts, or anticipates contact, with someone whom he considers r e j e c t i n g of him. The patient, misinterpreting many s i t u a t i o n s , often f e e l s rejected and therefore has seizures and subsequent h o s p i t a l admissions. This young man should have been referred to MSSD long before his eleventh admission,  but since r e f e r r a l , an inten-  sive work-up has been given the case-situation, and i f the patient i s able to understand and to u t i l i z e casework with his deep-rooted problem, he may be able to control his seizures more s u c c e s s f u l l y i n the future, and thereby have fewer hospital  admissions. (e) and ( f ) not i l l u s t r a t e d . (g) S o c i a l Assessment (1) Mr. Franke, 66-year-old World War I veteran, single,  was i n receipt of WVA and a small d i s a b i l i t y pension, and was considered medically unemployable.  He was referred to MSSD  during h i s eleventh h o s p i t a l admission, with the following statement: "The above-mentioned veteran was examined by Dr. _, who would now appreciate information regarding the p o s s i b i l i t y of care by friends o r r e l a t i v e s .  I f such care i s not a v a i l a b l e ,  the veteran w i l l be r e c l a s s i f i e d to Section 29 (domiciliary care),  fl  62 On the same date as the r e f e r r a l the f o l l o w i n g e n t r y was made by the medical s o c i a l worker: " P a t i e n t was v i s i t e d on ward f o l l o w i n g r e f e r r a l through Unit. The p a t i e n t r e c e i v e s a ... d i s a b i l i t y pension f o r a (designated) wound. H i s s i g h t i s extremely l i m i t e d and he a l s o has a h e a r t c o n d i t i o n . I t was l e a r n e d that he had been v i s i t e d weekly by VON nurses f o r i n j e c t i o n s . I was i n touch w i t h M i s s of the VON. She s t a t e d t h a t the v e t e r a n l i v e s i n a f l o a T house on the r i v e r bank. A t that standard of accommodat i o n he manages not too badly except f o r a tendency to a monthly d r i n k i n g spree w i t h f r i e n d s when cheques ... r e c e i v e d . She f e e l s that one of h i s p r i n c i p a l d i f f i c u l t i e s i s g e t t i n g out to shop and he i s not f i t to c a r r y s u p p l i e s from the s t o r e which i s a t some d i s t a n c e . On i n t e r v i e w the p a t i e n t presents himself as having d e f i n i t e l y made h i s own d e c i s i o n to come i n f o r ( d o m i c i l i a r y c a r e ) . He says t h i n g s have got too much f o r him and he i s not able to manage alone. The d i s a b i l i t y of which he comp l a i n s most i s ... h i s e y e s i g h t . He ... c a r r i e s a white cane ... and no l o n g e r f e e l s safe walking a l o n g the highway to h i s cabin .... The p o s s i b i l i t y of c a b i n accommodation s u i t a b l e f o r b a t c h i n g elsewhere o r boarding accommodation was d i s c u s s e d ... but he was not a c c e p t i n g of these. I t appears that both p h y s i c a l l y and s o c i a l l y p a t i e n t i s a b o r d e r - l i n e case as f a r as n e c e s s i t y f o r ( d o m i c i l i a r y c a r e ) . In view of h i s v a r i e d handicaps and h i s own d e f i n i t e wish f o r ( d o m i c i l i a r y c a r e ) , t h i s w i l l be recommended ...." (2) Mr.  Ney,  62-year-old d u a l war  veteran,  h o s p i t a l f i v e times f o r a s k i n c o n d i t i o n was  admitted to  r e f e r r e d to MSSD on  h i s f i f t h h o s p i t a l admission (and p r e v i o u s l y , on second admiss i o n ) f o r s o c i a l assessment pending c o n s i d e r a t i o n f o r domiciliary  care.  The s o c i a l worker forwarded the f o l l o w i n g i n f o r m a t i o n to the u n i t r e q u e s t i n g assessment: " F o l l o w i n g r e f e r r a l by Dr. _ t h a t p a t i e n t be c o n s i d e r e d a g a i n f o r ( d o m i c i l i a r y c a r e ) , worker i n t e r v i e w e d him i n room _. He e x p l a i n e d h i s s k i n c o n d i t i o n has improved c o n s i d e r a b l y f o l l o w i n g (treatmentI and h i s appearance and manner v e r i f y t h i s . He has a c h e e r i e r o u t l o o k than at time of p r e v i o u s i n t e r view and i s making p r e p a r a t i o n s to spend Christmas w i t h friends.  63 P a t i e n t does not wish ( d o m i c i l i a r y c a r e ) , i n t e r p r e t i n g E x t e n s i o n , Burnaby and George Derby as ' o l d men's homes'. A t age 62 (and appearing younger) he f e e l s able to cope w i t h a l i g h t c a r e t a k i n g j o b i f h i s s k i n c o n d i t i o n remains improved f o l l o w i n g d i s c h a r g e from h o s p i t a l , about which he i s o p t i m i s t i c . He a n t i c i p a t e s another course o f t r e a t ment and hopes w i t h DVA h e l p to secure a l i g h t job. H i s s k i n c o n d i t i o n has developed and p e r s i s t e d d u r i n g the past 10 y e a r s . He i s on h i s own. Depending on p a t i e n t ' s medical p r o g n o s i s he does n o t appear a s u i t a b l e candidate f o r (domic i l i a r y care). I f h o s p i t a l discharge p o s s i b l e , he would b e n e f i t from Veterans' Welfare S e r v i c e s c o u n s e l l i n g w i t h r e g a r d to j o b placement .... In both these s i t u a t i o n s r e q u i r i n g s o c i a l assessment f o r consideration  of d o m i c i l i a r y care, u l t i m a t e l y  culminating  i n o p p o s i t e recommendations, the assessment was made on the b a s i s o f the o b j e c t i v e  f a c t s , encompassing i n n e r and o u t e r  r e s o u r c e s , the way the v e t e r a n f e l t about the f a c t s , and h i s i n c l i n a t i o n o r l a c k of i n c l i n a t i o n f o r d o m i c i l i a r y care. both i n s t a n c e s , vided  information  on the d i s t r i c t o f f i c e f i l e  an i n d i c a t i o n as to the p a t i e n t ' s  past adjustment.  