tate UniverSity Michigan S f Social Work School 0 atients Aged P Services Veterans Administration Hospital Michigan Battle Creek, Donna R. Westrate A 333R PTIVE STUDY "? THEHTY'RSLD PATIEL‘S USING SOCIAL WORK SEEN CE AT TiE VET ENS ADE} INISTRATIO." HQSPI’TM BATTLE CREEK, MICHIGAN Donna R. Westrcte A O0JF"T R5? )RT Submitted to the School of Social Work Michigan State University in partial fulfillment of the requirements for the degree of Ni “3"”; "F SOCIAL E‘EOILK June 1961 Approved : WM Wm fbhaLZfian, Research C6¢.mittee of School Hit" I ’ ‘ ‘_‘ " ' . x 3.. T . ‘ . . , "‘ I» m" ‘51. ‘ital. Battle Creeli. .ichigan. has varied somewhat duzrinj the past sereral years. .In 1958. there were 328 patients 65 years plus. in 1957 there were 237 patie.ts 65 years and over. the number of pa tients 65 years and over in the hospital in 1959 was not available. and in 1963 there we: aggroximately 303 patients 65 years of age and older. 24 C21: Trill III METHODOLOG As several authors have been quoted in a previous chapter. the social worker in the profession of social work can be the prime factor to help the aged patient to help himself to become sufficiently well and stabilized to leave the mental hospital and to return to the community and make an adjustment there. A patient is considered to be making a satisfactory adjustment if he is able to care for his bodily needs. if he can function without harm to himself and others. if he can handle his finances or have them handled by a guardian or his family. A patient may be able to make a more positive adjustment. which may include his being able to make and maintain satisfactory relationships with others. being helpful to others, increasing in knowledge and skills. or even being productive. In this descriptive study. only those patients who left the hospital MHB, i.e.. with having received maximum hospital benefits. are condidered; not those who left AMA. i.e.. against medical advice, or AWOL. i.e.. absent without leave. The aged person is considered to be one Who is 65 years of age and older; and in this study. 65 years and 25 older by January 10. 1961. As closely as could be determined by interviewing social workers in the Veterans Administration Hospital. Battle Creek. Michigan. social work service. and by searching the social service files back to January. 1958. and from there through January. 1961. there are currently (up to January 10. 1961) 29 patients 65 years of age and older being worked with in social service. The records of these 29 patients were obtained and read. These records are compiled by the social workers working with the patient.. They include identifying information about the patient. the precipitating cause of the patient's entering the hospital. the history of his illness. the patient's social history-—including the military history of the patient. psycho-social diagnosis. treatment plans. information about the carrying out of treatment plans. about the social worker's contacts with the patient. In addition. the records may also include results of testing. reports on interviews with relatives. reports on the patient from collaborating agencies. reports on the social worker's contacts regarding the patient with other hospital personnel. and process recordings. These records were added to periodically by the social worker as he worked with the patient. The 26 length of the records varies. depending on the nature of the case. The records are used to facilitate treatment of the patients by the social worker. and also by other hospital personnel. After reading these 29 records several times. it was determined that four of the records provided insufficient information to warrant their being used in this study. This left 25 records which would seemingly prove of value to this descriptive study. 12 of these records being of patients in the hospital. and 13 of the records being those of aged persons who had left the hospital. having received maximum heapital benefits. Ten cases of elderly patients remaining in the hospital were selected randomly as were ten cases of elderly patients who had left the hospital. After this selection of a total of 20 cases. the various social workers. in the hospitals social work service were asked if they felt these particular records should prove of value to the study. or if they knew of some reason why they should not be utilized. They felt these 20 records should prove of value to this study. Pertinent and helpful background for this descriptive .study of 20 aged patients worked with by social work service at the veterans Administration HOspital. Battle Creek. Michigan. 27 was gained by a conducted tour of one of the two buildings housing most of the aged patients there. by a conducted tour of the hospital's family care ward. Background was also gained by assisting a social worker with two aged patients who left the hospital for a family care home. and by a visit to them in their family care home some weeks later. Further background was secured through interviewing the wife of one aged patient who remained in the hospital. and working with an elderly patient for the purpose of motivating him toward an interest in leaving the hospital. and helping him.move into family care. A school of social work second year field placement at the Veterans Administration Hospital. Battle Creek. Michigan. provided understanding of the situation there which was of inestimable value in this descriptive study. and also was invaluable in the understanding of the aged mentally ill