Integrated Care Teams Should Include Social Workers
By Melinda Young
Integrated care teams sometimes lack a social worker, which can undermine the team’s work and success. It is a shortsighted tactic because social workers can help with case management and care coordination in a variety of ways, including intake assessment and behavioral interventions, according to recent research.1
“We realize how important social workers are, but what’s happened is a lot of nurses are taking those roles, and they’re more reimbursable in inpatient settings,” says Patricia Findley, DrPH, MSW, study co-author and an associate dean of academic affairs at Rutgers University School of Social Work. “Social workers are the glue of interdisciplinary teams because we not only work with patients, but also work with families and are communicating with the team and family. We move them through their stay at the hospital to help them go home at discharge and to help them understand the care they’re receiving and why they’re receiving it.”
Social workers communicate with insurers to help patients with post-discharge services, such as therapy, substance use treatment, and home health services.
“We’re the ones talking to patients and helping them understand why they’re going [to another facility],” Findley says.
If the patient expresses child care concerns, the social worker will help the family find a solution. Social workers also let patients’ employers know how long the patient may be unable to work. “Social workers fill all the cracks,” Findley says. “Nurses do more of the medical pieces — getting prescriptions for medications, helping with wound care. Social workers deal with the outside — helping patients find a pharmacy and helping them deal with insurance companies when they receive a referral.”
Social workers also help patients with their Medicaid paperwork, and they complete forms for special pharmacy programs that may help patients with their medication costs.
“I did a lot of discharge planning and coordination,” Findley notes. “If the patient doesn’t speak English, that’s another area we deal with, or a disability adds another layer of issues.” Social workers help find interpreting services and keep the patient and team updated, she adds.
When team members become stressed, social workers can help them understand any discharge delays and how housing and other obstacles need to be addressed before the patient can be discharged safely.
“Social workers work with hospital administrators, families, teams, and all those resources. It’s a real juggling act,” Findley notes. “We’re all natural helpers, but social workers are trained and know how to bring team members together. We can do mindfulness exercises, take a deep breath, and if emotions run high, we try to take a break, having people come together in half an hour to talk about it.”
Social workers can encourage huddles where team members talk for several minutes about issues. They can help the team stay focused on patients and what is best for them and for positive outcomes.
For example, a social worker may hear about conflict between a nurse and a patient’s family, causing turmoil among staff. “The social worker will grab the nurse who is working and say, ‘Let’s talk about this and see what we can do to problem-solve, so this evening when the family member comes in, let’s have a strategy to help the patient,’” Findley explains. “We’ll be ready to face that family member again.”
Then, the social worker would call the family member and say, “I understand you’re a little stressed — how can I help you?” she adds.
In these situations, a lot of stress revolves around communication. Perhaps a family member felt left out of a conversation and wanted more information. Or maybe the nurse had already given a different family member the necessary update, but another person insists they be given all their attention.
“Everyone has their own perspective, and the social worker can help clarify what’s happening,” Findley says. “So many times, I’ve had a spouse mad at me because they felt left out of the conversation. They weren’t left out — there just wasn’t time to get to them.”
These experiences are a reminder that case managers, social workers, and nurses sometimes need to slow the process and make time for conversations, using customer service skills.
Another skill social workers bring to the care coordination team involves cognitive behavioral therapy techniques. This skill can reinforce a patient’s adherence to medication and diet.
“Let’s say a patient is a diabetic and wasn’t following their diet and medication regimen,” Findley explains. “They had an episode that takes them to the hospital, and the doctors and nurses are working on their body’s response to the medication.”
The social worker can talk to the patient to learn what is stopping them from following their diet and taking their medication. “You can challenge their thinking about what is happening to them and help them understand and shift their thoughts to being more open to participate in their treatment,” Findley says. “That’s a lot of cognitive behavioral — about how some of their thinking is shaping their thoughts.”
Social workers can use the technique for patients with substance use disorders who need specialized treatment. “There’s usually all this denial — ‘I’m fine. I don’t have a problem,’” Findley says. “The social worker could say, ‘Well, you crashed a car and now you’re in the hospital, so something is telling me there’s a bigger issue here.’”
Part of this tactic can be to develop a strength-based perspective in which the social worker builds on patients’ strengths and helps move them forward. “We build on those strengths to recognize what they’re doing, and that helps bolster the person’s sense of power to help move them forward,” Findley says. “You have to do it in a very deliberate way by not giving them false hope.” Instead, they can give patients realistic hope and help them make incremental changes on their own.
Using these skills, social workers provide added value to the care coordination team. “We’re helping the team work together more efficiently and effectively, and we just need to be more present,” Findley says. “With the growth in understanding of social determinants of health, we have even more of a role.”
REFERENCE
- Milano N, Petruzzi L, Covington E, et al. Social workers in integrated care beyond primary care: A scoping review. Transl Behav Med 2022;12:1038-1048.
Integrated care teams sometimes lack a social worker, which can undermine the team’s work and success. It is a shortsighted tactic because social workers can help with case management and care coordination in a variety of ways, including intake assessment and behavioral interventions, according to recent research.
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