In pro-  CHAPTER 4 RECOMMENDATIONS FOR IMPROVED PATIENT-SERVICE In t h i s f i n a l c h a p t e r a b r i e f r e c a p i t u l a t i o n of the f i n d i n g s of the preceding chapters i s i n c l u d e d , p l u s the s o c i a l i m p l i c a t i o n s o f these f i n d i n g s , and c e r t a i n recommendations f o r p o s s i b l e improvement o f MSSD s e r v i c e s (always dependent upon the c o - o p e r a t i o n o f o t h e r h o s p i t a l and community s e r v i c e s ) . With r e f e r e n c e to the p a r t i c u l a r theme of t h i s t h e s i s , the p s y c h o s o c i a l component i n readmissions, c e r t a i n r e v i s i o n s i n p o l i c y and p r a c t i c e might be employed to a i d i n assessment o f all  c h r o n i c readmissions, w i t h a view to l e s s e n i n g the f r e -  quency, o r p r e v e n t i n g the occurrence of f u t u r e admissions. The aim o f t h i s study has been to determine  whether  o r n o t v e t e r a n s w i t h numerous h o s p i t a l admissions have s o c i a l problems which might c o n t r i b u t e to these h o s p i t a l  admissions.  I t was n o t w i t h i n the scope o f t h i s t h e s i s to study the s o c i a l problems of the e n t i r e p a t i e n t - l o a d a t Shaughnessy H o s p i t a l over a l e n g t h y p e r i o d o f time i n terms o f whether o r not the p a t i e n t s had had p r e v i o u s h o s p i t a l admissions.  Rather,  this  study has been l i m i t e d , f o r p r a c t i c a l i t y , to a c o n s i d e r a t i o n of problems and f a c t o r s r e l a t i n g to a group o f 51 p a t i e n t s r e f e r r e d to the M e d i c a l S o c i a l S e r v i c e Department d u r i n g the 1952-53 f i s c a l y e a r , who have had more than three admissions to h o s p i t a l p r i o r to the MSSD r e f e r r a l i n q u e s t i o n , and who,  65 w i t h the exception  o f three p a t i e n t s , a r e under 70 y e a r s o f age.  Background o f the Study In the f i r s t p a r t o f t h i s study (Chapter 1) the s e t t i n g a g a i n s t which the f i n a l p i c t u r e i s viewed and the framework upon which the p i c t u r e i s b u i l t , a r e b r i e f l y o u t l i n e d .  The s e t t i n g  and the framework c o n s i s t , f o r the most p a r t , of the DVA  rehabi-  l i t a t i v e program e s t a b l i s h e d around the l e g i s l a t i o n (now comp r i s i n g 30 A c t s ) which has been passed to meet, i n s o f a r as poss i b l e , the needs o f d i s a b l e d and/or n e c e s s i t o u s  veterans.  R e h a b i l i t i v e measures have been e s t a b l i s h e d  slowly,  and i n r e l a t i o n to an i n c r e a s i n g r e a l i z a t i o n of the inadequacy of p h y s i c a l r e s t o r a t i o n and f i n a n c i a l compensation a l o n e , and of the r e s p o n s i b i l i t y o f the Government ( t h a t i s , the people) to make up the d e f i c i e n c i e s i n the program.  P r i o r to World War I ,  payment o f p e n s i o n s f o r d i s a b i l i t i e s d i r e c t l y a t t r i b u t a b l e to a c t i v e s e r v i c e was the o n l y b e n e f i t a v a i l a b l e to v e t e r a n s . Duri n g World War I , r e s o u r c e s were extended to i n c l u d e h o s p i t a l accommodation,  convalescent care,  and a s s i s t a n c e  i n obtaining  employment, f o r s e r v i c e - d i s a b l e d men, i n a d d i t i o n to pension payments.  F a c i l i t i e s f o r v e t e r a n s ' r e - e s t a b l i s h m e n t were g r a d -  u a l l y broadened under the Department of S o l d i e r s ' C i v i l Ree s t a b l i s h m e n t (1918-1928), Department of Pensions and N a t i o n a l H e a l t h (1928-1944), and the p r e s e n t body, the Department o f V e t e r a n s ' A f f a i r s , e s t a b l i s h e d i n 1944, to a d m i n i s t e r a l l veterans'  legislation.  66 Today, l e g i s l a t i v e provisions are made f o r such benef i t s as treatment (including medical s o c i a l s e r v i c e s ) , vocational r e t r a i n i n g , payment of d i s a b i l i t y pensions and other allowances, education, land and housing accommodation, and job placement. This l e g i s l a t i o n i s p e r i o d i c a l l y reviewed and amended as i t i s recognized to be inadequate.  Two branches within the DVA  ad-  ministration, Treatment and Welfare, respectively, have the major r e s p o n s i b i l i t y f o r ensuring that these provisions are c a r r i e d out. In the Welfare Branch, Welfare O f f i c e r s undertake many of the services such as job counselling and  placement,  f i n a n c i a l assistance, and l o c a t i o n of housing, which services, i n a non-DVA s e t t i n g are performed by s o c i a l workers. Medical s o c i a l service, incorporated as a professional service within DVA i n 1945  (although the e f f e c t of s o c i a l pro-  blems on medical treatment was recognized shortly a f t e r World War I, and " s o c i a l service nurses" were detailed to perform investigatory, educational, and reformatory duties) under the Welfare (Rehabilitation) Branch, was administratively re-aligned i n 1947, becoming part of Treatment Services.  This r e - a l i g n -  ment constitutes administrative recognition that medical s o c i a l service i s an "active treatment ingredient." Dr. Lynn Gunn, then Superintendent of Shaughnessy Hospital, Vancouver, i n a paper  1  prepared f o r presentation at  This paper was reproduced i n the Treatment Services B u l l e t i n , published by DVA, Ottawa, January 1948.  67 the Treatment Services Conference, December 1-4, 1947, very aptly described the p o s i t i o n and p o t e n t i a l i t y of medical s o c i a l services within DVA at that time.  