patient. including what is involved in his diagnosis. treatment planning and treatmente-including helping him to become sufficiently well to leave the hospital. to return to the community. and to make and. hopefully. to continue. an adequate adjustment there. The categories on which information were gathered. from the social work service case records of the patients. are as folio J5: age of the patient at admission to the Veterans Administration flospital. Battle Creek, iichigan; age oi the patient wnen sccial service began working with him; how long the patient Ezad bee ~11 in the hos ital before seeial work scz.i3s began wo.r.king with him; date of admission to the hosnital; 3331014 nt: competency: racy: religion; marital status. Other catcgoxiss inclujing schW 31in my; integest of his family in him: inter33t of his iriends in him; activities in which the patient engaged while at the hos;3ital; diagnosis; motivation for leaving the hospital: financial status of the pe'ati ant: birthplace; physical condition: war served in: so rvicc connectiw commitance: guardianship: direct activities of social work service with the patient. the scheiule can be found in the appendix. Social service activities vzith and for the patients were considered to include interviews with the patient. contacts with the patient's relatives. assist mg the patient to move to and utilize the family care ward, assisting the patient move to a family care homei following up a patient's move to a family care home to help him adjust there. assistance wi 3h financial matters. assistance with clothing needs, encouraging tile pat t's participation in activities, helping the patient witll his medical needs, assisting the patient's 29 arrangement for a trial visit. helpinj with arrange :aents with a patient's passes and leaves of absence. help with plans to leave the hospital other than to a family care home. contacting other resources w’.lich may be of help to the patient. bilitios. giving help in the patient's at. exploring job poss learning t3 improve his appearance anfl personal habits checking with other hos; 3it“l personnel regarfiing the patient. The following information on competency has been extracted from the M~2 Part X da ted Octol3e r11, 1938. and is used as a definition of competency in this thesis. The following general criteria will be observed in determining the competency of a veteran: 1. To ren Ger 3 medical opinion of inc onpetency it must be established that the veteran has: a. Psychosis or psychotic reac t.i.on. b. Chronic brain syndrome. c. Prolon god amnesia. confused, dissociated. clouded. r fugue state. d. Mental deficiency. 2. It must be shown that one of the above has led to one of these incapacities: Co 30 Sqnandering or dissipation of funds or other assets due to lack of appreciation of value. Incompetency cannot be adjudicated simply because of bad judgment due to laCk of sophistication. inadequate education. or inexperience. That the veteran has been. or almost certainly would be. victimized by designing persons and that such gullibility is due to one of the disorders listed. That there has been. or almost certainly would be. unnecessary refusal to spend money or to expend other assets because of delusional thinking or because of lack of appreciation of the needs of himself or his dependents. that such refusal is due to one of the disorders listed above. that such refusal would deprive the veteran or his family of otherwise obtainable comforts of life. 31 CHAPTER IV SUMMARY OF THESE FINDINGS The case records of each of the 20 aged patients using social work service at the Veterans Administration Hospital. Battle Creek. Michigan. were studied in an endeavor to obtain information about each category for each of the patients. It was found that information about each category for each patient was not always available. As much information as was available was gathered and listed for each patient. This information was then divided into two groupings. for those patients who had been helped to leave the hospital. and those who remained in the hospital. A comparison of these two groups was then made. A summary of the findings follows. and a table of the findings is to be found in the appendix. Admittance On the average. from the date December. 1960. patients remaining in the hospital were admitted 18 years ago. and patients having left the hospital were admitted 13 years ago. a difference of five years. Length of Time Patient Was In the HOspital Before Social Work Service Reached Him Patients who had left the hospital were reached by 32 social work service at an earlier stage of their hospitalization than those who are still in the hospital. For those who left. the average amount of time which elapsed between this entry into the hospital and their first contact with social work service was nine years. This compares with an average of 14 years for those who are still in the hospital. Five of the patients who have left the hospital had been seen by social work service immediately upon their original hospitalization. whereas. two of the patients remaining in the hospital had been seen by social work service immediately upon their original hospitalization. Age at Admittance The age at admission was younger for those patients remaining in the hospital. than for those who had left. Of those patients still in the hospital. four had been in the 30 to 39 age range at time of their admission. but five were over 50. Of the ten patients who had left the hospital. six had been