Background
Aim
Methods
Compassionate collaborative care (CCC) is a process through which caregivers from different professional and non-professional backgrounds work together with patients and families to deliver care that recognizes, understands and responds to concerns, pain, distress, or suffering, with the aim to promote positive patient-family, team, and organizational outcomes across healthcare settings.
Literature search
Data evaluation
CCC Indicators | Individual Level (patient-family- provider) | Team Level | Organizational Level |
---|---|---|---|
Structure | |||
Attributes and characteristics, the “what and where”, supportive resources (material and human) | Cell 1 | Cell 2 | Cell 3 |
Process | |||
Interventions, what is done in giving and receiving CCC, the “how”, actions, steps, change that occurs over time | Cell 4 | Cell 5 | Cell 6 |
Outcome | |||
Short-term and long-term effects and impacts of CCC on patients, providers, teams, and organizations | Cell 7 | Cell 8 | Cell 9 |
Data analysis
Literature abstraction
-
‘Structure’ denotes the attributes of settings where care occurs. It refers to health system characteristics that affect the ability to meet the health care needs of individual patients, families, or a community. Structural indicators describe the type and amount of resources used (i.e. staff, clients, money, beds, supplies, buildings) in order to answer whether care is provided under favorable or unfavorable conditions to good care.
-
‘Process’ denotes what is actually done in giving and receiving care. Processes are a series of inter-related activities undertaken to achieve objectives. Process indicators measure the activities and tasks in patient episodes of care. For some researchers, seeking care and carrying it out are also viewed as process indicators.
-
‘Outcome’ describes the effects of care on patient and/or population health status. These may include knowledge improvement, changes in behavior and ultimately, satisfaction with care. Outcome indicators are states of health or events that follow care and should be evidence-based.
Data reduction and display
Author (Year) | Country | Design | Setting/Sample | Disciplines/Roles | Relevant Findings and Extraction | Appraisal Gradea (1–5) |
---|---|---|---|---|---|---|
Addicott (2013) [56] | U.K. | Qualitative study based on 4 case studies Semi-structured interviews | 4 high-performing care homes in end-of-life care | Social workers, palliative care specialists, community nurses, care home managers, RNs, care assistants | Three pivotal factors to high-quality EoLC in care homes: advance care planning (ACP), multidisciplinary communication and work, dignified and compassionate care. ACP as a useful trigger for beginning communication with residents and other care professionals. Strong leadership can motivate compassionate care. | 2 |
American Academy of Pediatrics (2013) [37] | U.S. | Policy Statement / Pediatric Palliative Care-Pediatric Hospice Care (PPC-PHC) Guidelines based on published observational studies, expert opinion, and consensus statements. | N/A | N/A | Model Principles: 1. Patient-centered and family engaged 2. Respect & partnering 3. Quality, access & equity 4. Care across age spectrum & life span 5. Integration into the continuum of care 6. Universal preparedness & consultation 7. Research & continuous improvement Teams should have sufficient collective expertise and adequate staff to address child/family needs. Organizations should have dedicated interdisciplinary PPC- PPC-PHC teams that facilitate clear, compassionate discussions supporting families and staff beyond EOL period. PPC-PHC involves collaborative, integrated multimodal care (cure seeking, life-prolonging, comfort-enhancing, QOL-enriching) | N/A |
Borhani et al. (2013) [38] | Iran | Descriptive exploratory qualitative study | A teaching hospital in Islamic South-East Iran, 12 ICU nurses | Nurses | Commitment to care is expected until the last moment. Nursing challenges include ethical issues, family expectations, religious issues and miracles. Care involves awareness of the needs of dying patients, identifying impending death, promoting comfort and spiritual care, and caring relationships | 4 |
Cook et al. (2015) [39] | Canada | Mixed methods | Dying pts. in Med/Surg ICU, their families and clinicians | Physicians, residents, nurses, social workers, chaplains, family members | Honouring pt. wishes in ICU involved humanizing the environment, personal tributes, family reconnections, rituals & observances, dignifying the patient, giving the family a voice as partners in the caring process instead of “visitors”, fostering clinician compassion by encouraging self-awareness, reflection and sense of collective purpose | 2 |
Costello (2001) [57] | U.K. | Ethnographic study Participant observation, semi-structured interviews | 74 pts. in elderly care wards in a large hospital, 29 nurses, 8 physicians | Nurses, physicians | Hospital culture, mores and beliefs impact the experiences of older dying pts. Bracketing out time provision of psychological care. | 4 |