He stated:  A comparatively recent addition to our hospital s t a f f s i s the provision f o r well trained and experienced Medical S o c i a l Workers. Previously, they were under the d i r e c t i o n of the Rehabilitation Branch, but they are now a part of the Treatment Services. Many of us have had an e n t i r e l y erroneous idea of t h e i r duties i n the past and have regarded them as private investigators, or pictured them i n the role of providing patients or t h e i r families with cast-off clothing and other comforts. I t should be understood that they only work on a case at the request of the attending doctor. An increasing number of medical men f i n d that, i n many cases, a medical s o c i a l service history i s a valuable a i d i n evaluating the significance of the emotional f a c t o r i n r e l a t i o n to symptoms. This i s of importance, not only i n diagnosis, but also i n determining factors i n treatment and prognosis. Furthermore, the S o c i a l Service Worker i s i n close contact with the various C i v i c Welfare Organizations and i s able to e n l i s t the help of other organizations i n the case of needy patients or t h e i r dependents. C l i n i c i a n s might well be advised to include the Medical Social Workers i n some of t h e i r ward rounds and conferences. Central Theme The central portion of this study (Chapters 2 and 3) includes an o v e r a l l survey of the r e f e r r a l s made to the Medical Social Service Department i n order to determine the number of patients among those referred who have had multiple h o s p i t a l admissions.  This survey points up the fact that just over half  of the veterans referred have been i n Shaughnessy Hospital p r i o r to t h e i r current admission (or, i f out-patients, p r i o r to t h e i r current r e f e r r a l ) . Among the patients with previous hospital admissions, 150 have been i n Shaughnessy Hospital only once before, 73 have been hospitalized twice previously, 52 have been i n hospi-  68 t a l on three p r i o r o c c a s i o n s , and 100 v e t e r a n s have been t r e a t e d i n Shaughnessy H o s p i t a l more than three times.  Within t h i s  l a t t e r group of 100 readmitted p a t i e n t s , a t the time o f r e f e r r a l , one h a l f o f them were 70 y e a r s o f age o r over, and 2 were women.  The remaining v e t e r a n s , p l u s 3 from the 70-and-over  group were s e l e c t e d f o r s p e c i a l study i n o r d e r to explore the w e i g h t i n g which p s y c h o s o c i a l f a c t o r s p l a y i n h o s p i t a l  admissions.  Many f a c t o r s p e r t a i n i n g to these 51 v e t e r a n s were c u l l e d from d i s t r i c t o f f i c e f i l e s and MSSD r e c o r d s (which a r e o f t e n more d e t a i l e d than the MSSD r e p o r t p l a c e d on the d i s t r i c t o f f i c e f i l e ) i n an attempt  to h i g h l i g h t  t h e i r handicaps and  a s s e t s ; the tendency f o r c e r t a i n f e a t u r e s to be common to the m a j o r i t y of the group, and o f o t h e r f e a t u r e s to be o f s i n g u l a r significance;  the p r o b l e m - p i c t u r e and i t s r e l a t i o n ;to h o s p i t a l  admissions; and f i n a l l y , rendered i n each  the nature o f the s o c i a l s e r v i c e s  situation.  The " C r e d i t " P i c t u r e The facts  c r e d i t f e a t u r e s o f the group of 51 i n c l u d e the  that approximately two-thirds o f the v e t e r a n s have a p a s t  employment r e c o r d which i s a t l e a s t " f a i r , " and o n l y o n e - t h i r d of  the group (with o v e r l a p p i n g ) have p h y s i c a l o r mental  disabi-  l i t i e s o f a s e r i o u s enough nature to p r e c l u d e steady employment. The  "Debit" Picture The main d e b i t c h a r a c t e r i s t i c s of the t o t a l group  (51) as f a r as p o t e n t i a l r e h a b i l i t a t i o n i s concerned i s that t w o - t h i r d s of these v e t e r a n s a r e o v e r 40 y e a r s of age;  another  69 two-thirds did not proceed i n t h e i r education beyond the elementary school l e v e l ; and the work experience of the majority of the group was  of a manual nature, whereas continuation i n  manual work might now  be impossible f o r many of the group due  to t h e i r physical condition. S o c i a l Problems and Social Services The weighting of psychosocial problems, designated as material, family r e l a t i o n s , lack of response to, or co-operation i n treatment  (on apparently non-medical grounds) and personality  and mental aberrations, f e l l l a r g e l y upon the group of veterans with poor employment p o t e n t i a l .  Vocational problems are no  longer of major concern to most of t h i s group because these veterans are aged, r e t i r e d , or do not plan to work i n the future f o r some other p r a c t i c a l reason.  The greatest number of major  problems among the group of 51 concerns family relationships and material necessity, which together constitute the primary psychos o c i a l problems of 25% more veterans than do the other three designated problems combined. Other than r e f e r r i n g c l i e n t s to the appropriate resource, MSSD personnel performed more services i n the area of supportive help than i n any other area.  Interpretation and s o c i a l assess-  ment were undertaken with next greatest frequency, followed by s o c i a l history taking and explanation of services only.  Mat-  e r i a l a i d was rendered i n only one instance (other than through referral).  