between 60 and 69 upon admittance but eight were over 50. Religion The faiths represented were the Catholic and the Protestant. Of those patients remaining in the hospital. eight were reported on. and of these six were Protestant. and 33 two were Catholic. Of those patients in the study who had been helped to leave the hospital. six were reported on and of these. four were Catholic and two were Protestant. Mital Status Of the ten patients remaining in the hospital. four were married and of those out of the hospital. three were married. In addition. of the patients in the hospital. three were single. while of those out of the hospital. five were single. The remainder were divorced or widowed: two of those in the hospital were divorced and one widowed: one of those out of the hospital was divorced and one widowed. Activities. Socializing and Community Contacts Concerning activities. socializing and community contact by the patient. of those in the hospital. nine were reported on. Of the nine. five engaged in activities (such as occupational therapy. educational therapy. corrective therapy. manual arts therapy. recreational activities. etc.). Of the nine. six were said to socialize. and two had community contacts (such as going into town on passes). Of those patients who had left the hospital. seven were reported on. 34 Of these seven. six engaged in actities. six were said to socialize. and three had community contacts. fiflucation Such information is given for only three of the patients remaining in the hospital. and these had reached the seventh and eighth grades. while information is available for five of the patients out of the hospital. and these were evenly distributed between grades four and eight. It is of interest to also note that of the total of eight patients for whom educational information is available. none went beyond the eighth grade. It should probably be borne in mind that in the days of the youth of these elderly patients. such a limited education may have been quite general and not unusual. Competency Of those out of the hospital. seven were reported on. and of those in the hospital. five were reported on. Of these. of those out of the hospital. six were not competent. whereas four of those remaining in the hospital were non- competent. Information is available for five patients out of the hospital. and available for seven patients remaining in the 35 hospital. Of these. of those out of the hospital. one was a Negro and four were white. Of these. of those remaining in the hospital. none were Negro and all were white. War Served In All of those patients considered in this study. both in the hospital and those who had left it. served in World War 1. Service Connection Of those in the hospital. nine were reported on: seven were service connected. two were not. Of those out of the hospital. eight were reported on; three were service connected and five were not. Cusrdianship_ Of those in the hospital. eight were reported on: seven had a guardian. Of those who had left the hospital. six were reported on; five had a guardian. Occupation Of those who had left the heapital. ten were reported on. Of these. eight were laborers. and two were skilled laborers. Of those remaining in the hospital. six were reported on: three were laborers. one was a skilled laborer. one was in management and one was in sales. Also. the 36 occupations for 16 of he total of 20 patients were given. and ll were laborers. Motivation 0f tnose patients who had left the hospital. information is given for eight. Of these. two had no motivation. four had average motivation. two had high motivation. Of those remaining in the hospital. information is given for ten: three had no motivation. two had little motivation. two had average motivation and three had high motivation. Five of those in the hospital had no or little motivation and two of those who had left: whereas five of those in the hospital had average or high motivation and six of those who had left had average or high motivatioz. I. Juiauuz‘qu'us‘ul» Of those out of the hospital. information is given for nine patients. but not complete information for all of these. Of these. one had between $700 and $2.999. one between $3,000 and $8.999 and two had $9.000 or more. Of those remaining in the hospital incomplete information is given for nine patients. Two had between $700 and $2.999. three had between $3.000 and $3.999. Of those in the hospital. five had funds. and of those out of the hospital. seven had funds saved. Of those out of the hospital. six had a monthly income. and of those staying in the hospital. all reported on did. Afiirthplace Only seven of the 20 cases provided this information. so that this evidence is. therefore. too inconclusive to consider. Areas Help Given With Social work service helped those patients remaining in the hospital with fewer areas in which aid was needed. six: than those patients leaving the hospital. ten areas. Qiagnos is Of those in the hospital. six had a diagnosis of schizophrenia. two had a diagnosis of chronic brain syndrome. one had a diagnosis of dementia praecox. and another one was diagnosed as a medical problem. Of those patients Who had left the hospital. six were diagnosed as schizophrenic. three were diagnosed as chronic brain syndrome. and one as psychosis. In the total number of cases studied. 