Cox (2004) [40] | U.S. | Review of literature and position statement (Emergency Nurses’ Association, American College of Emergency Physicians, American Trauma Society) | Comprehensive Pediatric Bereavement Programs (CPBP) | Multidisciplinary Bereavement Committee (nurses, physicians, SWs, chaplains, child life specialists) | Key elements of CPBP: team approach, recognition of cultural differences, integration of family into care of the dying, memory packets or boxes, support groups, resource lists and information, remembrance ceremony, continued contact with family, staff education and development, program evaluation and feedback. | N/A |
Hanson & Cullihall (1996) [41] | Canada | Care study (for teaching purposes) | Palliative care team: nurse, physician, SW, chaplain, domiciliary care sister | Patient and family holistic care was delivered by an interdisciplinary palliative team. Primary nursing role involved coordination and integration with other health team members continuity of care, provision of comfort care and symptom management. The care model improves quality of life for the dying and enables informed choices for patients and families | N/A | |
Kayser-Jones et al. (2005) [58] | U.S. | Content analysis | 33 residents in a 25-bed hospice unit within a large long-term care facility | Hospice team (certified physician, nurse manager, RNs, LVNs, CNAs, SW, activity therapist, spiritual counsellor, volunteer coordinator) | The hospice environment provides physical-psycho-social-spiritual care as a therapeutic community, and reflects compassion. The hospice team core values include communication at all levels and development of sense of community. There is awareness of how the environment influences care (attention to details, minimum noise, soft background music, common meal area, garden homelike, supportive, family). Alternative, creative approaches to symptom management were used Social and spiritual events (Happy Hour, Memorial Service) provided a sense of community. Needs of resident prioritized over paperwork. | 1 |
Kehoe (2006) [42] | U.S. | Metasynthesis of qualitative studies | 65 US hospice nurses (in 5 qualitative studies) | Hospice nurses / hospice team | Strong personal foundations are complemented by firm professional supports. Team includes the patient’s family, nurses, social workers, physicians, and other professionals and volunteers who “cocoon” the dying. Hospice nurses are collaborators, valuing, seeking, and offering support to the IP team. For nurses, is important to develop a sense of the abilities of others on the hospice team. | N/A |
Knuti et al. (2003) [43] | U.S. | Non-research Schwartz Rounds – case study focused on caregiver (physician) who becomes pt. (cancer surpriser) | Oncology | Physicians (oncologist), patient (physician), spouse (psychologist), social worker, clinical nurse practitioner, nurse, fellow | Processes involve active planning, ongoing support from relatives, friends and the team as resources described as “circles of strength”, being honoured and cared for by the team; patient and family involvement in decisions; open and direct communication; promoting self-care; proactive and timely referrals; IP mentoring. Outcomes include intimacy, happiness after diagnosis, hope, changing relationships and perspectives, enhanced spirituality. | N/A |
Krakauer (2000) [44] | U.S. | Non-research Schwartz Rounds – case study focused on acute palliative care and the way comfort was provided to a young adult in his last days of life (principle of double effect) | Hematology – Oncology Dept. & Palliative Care Service | Facilitator, Ward Nurse, SW, Chaplain, Palliative Care Nurse, Palliative Care Physician, Pt’s family, Pharmacist | Patients expected caregivers to listen to needs and respect wishes. Care involved tremendous integration and teamwork between patient, family, nursing, palliative care, and pharmacy. The team considered the best place for the patient to die taking into account family wellbeing. Having a safety net is important to protect a dying patient from acute suffering. Support from, consultation and collaboration with other providers improved pain management. Family perceived making the right decision and felt like part of the team. Positive outcomes included protocol development for use of barbiturates for intractable suffering. Spiritual peace was achieved for family, friends and staff. Team education is needed to address ethics of the “double effect”. | N/A |
Lintz et al. (1999) [45] | U.S. | Non-research Schwartz Rounds – case study focused on aggressive palliative treatment & psychosocial issues faced by pts., families and caregivers | Hematology-Oncology Dept. | Physician, nurse, medical oncologist, psychiatrist, SW | The team worked with the family to proceed through fertility treatments, pregnancy, and birth. Instilling hope and helping patients address difficult questions, and make decisions is a significant part of care. The team works together to decide to continue or cease treatment. Acknowledging the patient’s positive impact on the caregiver’s life. | N/A |