Medical s o c i a l services were distributed among the  employment potential groups i n equal r a t i o , the greatest number  70 of services (60$) therefore f a l l i n g to the poor employment p o t e n t i a l group, which includes 60$ of the t o t a l group. Point Summary (1) In many respects veterans are a unique group and have certain problems and handicaps which they would not have i f they were not veterans; (2) In keeping with t h e i r unique c h a r a c t e r i s t i c s , the veterans have e l i g i b i l i t y f o r special l e g i s l a t i v e benefits and services; (3) In addition to unique c h a r a c t e r i s t i c s and problems, veterans have c h a r a c t e r i s t i c s and problems common to the general population; (4) Some veterans are able to take constructive advantage of proffered benefits, whereas, others are further incapacitated through the use of available resources; (5) Veteran patients tend to be hospitalized more frequently and f o r longer periods than do general hospital patients; (6) A high proportion of readmitted veteran patients referred to the Medical S o c i a l Service Department are past middle age, have had l i t t l e formal education, and have poor employment p o t e n t i a l .  The work of the MSSD i s l a r g e l y with  t h i s group which i s least able to "contribute" to society. (7) Physical d i s a b i l i t y i s only one of a number of factors which contribute to a handicapped  state; i n many instances,  s o c i a l factors are more disabling than are physical handicaps. (8) In the majority of the situations examined, psychos o c i a l problems affected some phase of the veteran's h o s p i t a l i -  71 zation ( f o r example: contributed measurably to the patient's need or desire f o r admission to hospital; prevented optimum co-operation i n , o r response to treatment; occasioned the veteran to r e s i s t discharge; or, l i m i t e d the resources f o r the patient's a f t e r - c a r e ) . S o c i a l Significance and Social Consequences The goal of DVA (as was the goal of i t s antecedent l e g i s l a t i v e bodies) i s to re-establish veterans i n c i v i l i a n life;  to d i l u t e t h e i r uniqueness, as i t were, and yet to r e -  cognize i t , should re-establishment be impossible or only partial.  Based on the r e l a t i v e l y small proportion of the t o t a l  veteran group who are hospitalized, i t would seem that the majority of veterans have made an adequate re-adjustment i n c i v i l l i f e , or at least have not come to the attention of DVA i f t h e i r adjustment has been inadequate.  Other veterans, f o r  a v a r i e t y of reasons, including medical necessity, have been a DVA r e s p o n s i b i l i t y almost constantly since t h e i r service discharge. In  t h i s study, the concern i s f o r veterans who have  had a number of admissions to Shaughnessy Hospital, because t h e i r hospital admissions, i n many instances, create s o c i a l consequences.  These consequences  may include i n a b i l i t y to hold  a job because of repeated absences, resultant interrupted income, and a low standard of l i v i n g ; and may constitute as well an expense to DVA (that i s ,  to the Canadian people).  72 Each s o c i a l lack can lead to further s o c i a l consequences.  A marginal income family, unable to cope with medi-  c a l and dental b i l l s , may postpone obtaining needed attention; a veteran's absence from work may a f f e c t production even i f i t does not r e s u l t i n loss of the job.  Repeated absences from the  home due to h o s p i t a l i z a t i o n may v i r t u a l l y create a "broken" home, and i f children are i n the home they may react unfavorably to the a i r of i n s e c u r i t y . In short, myriads of problems can stem from i l l n e s s . On the other hand, i t i s often possible to thwart, or at l e a s t to ameliorate, an unwieldy problem-spread.  Numerous s o c i a l  agencies e x i s t to attempt accomplishment of the l a t t e r .  The  Department of Veterans' A f f a i r s , which without doubt, has the most extensive program of r e h a b i l i t a t i o n i n Canada, steps into the problem-situation on behalf of disabled or necessitous veterans. Implications and Recommendations Medical s o c i a l service personnel, who form part of the DVA r e h a b i l i t a t i o n program, are interested i n extending t h e i r services i n the most e f f e c t i v e manner, to the greatest number of persons able to benefit from t h e i r services. The effectiveness of any s o c i a l service program, embodying treatment and prevention, depends upon a good working relationship or co-ordination of e f f o r t between the s o c i a l service s t a f f and whomever else i s concerned with, or could be instrumental i n , e f f e c t i n g r e h a b i l i t a t i o n or improved  73 functioning on the part of the c l i e n t .  Towards the e s t a b l i s h -  ment of an e f f e c t i v e r e h a b i l i t a t i v e program, s o c i a l workers must endeavor to bring t h e i r own work up to the highest poss i b l e standards; and to interpret t h e i r services and the t o t a l needs of t h e i r c l i e n t e l e to those simultaneously concerned with the c l i e n t , and to the wider community i n which the c l i e n t must l i v e and adapt. With special reference to medical s o c i a l service at Shaughnessy Hospital generally, and i n r e l a t i o n to the p a r t i cular group of veterans selected f o r special study, the most obvious hindrance to a program of optimum effectiveness appears to be lack of inclusion of s o c i a l workers i n diagnostic and early treatment phases of the patients' h o s p i t a l i z a t i o n (with some notable exceptions).  Medical S o c i a l Service Department  personnel are s t i l l used l a r g e l y as resources f o r determining the disposition of patients as discharge nears.  