12 were schizophrenic. five were chronic brain syndrome: with medical problem. dementia praecox and psychosis accounting for one patient each. 38 Committed Of those patients remaining in the hospital. seven were reported on. Pour were committed and three were not. Of those patients who had left the hospital. six were reported on and all six were committed. Family and Friends Of those patients in the hospital. four had family or friends to return to. whereas of those who had left the hospital. three had family or friends to return to. Of those in the hospital. one had no family or friends at all. and of those out. two had none. Of those out of the hospital. one had family or friends but they expressed no interest. while two of those in the hospital had the same situation. Of those who had left the hospital. four had interested friends and of those patients in the heapital. three had interested friends. Beginninngge at Which Socia;_flg£k Service Worked With a a ent The majority of all patients of the total of 20 cases were in the 60 to 69 age range. seven of those in the hospital. and eight of those out of the hospital. Two of those in the hospital were in the 70 to 79 age range and one was in this age range of those who had left the hospital. One of both those in and out of the hospital were in the 50 to 59 age range. Physical Condition Of those in the hospital. eight were reported on. and seven of those out of the hospital. Of these. of those in the hospital. approximately four had physical difficulty. and four had none. Of those patients having left the heapital. it was indicated that approximately six had physical difficulty and one had none. 40 smear It seems that the patients who are older at admittance are most likely to leave the heapital. There is some indication that the younger the age of patients when they are begun working with. the groater is the possibility they will be able to be helped to leave the hospital. It seems that possibly patients admitted the most recently have a better possibility of leaving the hospital. ‘with the aid of social work service. However. the two patients who entered the hospital in 1925 and were in the hospital 32 and 35 years were helped to leave. so there is hope for such. The sooner social work service begins work ng with a patient after his admittance. the stronger may be the possibility of helping him to leave the hospital. More of those who were Catholic left than those who were Protestant. t would seem that having physical symptoms is not necessarily a deterrent to helping a patient leave the hospital. It seems committed patients are more likely to leave the hospital. 41 There is some indication that a patient is more likely to be helped to leave the hospital if he were judged in» competent. Service connected patients seem more likely notto leave the hospital than nonwservice connected. There is some indication that patients with a guardian are more likely to be in the hospital than those without a guard ian. There is some indication that patients in the laboring class are more likely to leave the hospital than other working classes. and that the majority of the 20 patients were in the laboring class. It appears that the single patient is more likely to be able to be helped to leave the heapital. Apparently those with family or friends to return to are more likely to stay in the hospital. Those who do not have a family home to return to. but do nevertheless have interested relatives and friends. are most likely to leave the hospital. But the difference is not very great. which indicated these factors can be overcome through the help of social work service. It seems it is important that social work service help the aged mental patient with such matters as medical and 42 financial problems. activities, contacts with relatives. and so on. The patient's degree of motivation for leaving the hospital is significant. the higher the more likely he is to be helped to leave the hospital. Findings on financial status, birthplace, education and race were too incomylete to warrant any conclusions. There does not seem to be too great a difference between those in and those out of the hospital as far as diagnosis is concerned. 43 CONCLUS ION S The following are not definite conclusions. The material gathered in this study is too limited to permit generalizations. The purpose of the study was to try to identify some of the factors that might contribute to the adjustment of an aged person. so that he may be helped to leave the hospital. as following are not conclusions. but suggestions as to what factors may have such significance. Only more systematic research with large numbers of cases could determine their actual effect. It seems to be indicated that the older a patient is at admittance. the more likely he is to leave the hospital. Therefore, the question may be raised. should patients be encouraged to remain out of the hospital as long as possible. perhaps with the help of a mental health out-patient clinic. or mental health private services? On the other hand. he younger in age patients are when worked with in the hospital. oncefthere. the more likely they are to leave the hospital. The sooner they are worked with after admission. the more likely are patients to leave the hospital. Perhaps a big factor here is helping to prevent the patient from becoming institutionalized. 