Moore & Phillips (2009) [61] | U.S. | Non-research Schwartz Rounds – summarizes findings from an independent study commissioned by Schwartz Center (SC) that examines Rounds’ outcomes, discusses their utility in providing support and offers lessons learned for others who may want to consider Rounds’ implementation | VA Hospital | SW, hospice/palliative medicine physicians | Implementing Schwartz Rounds requires commitment by hospital administration, human resources and formalized planning. Reflecting on the emotional aspect of care enhances caregivers’ ability to deal with a similar situation in the future. Rounds provide support towards empathic practice of medicine (i.e. reflection, self-monitoring, processing emotion and coping with its effects). Unanticipated outcomes: patient-centered changes in institutional policy or practice; greater use of palliative care teams/enhanced palliative care services; improved linkages among hospital services to better meet the needs of veterans with mental health disorders and substance abuse; discussion among staff about advanced illness and palliative care issues. | N/A |
Penson et al. (2000) [60] | U.S. | Non-research Schwartz Rounds – case study focused on burnout | Oncology | Physicians, social worker, clinical nurse practitioner, nurse, fellow | Participants emphasized communication, partnership, having the right attitude and the team as being “what saves all of us”. The rounds provide spaces for connecting with the team and learning about the patient as an individual. Reported positive outcomes included reduced burnout and stress, ability to recognize stress and burnout in self and others, improved coping and teamwork and team support. | N/A |
Penson et al. (2002a) [46] | U.S. | Non-research Schwartz Rounds – case study focused on bereavement | Oncology | Social worker, oncologist, palliative care nurse, infusion nurse, pediatric oncologist, palliative care physician, psychologist | The team was viewed as an extended family. Caring involves honouring the personal relationship, meeting patient’s needs as survivors, and realizing the need to sacrifice. Processes included: phone calls, bereavement care programs (sending cards, memorial services, saying good-bye to patient, family, friends), bereavement rounds for staff. Family valued receiving phone calls, cards and letters. | N/A |
Penson et al. (2002b) [47] | U.S. | Non-research Schwartz Rounds – case study focused on negotiating cancer treatment in adolescents | Oncology | Social worker, ward nurse, oncologist, palliative care nurse specialist, psychiatrist | Discussion centred around several topics: care decisions, sharing prognosis and options, maintaining supporting patient wishes, mobilizing transition to hospice care, saying good-bye, team communication, commitment and working relationships. Positive outcomes were allowing “different family members to establish their own relationship with team members… members of the team [were able] to share the sadness and the challenges of working with the family and to ‘hold’ the emotion that these cases evoke”.
| N/A |
Penson et al. (2005) [48] | U.S. | Non-research Schwartz Rounds – case study focused on fear of death | Oncology | Physician, nurse, chaplain, psychiatrist, oncologist, social worker, palliative care physician | Discussion emphasized the challenges and benefits of addressing conflicts, responding to difficult questions, being empathetic and taking time to listen and be present. Careful care planning alleviated fear and depression. The process resulted in team role fulfillment. [ | N/A |
Puchalski et al. (2006) [49] | U.S. | Non-research Model for interdisciplinary spiritual care | N/A | Applicable to physician, social worker, nurse, chaplain | The document integrates a “Call to Action”. The model emphasizes adherence to a biopsychosocial-spiritual model of care that is practised by all members of the healthcare team. Self-awareness, ongoing interdisciplinary team communication ensures that patient and family have comprehensive compassionate plan of care. Compassionate presence involves intention, openness, connections with others, and comfort with uncertainty. It is relationship-centred, not agenda-driven. It enriches the work of each healthcare professional richer through collective action. | N/A |
Puchalski et al. (2014) [50] | U.S. | Non-research Consensus findings re standards and strategies for integrating spiritual care | N/A | Organizational policies should promote spiritual compassionate care across the organization, at the bedside with patients and families, in staff relationships, and at all levels of leadership. It has potential to transform and heal all parties. | N/A | |