This l a t t e r  service i s important, but patients' needs would better be served, even i n t h i s regard, i f s o c i a l workers were requested o r permitted to enter situations during early treatment phases. Although certain practices might be modified and others incorporated by the MSSD to enhance i t s position as a treatment service, optimum e f f i c a c y of medical s o c i a l services cannot be achieved through the e f f o r t s of the MSSD s t a f f alone. Comments and recommendations are therefore directed towards whichever faction may best be suited to bring about improved medical s o c i a l services.  74 Screening A broader routine coverage or screening of patients upon admission to h o s p i t a l , or p r i o r to admission (that i s , on outpatient services) would probably be b e n e f i c i a l i n stemming repeated admissions on s o c i a l grounds.  At present, only  tuber-  culous patients admitted to the Chest Unit, and patients r e ferred or admitted to p s y c h i a t r i c services, are seen routinely by MSSD.  The present s t a f f of 6 s o c i a l workers, including the  head of the department, i s hardly s u f f i c i e n t to enable a t o t a l screening or s o c i a l assessment service, but certain measures, such as allotment of a s o c i a l worker to the Outpatient  Depart-  ment, and, when s t a f f i s increased, assignment of workers to a l l services, might be employed to extend this coverage. Meanwhile, i t cannot be recommended too strongly, that, whether o r not workers are a l l o t t e d to s p e c i f i e d wards, doctors, o r other persons concerned with the patients' t r e a t ment, r e f e r f o r s o c i a l assessment, a l l patients with a chronic admission pattern, when medical evidence i s inconclusive. Certain patient-benefits might be anticipated as accruing from assignment of s o c i a l workers to s p e c i f i c wards. These benefits could include: a c l o s e r working r e l a t i o n s h i p between MSSD, and the medical s t a f f (doctors, nurses, o r d e r l i e s ) , and between MSSD and the Veterans' Welfare O f f i c e r s , who are already a l l o t t e d to s p e c i f i c wards; opportunity  to i n t e r -  pret medical s o c i a l services on a p r a c t i c a l , demonstrable l e v e l ; provision f o r a constant  reminder that medical s o c i a l  75 services are available to the patients; s i m p l i f i e d r e f e r r a l procedure, and more convenient (hence, more frequent) consultation with other treatment personnel; opportunity f o r the s o c i a l worker to screen the patients with reference to t h e i r admission pattern. It i s suggested that i f s o c i a l workers are a l l o t t e d to s p e c i f i c wards or services at some future date, they be a l l o t t e d to mixed wards, (that i s one worker should not handle several s u r g i c a l , p s y c h i a t r i c , or general medicine wards, but rather should handle a combination of services); and furthermore, that the workers be rotated at least once annually. Conferences In addition to, or i n l i e u of, contact with Veterans' Welfare O f f i c e r s through the allotment of s o c i a l workers to specified wards, periodic conferences could be held with the Welfare s t a f f i n order to pool information, and to promote coordination of the complementary services performed by each group on behalf of mutual patients.  These conferences could  also serve to determine which group should handle certain "borderline * cases or case-situations (subject to the approval 1  of the attending doctor). The Medical Social Service Department holds a case conference following each weekly s t a f f meeting.  These case-  conferences could conceivably be open to treatment personnel concerned with the p a r t i c u l a r case(s) under discussion, or with the situations or theme discussed.  Notices might be posted  76 as are notices f o r medical, s u r g i c a l , and psychiatric rounds, naming the patient and/or the topic.  Evidently, MSSD case d i s -  cussions at one time were open to the doctor concerned with the case, and met with a meagre response f o r a variety of reasons, including the doctors' lack of time to attend conferences. However, i f conferences were constantly a v a i l a b l e , and were posted, some of the people would be able to attend some of the time, to the ultimate benefit of the patient. Records The MSSD records reviewed f o r t h i s study were not a l ways s a t i s f a c t o r y f o r research purposes, and i n some s i t u a t i o n s , were incomplete and would not be too helpful i f other services were to r e f e r to them f o r s o c i a l information.  Brief records are  required i n a hospital setting to f a c i l i t a t e prompt a v a i l a b i l i t y and easy reference, but i t i s essential that factors such as the reason f o r r e f e r r a l , the doctor's impression, the present s o c i a l s i t u a t i o n , and, where a v a i l a b l e , the past adjustment  trend ( i n -  cluding the admission pattern), and the etiology of the present s o c i a l maladjustment or imbalance, be included i n the records, as well as the s o c i a l worker's s o c i a l diagnosis or impression, and the projected treatment plan.  Periodic progress reports  should be made; and f i n a l l y , the d i s p o s i t i o n of the case should be indicated before the f i l e i s marked f o r closure. The presence of a worker on s p e c i f i c wards would allow s o c i a l progress to be recorded at least bi-weekly on the ward charts and could thus promote closer co-ordination of a l l patientservices.  