44 This seems indicated also by the fact that those patients admitted more recently have more tendency to leave: and it is of late years that it has become apparent that patients can become institutionalized. and efforts to prevent this have been worked toward. It seems important that the patient be motivated to leave the hospital. That a major help in this may be encouraging his participation in activities. socialization and community contacts. It seems evident also that unless a patient is severely incapacitated physically. his physical condition need not be a deterrent to his leaving the hospital. Nor need the patient's diagnosis prevent his leaving the hospital. unless he is severely emotionally ill. It does not seem to deter a patient's leaving the hospital if he is incompetent nor does it seem to deter his leaving if he is committed. Those patients not having guardians are more likely to leave; therefore. it seems that more work need be done with guardians to help them to be able to become a positive help in a patient's leaving the hospital. If patients are to be helped to work upon leaving the hospital. it seems jobs for the unskilled will have to be searched for. as most patients Who had left were laborers. indeed. the great majority of the patients in this study were laborers. As religion seems to be a factor in a patient's leaving. perhaps continued cooperation with the patient's pastor. priest or rabbi. and the hospital chaplains can be continued. As more single patients leave the hospital. it seems necessary to do more work with married patient's families. that they may be better able to accept the patient's return home. and so better able to encourage him to leave the hospital. As. at the present at least. the single patient is more likely to leave the hospital. family care homes seem needed for him as he is not likely to return to his family. according to the findings. Service connected patients are less likely to leave the hospital: they are more likely to have funds connected with their remaining in the hospital and/or being declared ill. Here financial assistance and motivation may perhaps play an important part. APPENDIX 47 APPENDIX TABLE CHARACTERISTICS OF AGED PATIENTS LEAVING OR REMAINING IN THE VETERANS ADMINISTRATION HOSPITAL. BATTLE C '3‘? . MICI-EGA}? number of Aged Patients Who Remained in Who Left the Characteristics the Hospital Hospital TOTAL lo 10 Age At Admission 20—29 0 1 30-39 4 1 40-49 1 0 50-59 2 2 60-69 1 6 70-79 2 0 Age When Social Service Initiated 20-29 30-39 40-49 50-59 1 1 60-69 7 8 70-79 2 1 Length of Stay in Hbspital Before Social Service Initiated At once Within 1 year 2 to 6 years 7 to ll years 12 to 16 years 17 to 21 years 22 to 30 years 31 to 35 years Elecococauakan: alocotacaraha01 APPENDIX TABLE Continued Characteristics Number of Aged Patients 48 Vno Remained in the Respital Who Left the Hospital Date of Admission 1924—1934 1935-1944 1945-1954 1955-1950 Diagnosis Schizophrenia Medical Problem CBS Dementia Praecox Psychosis Motivation for Leaving Easpital None Little Average High Unknown Financial Amount Saved 5 7G) - 2.999 3.000 ~ 8.999 9.030 plus Unkns'zm Had Funds Saved Unknown Had Monthly Income unknown 4 {1 OUNNM OPNl-‘Ol U10 UIOLUN U'IU'I th-‘N Howom NNbON N0) hNO-h UN APPEEUIX TAELE Cantingcfi ‘___a— A——-— A Number of Aged Patients Who Remained in ‘ Who Left the 49 Characteristics the Hospital Hospital Physical Condition Difficulty 4 6 No Difficulty 3 1 Unknown 3 3 Service Connection Yes 7 3 No 2 5 Unknown 1 2 Cuz‘maitted Yes 4 6 No 3 0 Unknown 3 4 Guardianship Yes 7 5 Na 1 1 Unknown 2 4 Employment Laborers 3 8 Skilled Laborer l 2 Manufacturer 1 Sales 1 Unknown 4 0 Competency Yes 1 1 No 4 6 Unknown 5 3 Race White 7 4 Negro 0 1 Unknown 3 5 appugaxx TABLE Continued Number of Aged Patients U1 C.) Who Remained in Who Left the Characteristics the Hospital Hospital .41 ‘- Religion Catholic 2 4 Protestant 6 2 unknown 2 4 Marital Status Married 4 3 Single 3 5 Divorced 2 l Widowed l 1 unknown 0 0 Schooling -- Highest Grade Attended 4th 1 5th 1 6th 1 7th 1 1 8th 2 1 unknown 7 5 Family Situation Home Available with family 4 3 Relatives -- No home 3 4 No Family 1 2 Family -- Not interested 2 1 unknown 0 0 Areas Help Given With - Average 6 10 Unknown 0 O Birthplace Small town 3 0 Large City 2 2 Unknown 5 8 APPEUDIK TEBLE Continuni Number of Aged Patients who Ranained in Who Left the Characteristics the Hosuital spital Activities In Which Patient Engaged at Hospital - Number of Patienta Doing Same Aczi ities Socialization Community Contacts Unknown l-‘NO‘U‘I wwmm m Pd 52 °CEEDULE Age of patient at acmlDSLDI -- as of December 31, 1960. Age of patient when social work service began working with him. Lenytl of time the patient had been in the ho spital before social work service initiated. Date of admission to the hospital. Empl yment the patient wa.e engaged in the majority of his lifetime. Competency cf then We cut ~- at time of ad asiasion to the 119-51)l 1.31 o Ra1e of the natient. Religion ~~ at the time the patie:r.t ente M the hospital. Her tal status —- at the time the patient entered the hosPital. _y:haoting ~- hijie at ctaie attended. I‘anily ~- its interest in the patient, and friends whether or not they were iutercsth in him. determined by whether they vieitefi. called. wrote the pati rent. or contactefl the hospital about him. Activities in Which the patient engaged at the hospital -- his socialization. Diagnosis. Motivation of the patient for leaving the hospital -- determined by the patient'e expressed interest. and his reactions as ob se rved anfl recorded by the social worker. Financial condition of the patient. including source of his financial resources. Physical condition. War served in. Service connection. Committance. Guardianship. 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