Rushton et al. (2006) [51] | U.S. | Quality Improvement Evaluation of an IP grief program | Children’s hospital | Physicians, nurses, social workers, child life specialists, bereavement coordinator, family care coordinator, volunteers | The grief program involved all units, departments, disciplines, leaders and volunteers. Timing and training were provided. Change was guided by a hypothesis: “health care professionals will provide better care and support to seriously ill children and their families when they feel supported personally and professionally in their work.” There were four interventions: 1. Compassionate Care Network - integrated palliative and EoLC information and expertise across all units 2. Institutional palliative care rounds 3. Patient care conferences 4. Bereavement debriefing sessions Surveillance data were collected. The team benefited from increased teamwork and morale, knowledge about others’ expertise, knowledge about advocacy, and patient and family care in the terminal phase. Frequency of referrals, conferences and meetings increased. | 1 |
Schermer Sellers (2000) [52] | U.S. | Research evaluation of an integrated treatment model – psychosocial needs assessment | Medical oncology | Patients, cancer physician, oncology nurses, lab technicians admin staff | The integrated treatment model was driven by collaborative healthcare guidelines and a mission statement: The mission statement was: 1) to reduce suffering created by the effects of cancer on patients and loved ones; 2) to work with patients and their families to diminish stress and channel all available resources toward health, healing, and quality of living; 3) to provide ongoing support to staff and physicians; 4) to strengthen and support the physician/ patient relationship, and 5) to relieve staff and physicians of lengthy and/or complex psychosocial patient interventions. Proximity, accessibility and availability of the therapist enabled frequent team communication, a whole person approach, assessment of patient and family complex needs, resources, goals (lifestyle, faith, sexuality, grief). It supported crisis prevention and management. Outcomes were collective action, team shared learning, team satisfaction with care delivery, patient reduction in suffering, improved quality of life, and increased hope and perceived agency for patient and family. | 1 |
Teno & Connor (2009) [53] | U.S. | Non-research Evidence-based commentary using a patient case | Hospice & palliative care | Physician, clinical nurse specialist, social worker, chaplain | Patient values, expectations, choice and cultural tradition, and patient dignity must be respected. The case exemplifies attendance to the patient physical and emotional comfort, evidence-based practice, shared decision making, family information needs. Team crisis care was available. Bereavement care was available before and after death. Compassionate care was coordinated across care settings and facilitated by IP referrals, transitions in care, and participation in important family events. An individualized, holistic care plan addressed the person’s priorities and contributed to perceived hope. | N/A |
Thompson (2013) [59] | U.K. | Non-research Reflection | Schwartz Rounds in a UK hospital | Rounds require a supportive environment, open discussion between equals, time and facilities, Any member of staff, from porters to executive directors, can attend and participate. Senior clinicians acknowledged the complexity of the case and appreciated the team challenges. Positive outcomes were: improved communication, team members reminded of their value and why they entered a caring profession, emotional support from colleagues, catharsis, learning and understanding roles and challenges of others, celebrating achievements, led to improved patient experience | N/A | |
Wentlandt et al. (2016) [54] | Canada | Qualitative Interviews, focus groups | Hospital palliative care units | Physician, nurse, social work, PCU manager, chaplain, OT, Volunteer | Connection with patients and family members goes beyond just doing the job. A sense of community is appreciated by family. A quick response by the team was seen as “giving reassurance, pulling out all the stops and going the extra mile” to support a family’s wellbeing. Patients and caregivers expressed satisfaction with care that was seen to be “engaging”, sometimes humorous, and “genuine”. | (3) |
Williams et al. (2008) [55] | Canada | Non-research Literature review | Perinatal /neonatal | Multidisciplinary team but specific reference to physician, social workers and nurses. | Families value speaking during meetings, continuity of the care team, timely communication, sharing sorrow, and being informed of changes in the care plan. Parents want to feel supported regardless of their decisions. Every team should exercise compassionate, individually tailored, and non-judgmental care including respectful treatment of the body. Respect can also be given through verbal and emotional support of family and co-workers. Shared decision-making should be viewed as a multidisciplinary process. The team should help parents feel that the right decision has been made. Compassionate care demonstrated through assistance with religious rites, funeral support, bereavement care. Interdisciplinary morbidity and mortality sessions or small group debriefings may help reduce the heavy emotional stress. Forming a connection with patients and family members and not “just do their job” | N/A |
Data presentation
CCC Indicators | Individual Patient / Family / Provider | Interprofessional (IP) Team | Organization |