77 Case Review With special emphasis on pursuing the readmission problem, i t i s suggested that each member of the medical s o c i a l service s t a f f check the number and possible psychosocial e t i o logy of the hospital admissions of each patient i n his caseload, and that new r e f e r r a l s be s i m i l a r l y noted.  The s t a t i s t i c s  concerning the number of admissions could be compiled monthly ( f o r example, when the monthly narrative report i s submitted by the Head of the Medical Social Service Department) f o r purposes of reviewing the t o t a l admission trend of MSSD r e f e r r a l s .  Per-  i o d i c a l l y , (say, every 3 months) sessions could be held among the MSSD s t a f f to determine the psychosocial component of the chronic readmissions, always with a view to lessening the need f o r future readmissions attributable to psychosocial factors. Educational Program In addition to i n d i r e c t interpretation of medical s o c i a l services through day to day work and case conferences, some method of direct teaching o r interpretation should be eraployed.  A recent MSSD survey,  1  i n which 28 doctors of Shaugh-  nessy Hospital answered a questionnaire concerning medical s o c i a l services, indicated that the majority of the doctors responding would appreciate further information on the function of MSSD, and some of the respondents emphasized the fact that i  This survey was undertaken, v i a a questionnaire, by A.ff. Barsky, May, 1954, i n connection with her M.S.W. thesis: "Casework i n a Veterans' H o s p i t a l : An A n a l y t i c a l Study of Ref e r r a l s from Doctors, Shaughnessy Hospital, 1953-54."  78 they would l i k e this information during t h e i r i n i t i a l orientation period.  This response would indicate that the Medical  S o c i a l Service Department should be included on an i n s t r u c t i v e l e v e l during the interne orientation period. 1 The "Internes* Manual,"  another i n t e r p r e t i v e device,  should continue to include a b r i e f synopsis of the MSSD function, and examples of case-situations which should be referred. The present MSSD synopsis was written f o r i n c l u s i o n i n the manual i n 1950,  and i n view of the changes which have occurred within  the Medical S o c i a l Service Department since that time, revision of this resume of medical s o c i a l services i s i n order. Currently, the Medical S o c i a l Service Department at Shaughnessy p a r t i c i p a t e s i n the teaching program of the School of S o c i a l p r k , University of B r i t i s h Columbia, through medicalw  s o c i a l demonstration lectures given to the student  s o c i a l workers;  and acts as a f i e l d placement f o r s o c i a l work internes and students. Conclusion In conclusion i t should be mentioned that c e r t a i n additional aspects of the hospital readmission  problem and the  role of the s o c i a l worker i n r e l a t i o n to t h i s problem came to mind, but were not considered to be within the scope of this study i n view of the r e l a t i v e l y short period of time a l l o t t e d  The "Internes' Manual" i s a mimeographed brochure prepared f o r the use of medical internes at Shaughnessy H o s p i t a l , and was l a s t revised i n 1950.  f o r i t s completion. Some of the additional factors or suggestions which might be considered i n a further examination of the psychosocial component of patient readmissions include:  (1) use of a control  group (that i s , a group with objective d e t a i l s s i m i l a r to the group of readmitted patients studied, but having managed outside the hospital setting f o r a considerable period) i n studying the readmission problem; (2) follow-up study o f Medical S o c i a l Service Department c l i e n t e l e with multiple h o s p i t a l admissions, to determine the effectiveness of the s o c i a l services rendered, i n preventing t h e i r further hospital admissions; (3) study of readmissions based on a sampling of a l l readmitted patients, o r at least a l l readmitted patients referred to MSSD, within a given period, rather than a selection of chronic r e admissions. It i s anticipated that some future study w i l l be d e f i n i t i v e i n pointing up the contribution made by medical s o c i a l services, as part of the treatment team, i n lessening the number of hospital readmissions at Shaughnessy.  80 APPENDIX A: D.V.A. HOSPITALS AND INSTITUTIONS Name and Location of DVA Hospitals and I n s t i t u t i o n s  Operating Capaci ty  1. Active Treatment Hospitals Camp H i l l Hospital, Halifax, N.B. Lancaster, Hospital, F a i r v i l l e , N.B Veterans' Hospital, Quebec, P.Q. Queen Mary Veterans' H o s p i t a l , Montreal, P.Q. Ste. Anne's Hospital, Ste. Anne de Bellevue, P.Q. Sunnybrook Hospital, Toronto, Ont. Westminster Hospital, London, Ont. Deer Lodge Hospital, Winnipeg, Man Veterans' Hospital, Saskatoon,Sask Colonel Belcher Hospital, Calgary, Alta. Shaughnessy Hospital, Vancouver,B.C Veterans' H o s p i t a l , V i c t o r i a , B.C.' 2. Active Convalescent F a c i l i t i e s Ridgewood H & 0 Centre,"** Saint John, N.B. (Lancaster) Veterans' H & 0 Centre, Senneville P.Q. (Ste. Anne's) Rideau H & 0 Centre, Ottawa, Ont. Divadale H & 0 Centre, Leaside, Ont. (Sunnybrook) Veterans' Convalescent H o s p i t a l . Calgary,Alta. (Colonel Belcher) George Derby H & 0 Centre, Burnaby, B.C. 3 . Special I n s t i t u t i o n s Veterans' Hospital, St. Hyacinthe, P.Q. Western Counties Veterans' Lodge, London, Ont. (Westminster) 4. I n s t i t u t i o n s Designed Primarily f o r Veterans' Care Cases The Red Chevron, Toronto, Ont. Bellvue Veterans' Home, London, Ont. Veterans' Home, Winnipeg, Man. (Deer Lodge) Veterans' Home, Regina, Sask. Veterans' Home, Edmonton, A l t a . Hycroft, Vancouver,B.C.