---|---|---|---|
Structures (attributes) | Overarching Structures: Patient and Family-Centered Care Overarching Values: Empathy, Sharing, Respect, and Partnership | ||
Patient-Family Values & Expectations | Values | Culture | |
• Commitment • Dignity • Supportive care | • Commitment • Authenticity • Holism | • Shared mission and vision • Leaders and champions • Inclusivity | |
- Continuous - Non-judgmental | Skills | Policies | |
• Relational • Leadership and advocacy • Reflection and self-awareness | • Support for IP patient-centered care | ||
Provider Needs & Expectations | Resources | ||
• Commitment • Support • Education | • Human (professional and non-professional) • Compassionate spaces • Time | ||
Resources | |||
• Shared IP space • Time | |||
Processes (tools / mechanisms) | Overarching Processes: Communication, Shared decision-making, and Goal setting | ||
Formal | Strategic planning | ||
• Symptom management • Spiritual care • Transitional care • Advance care planning • Bereavement care | • Care rounds and case conferences • Referrals and consultations • Transitional care • Advance care planning • Bereavement rounds • Schwartz Rounds | • To achieve priorities and goals | |
Policy and program development | |||
• To support formal processes and pilot projects | |||
Informal | |||
• Impromptu communication (hallway, telephone) | |||
Outcomes | Overarching Outcomes: Development and Satisfaction | ||
Patient- Family Development and Satisfaction | Knowledge | Organizational Development | |
• Self-care • Coping • Holistic care • Dignity and “being known” • Patient-provider relationships | • Complex end-of-life care • IP team roles and contributions | • Innovative programs and partnerships • Policies and processes | |
Behavior | Organizational Satisfaction | ||
• IP communication • Collective purpose • Coping • Reflective practice | • Reduced provider burnout and compassion fatigue | ||
Provider Development and Satisfaction | |||
• Patient-family goal achievement • Self-compassion • Self-care | |||
Satisfaction | |||
• Role fulfillment • Teamwork |
Results
Overarching findings
Sharing is manifested when patients, families, and caregivers relate care concerns and preferences [52, 55, 56], learning needs [52], decisions [47, 53, 55], and care experiences [46, 47, 59]. Respect involves careful attention to the patient’s physical and bodily needs [55, 56], patient and family wishes [44], and verbal and emotional support for patient and family members [55, 56], as well as team members [37, 42, 46, 47, 59]. Finally, partnership involves forging formal and informal connections between patient, family, the team, organization, and external agencies or resources [37, 40, 42‐44, 46‐49, 52‐54, 59, 60]. Partnerships among patients, families, and providers involve a shared journey [49, 59] that is not agenda driven and transcends sectors and settings [37].“You need to know that the people caring for you, whether they can or can’t help you with your disease, honor you for who you are and care about you” [43].
Structures
Individual structures
Promoting and protecting dignity emerged as another important element of supportive care among patients and families [39, 43, 53, 56].“Family member: I never felt like we weren’t part of your team… You always validated our thoughts and feelings... that’s so important to hear because we have to live with that [decision]” [44].
With regard to providers, the analysis revealed personal and professional commitment [38, 42, 47, 58] as a prominent structure.“You [the patient] need to know that the people caring for you, whether they can or can’t help you with your disease, honor you for who you are” [43].
Two additional provider structures that promote provider engagement in CCC include professional support [40, 42‐44, 46, 47, 51, 52, 55, 59, 61] and education [39, 40, 51, 58, 61]. Education can be formal or informal, with patients and families sometimes serving as teachers:“If I don’t do it from the heart, then the care isn’t good…I really don’t know what it is like to die” [58].
“Sometimes it’s learning from the family. Sometimes we’re not the expert. ‘You know your mother. You understand your culture…Help us…so that it’s meaningful for all of us’ [39].
Team structures
Skills at the team level are relational [49, 52, 54], and involve active listening [48, 49], leadership [50, 51, 56, 61], advocacy [51, 56], reflection and self-awareness [39, 43, 46‐48, 59‐61]. According to our analysis, human resources and time are key structural indicators at the team level. In particular, the literature sample supports an IP team approach in delivering CCC [37, 39, 40, 43‐52, 54, 55, 58, 59]. Time and shared spaces for planning, sharing, and debriefing are essential to support CCC among teams [46, 47, 51, 52, 55, 59, 61].“When a resident dies and they leave the home…the staff will line the corridors to say cheerio to them and that includes domestic staff, kitchen staff, everyone…I always go with the undertakers because I want to make sure that the person I’m looking after is still being looked after” [56].
“…time needs to be allocated for this initiative to work, and it needs to be integrated into staff professional development as opposed to being a forum that can be attended only if staff have spare time” [59].
Organizational structures
Finally, adequate organizational resources are required for patient and family programs [37, 40, 52], IP staffing and support across the institution [40, 52, 59, 61], and compassionate spaces for patients and families [54, 58] as well as staff [56, 60].“Organizational policies should promote and support spiritual compassionate care at the bedside, in the boardroom, and in staff relations” [50].
“We try to create a home-like rather than an institutional environment…. When everything is right, we’re sending a message that we do care…” [58].
Processes
Individual and team processes
SCR provides a venue for sharing the emotional work of caring with other carers [43‐48, 60, 61], and this sharing can support CCC.“The more formal venues, such as the rounds or the chemo meetings, are not just meetings where we talk about what therapy someone’s on, they become, “Oh my God. She is 38. She has two kids and she has cancer” [60].
“For the responsible and empathic practice of medicine, health-care providers have to engage in the routine process of reflecting, self-monitoring, processing emotion, and coping with its effects; tasks that are quite challenging without support. We have found the Rounds help to provide that support” [57].
Organizational processes
Outcomes
Individual outcomes
Provider satisfaction is associated with the achievement of patient end-of-life care goals, [43, 44, 46, 48, 49, 56, 58, 60], including spiritual peace [49, 60], pain and symptom management [43, 44, 48], and the provision of patient-family support across the continuum of care through bereavement [46, 58].“This service is very important because of the intensity by which fear, love, anger, grief, stress, and loss overtake you. By giving compassion and tools to cope, patients and families are helped to love one another and stay connected. This is vital to making the process a healing one” [52].
Finally, the ability to engage in self-care and self-compassion are additional prominent indicators of provider satisfaction [42, 56, 60, 61].“Both cure and healing fall within the responsibility of the health care profession. I think doctors and nurses offer the most powerful kind of healing possible when they really care about someone. You weren’t just a pro doing what you had to do. You went beyond being technically competent” [46].
“One must acknowledge the losses, accept the pain, strive to move beyond the grief, and then be willing to embrace new relationships guaranteed to include more loss” [38].
Team outcomes
According to our analysis, team satisfaction is evidenced through role fulfillment [44, 45, 48, 51, 56] and positive teamwork experiences associated with collectively achieving the patient-family goals of care [43‐45, 51, 53].“The synergy between all those interacting with the patient enhances the overall care and wellbeing of the patient. But it also makes the work of each individual healthcare professional richer in that the contribution of each healthcare member to the treatment plan potentiates each individual contribution. The wholeness is more than the sum of its parts” [49].
“It’s really important to bring someone out of the world. I think it’s a real privilege to do it. After they have passed away – changing them, laying them out and everything, putting the flowers on and seeing their family’s reactions when they see them like that – it makes you feel really proud of what you do” [56].
Organizational outcomes
Secondly, indicators of organizational satisfaction that include reduced healthcare provider burnout and compassion fatigue emerged from several articles [42, 51, 56, 60, 61].“Findings indicate high levels of engagement and intentionality about building community…equally important was the benefit of interdisciplinary exchange and understanding. Participants reported that the sessions increased their capacity to provide palliative care and integrate it into care on the units where they practiced. Participants in each [bereavement care]session identified specific new learning that would influence their clinical practice” [51].
“The thing that keeps you going, even in the middle of a busy, frustrating day is when you can’t help all of the patients, is being able to connect with people. That is the only thing that keeps me coming back every day [clinical nurse practitioner]…I’ve been here…for about four years and have seen incredible changes. I’ve been thinking about how you survive in a place like this that keeps growing and growing and getting busier and busier every year…The goal for the day can be that you’ll connect someone…I hear the positive perceptions that patients have of their care providers…The regular newsletter “Hotline” occasionally publishes encouraging letters from patients. Reading these makes you feel really good because they identify the people that the patient had come into contact with [social worker]” [60].