(Shaughnessy) Total  S o c i a l Work Staff (a)  9082 550 450 275  40(7) 2 1 2  700  8(1)  1135 1650 1522 850 125  4 7 4(3) 3(1)  425 1100 300  1 7(1) 1  365 &  2(1) 2(1)  9774  42(8)  (a) Vacancies at t h i s date shown i n brackets & The Operating Capacity f o r these i n s t i t u t i o n s i s included i n the figures f o r the Hospital shown i n parenthesis. &ft H & 0: Health and Occupational Centre Source: Compiled from D.v.A.Head Office Monthly S t a t i s t i c s Reports  81 APPENDIX B.  D.V.A. TREATMENT CATEGORIES  Section 5 5 6 6 6 6  6 6 6 6 7a 7b 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28  29  (As at A p r i l ,  1953)  D e f i n i t i o n Pensionable D i s a b i l i t y - Active Treatment Sequelae of Pension - Venereal Disease North West F i e l d Force - 1885 Pension Section 48 or 49 of the Pension Act Pensionable D i s a b i l i t y - Newfoundland Merchant Seamen, A u x i l i a r y Service Personnel, F i r e Fighters (Overseas), A i r Raid Wardens, Voluntary Aid Detachment Personnel, C i v i l i a n Government Employees (Wartime) Special Operator (Overseas A i r Crew) Injured on F l i g h t Duty Red Cross and Welfare Workers i n the Far East Non-Permanent Active M i l i t i a and Reserve Army Personnel Newfoundland Special awards Permanent Force and R.C.M.P. f o r Poor Condition H o s p i t a l i z a t i o n f o r Pensioner i n J a i l l Treatment within 30 days of Discharge: D i s a b i l i t y e x i s t i n g at that time Trainees Permanent Force: D i s a b i l i t y existing at time of Discharge War Veterans Allowance Cases requiring active remedial treatment. Veteran earning less than $900 ( s i n g l e ) ; $1800 (married) For Psychiatry I n s t i t u t i o n a l or Custodial Care of non-pensionable Venereal Disease Pensioner when uncertainty exists on Diagnosis Staff - Infectious Disease Case Persons referred by the Department of National Defence Persons referred by the Royal Canadian Mounted Police On request by f i n a n c i a l l y responsible authority On request of any department of the Government of Canada At the request of Imperial or other A l l i e d Government Under P r o v i n c i a l Hospital Insurance (Veterans only) Too i l l to turn away. Admitted and charged. In h o s p i t a l . Diagnosis changed to non-eligible condition H o s p i t a l i z a t i o n f o r Research Purposes Pensions Medical Examination - f o r observation Quarters and Rations f o r Pensions Medical Examination; f o r D.V.A. examination i n reference to prosthetic appliance; f o r examination required by War Veterans* Allowance Board; f o r examination of Prisoner of WarI n s t i t u t i o n a l Care 1  Source: Compiled from D.V.A. Treatment Regulations as contained in The Veterans Charter and Amendments.  82 APPENDIX C ( l ) : CASE ANALYSIS FORM  I  CASE ANALYSIS FORM  AGE:  20  WAR:  PWWI  25  30  35  WWI  s  40  45  WWII  P3DI:  50  55  60  70  ____  ?E#: 5-20  S  M  W  SP  D  DEP:  F  K  W  CE.T  NoJE:0-3 NoPEA:  UE  4-6 1  OE  3  STE  DCo  65-80  RRes  DRes  85-100 Ru  E  (U) 1 2 3 4 D  (PG) 1 2 3 0  IQ: 0-M  3  D  N  2 3  5  6 7  S  VS  G  8  9 10 11-15 16+  TJ:  11-15 16+ LJK:0-1  4  03 (4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19)  DIAGS (A) ) (A) SECTION ( A ) ) PROGS (3) )  : . '•-  1  DLKA (C)  45-60  OTHERS:  (S) 1 2 3 4  SE  7-10  2  RCo  CK..D  (3) 1 2 3 (0THER)__ HU  80*  Remarks:  EDUC: (E) 1 2 3 4 5 6 7 8  RTD  80  25-40  ESG: SRo  MS:  75  KOREA  T.IN:  E5:  65  Reg. *No7T  ,)  —  SECTION ( C ) ) PLKA (D) ) DLFM (E) ) 1  1,1  • — " ~  (A)  :  (3) R S R R R R R R R R R R  1  " • '  I I I I I I I I I I I I  SI HI MI HI HI HI HI H H HI HI HI  DIO (C) (C) DIO DIO DIO DIO DIO (D) R I NI DIO DIO DIO DIO DIO DIO (E) DIO  Remarks:  PARENTS  ' 3D  TSl (R30)  FD  GAW  MD  HGA  LTOG GAF  SI3S TWJ 1 2 3 4 5 Remarks:  SP  (SEX)  (HEAL)  6 7 3 9 0  (j&Cl) 3G  3A.W  3A.S  (ClHo)  NG  FG  FA.W -FA.fr HA.W (RC1) AGW  HGA  MG MA.S  FGA  MGA  MSS  7wI"RefMSS):l 2 3 4 5 6 7 3 9 10 11 12 13 14 15 0 (SRef)D OH DV.D DVP P R C RT (RRef): A 3 C D E F G G E I J K L OTHER: (pp ( D ( 2 ) ( 1 ) (2) ( l ) ( 2 ) ( l ) ( 2 ) ( l ) ( 2 ) ( 3 ) ( 4 ) ( l ) ( 2 ) 1  ) :  A  2  c  3  D  E  F  ( + )  OTHER: (MSSRen): Remarks:  A  B  C  D  B  F  G  H  OTHER:  G  (l)(2)  83 APPENDIX C(2): LEGEND FOR CASE ANALYSIS FORM Name: Reg..No.: AGE: 20 25 30 35 40 45 50 55 60 65 70 75 80 80 plus WAR: P r i o r to World War I : World War I : World War I I :  Korea  PENSIONABLE DISABILITY: PENSION %i 5-20 25-40 etcetera TOTAL INCOME: HOUSING: Skid Row, Reputable Commercial, Disreputable Commercial, Reputable Residential, Disreputable Residential, Rural, Hermit or Isolated. MARITAL STATUS: DEPENDENTS:  S  Father  M  W  SP  Mother  D Wife  REMARKS: Children  OTHERS:  EDUCATION: (Elementary) 1 - 8: (Secondary) 1 - 4 : (University) 1 - Degree: (PostrGraduate) 1 etcetera: (Business) 1 etcetera: (Other): IQ. EMPLOYMENT STATUS:  Retired: Medically Unemployable: Unemployed: Occasionally Employed: Seasonably Employed: Steadily Employed: Type of Job.  NO. OF JOBS HELD: 0-3 4-6 etcetera.  Longest Job Held: 0-1 etcetera  NO. OF PREVIOUS HOSPITAL ADMISSIONS: 1 2  3  etcetera  (A) DIAGNOSIS (A)SECTI0N (B) PROGNOSIS (Recovered, Improved, Not Improved, Diagnosis Only) (C) DIAGNOSIS ON LATEST HOSPITAL ADMISSION (C ^SECTION (D) PROGNOSIS ON LATEST HOSPITAL ADMISSION (E) DATE LIKELY FIT FOR WORK. ............ 1  Remarks: PARENTS: (STATUS) Both Dead: Father Dead: Mother Dead: L i v i n g Together: Separated. (RELATIONSHIP TO CLIENT): Both good: Neither good: Father good; Mother good. (RELATIONSHIP TO OTHER): Got along w e l l : Never got along w e l l : Got a l o n g . f a i r l y w e l l . (HEALTH): Both alive and w e l l : Both alive and s i c k : Father alive and w e l l : Father a l i v e and sick: Mother a l i v e and w e l l : Mother a l i v e and sick.  84 APPENDIX C(2):  (Continued)  (SIBLINGS): (No.) 1 2 3 etcetera. (POSITION OF CLIENT AMONG SIBLINGS) (RELATIONSHIP OF CLIENT TO SIBLINGS): Always got along w e l l : Never got along w e l l : Some got along: Most got along. Remarks: MEDICAL SOCIAL SERVICE (WHICH ADMISSION REFERRED TO MSSD): 1 2 3 etcetera. (SOURCE OF REFERRAL) Doctor: Other Hospital S t a f f : Other DVA Hospital or D i s t r i c t : Other DVA Personnel: Patient: Relatives: Community: Routine. (REASON REFERRED): Diagnostic a i d : Routine screening: Arrange post-discharge housing accommodation: Determine s u i t a b i l i t y of home conditions f o r patient's return: S o c i a l assessment f o r Section 29 ( I n s t i t u t i o n a l care): Patient not responding to treatment: Help (1) patient and/or (2) family to accept diagnos i s and i t s implications, including h o s p i t a l i z a t i o n , i n s t i t u t i o n a l i z a t i o n , r e s t r i c t e d regime, committal; Help patient to accept discharge and to assume outside r e s p o n s i b i l i t y : A s s i s t patient and/or family f i n a n c i a l l y : or determine f i n a n c i a l s i t uation: Vocational help: Help patient to attend to outside family and/or business concerns: Family r e l a t i o n s - explore: Other. (PROBLEMS FOUND): Combined as: I Vocational, I I Material, III Family Relationship, IV Lack of Response or Cooperation i n treatment, V Personality or Mental Aberrations. (MEDICAL SOCIAL SERVICES RENDERED): Referral: Supportive Help: Interpretation: S o c i a l History Taking: Explanation and Offer of Services Only: Material A i d : S o c i a l Assessment. Remarks:  85 APPENDIX D.  PRINCIPLES GP SOCIAL CASE WORK  1.  "I respect the dignity of the i n d i v i d u a l human personality as the basis f o r a l l s o c i a l r e l a t i o n s h i p s .  2.  "I have f a i t h i n the ultimate capacity of the common man to advance toward higher goals.  3.  "I s h a l l base my relations with others on their q u a l i t i e s as i n d i v i d u a l human beings, without d i s t i n c t i o n as to race or creed o r c o l o r or economic or s o c i a l status.  4.  B  I stand ready to s a c r i f i c e my own immediate interests when they c o n f l i c t with the ultimate good of a l l .  5.  "I recognize that my greatest g i f t to another person may be an opportunity f o r him to develop and exercise h i s own capacities.  6.  "I s h a l l not invade the personal a f f a i r s of another i n d i vidual without h i s consent, except when i n an emergency I must act to prevent injury to him or to others.  7.  "I believe that an individual's greatest pride, as well as his greatest contribution to society, may l i e i n the ways i n which he i s d i f f e r e n t from me and from others, rather than i n the ways i n which he conforms to the crowd. I s h a l l therefore accept these differences and endeavor to b u i l d a useful relationship upon them.  8.  "I s h a l l always base my opinion of another person on a genuine attempt to understand him—to understand not merely h i s works, but the man himself and his whole s i t uation and what i t means to him.  9.  "As a f i r s t essential to the understanding of others, I s h a l l constantly seek a deeper understanding and control of mys e l f and of my own attitudes and prejudices which may a f f e c t my relationships." Linton B. Swift  86  APPENDIX E.  BIBLIOGRAPHY  Books 1.  Binger, C a r l , The Doctor's Job. Norton, New York, 1945.  2.  Elledge, Caroline H., The Rehabilitation of the Patient. Lippincott, Philadelphia, 1948.  3.  Hamilton, Gordon, Theory and Practice of Social Case Work. Columbia University Press, New York, 1951.  4.  Upham, Prances, A Dynamic Approach to I l l n e s s , Family Service Association of America, New York, 1949.  A r t i c l e s , Documents, Publications.  Statutes  1.  Barsky, A. N., "Casework i n a Veterans' H o s p i t a l : An A n a l y t i c a l Study of Referrals from Doctors, Shaughnessy Hospital, 1953-54," unpublished Master's of S o c i a l Work thesis, University of B r i t i s h Columbia, 1954.  2.  Canada, Department of Veterans' A f f a i r s , C i r c u l a r L e t t e r No. 138 - 47: Medical Social Service General Policy, 1947.  3. 4  »  , Treatment Instruction Letter No. 1 - 49: P o l i c y - Function of the S e r v i c e . 1949. .  Casualty Welfare O f f i c e r s ' Manual, King's P r i n t e r , Ottawa, Revised 1950.  5.  Canada, Department of Soldiers' C i v i l Re-establishment, 1920 Annual Report. King's P r i n t e r , 1921.  6.  Chisholm, Brock, "Organization f o r World Health," Mental Hygiene, July, 1948.  7.  Clayden, Florence, "The Social Service Division of the Department of Veterans' A f f a i r s : I t s Origin, Setting, and Function -- a.study based on the Division i n the B. C. D i s t r i c t , " unpublished Master's of Social Work Thesis, University of B r i t i s h Columbia, 1950.  8.  Gunn, Lynn, M.D., "Team Work i n Hospital Administrat i o n , " Treatment Services B u l l e t i n , DVA, Ottawa, v. I l l , January, 1948.  87 9. Heckman, A. A., and Stone, A., "Testing Casework Results: Forging New Tools," Survey Midmonthly, Survey Associates, Philadelphia, October, 1947. 10.  Internes  11.  Temple, A. D., M.D., "Rehabilitation as i t Concerns the Physician," Treatment Services B u l l e t i n , D.V.A. Ottawa, v. V, November, 1950.  12.  Veterans' Charter, The, Acts of the Canadian Parliament to A s s i s t Canadian Veterans, King's P r i n t e r , Ottawa, 1947.  13.  Winfield, G. A., M.D., andWellwood, L., "A Study of In-Patients, Department of Veterans' A f f a i r s , as at 31 March, 1951," Treatment Services B u l l e t i n , D.V.A., Ottawa, v. VIII, November, 1953.  1  Manual, Shaughnessy Hospital, Revised 1950.  

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