Medical Social Work in an Interdisciplinary Health Care Team

Interdisciplinary Medical Social Work: A Working Taxonomy

Interdisciplinary Medical Social Work: A Working Taxonomy PETER MARAMALDI, PhD, MPH, LCSW Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, Boston, Massachusetts, USA ALEXANDRA SOBRAN, MSW, LICSW, LISA SCHECK, MSW, LICSW, NATALIE CUSATO, MSW, MPH, LICSW, and IRENE LEE, MSW, LICSW Social Work Department, Massachusetts General Hospital, Boston, Massachusetts, USA ERINA WHITE, PhD Candidate, LICSW, MPH Simmons School of Social Work, Boston Children’s Hospital, Boston, Massachusetts, USA TAMARA J. CADET, PhD, LICSW, MPH Simmons College School of Social Work, Harvard School of Dental Medicine, Boston, Massachusetts, USA Findings from a year-long exploratory study aimed at describing universal functions of medical social work with interdisciplinary teams in acute care settings are reported here. A universal taxonomy of interdisciplinary social work skills and competencies was empirically identified through a participatory action research framework. Findings support previous conceptual descriptions of medical social work’s overarching and historical role to help interdisciplinary teams in acute care to consider patients’ home environment, knowledge, beliefs, culture, and resources during assessment, treatment, and discharge planning. The empirically determined taxonomy reported is intended to provide social workers a framework with which to articulate and evaluate their core competencies on interdisciplinary medical teams. KEYWORDS medical social work, interdisciplinary teams, participatory research Received March 10, 2014; accepted March 14, 2014. Address correspondence to Peter Maramaldi, Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, 300 The Fenway, Boston, MA 02115. E-mail: [email protected] 532 Interdisciplinary Medical Social Work 533 THE PROBLEM Although health care in the United States has made tremendous technological gains during the last century, it has also taken on unforeseen dimensions related to distribution and utilization of scarce resources (Berkman, 1996; Rehr & Rosenberg, 2006). Prior to the passage of The Patient Protection and Affordable Care Act (2010), health care was traditionally distributed as a commodity, rather than an inalienable right. Market forces dictated the distribution of resources on both the supply and demand sides of healthcare (Chirba Martin, 2009). Social work has not fared well in resource allocation for a variety of reasons including an erosion of government funding, limited support for social services by insurance companies, and the inadequate demonstration of its potential contribution to health care (Rehr & Rosenberg, 2006). Medical social workers tend to under-articulate their clinical contributions to patients and interdisciplinary teams (Abramson & Mizrahi, 2003; Carrigan, 1978; Globerman, White, Mullings, & Davies, 2003). Descriptors such as “providing support,” “counseling,” and “working with family” do not capture the full extent of the interdisciplinary clinical social work practice. Interdisciplinary curriculum scholars note the importance of standardizing the “objectives, outcomes, and competencies expected for each discipline” (Newhouse & Spring, 2010, p. 315). Thus, our findings offer an empirically determined taxonomy to assist clinical social workers to frame their contributions in operational terms that are easily recognized by other health disciplines and clearly defined for measurement and evaluation. We demonstrate here the potential disciplinary contributions that social work brings to interdisciplinary teams as part of the larger national effort to improve the overall quality of health care. This taxonomy may help clinicians demonstrate their clinical effectiveness and utilize evidence informed interdisciplinary approaches with patients and their families. The recent passage of the Patient Protection and Affordable Care Act (ACA) (2010) indicates that health care quality improvement programs should “assist health care providers in working with other health care providers across the continuum of care” and should work at “engaging patients and their families in improving the care and patient health outcomes” (The Patient Protection and Affordable Care Act, 2010). The law offers a unique opportunity for social workers to participate in teams intended to increase quality while reducing costs. BACKGROUND For more than a century, social workers engaged in interdisciplinary collaboration and practice have worked from a values-based commitment to provide the best available care to vulnerable populations, to develop interventions aimed at health promotion and disease prevention, and to maintain 534 P. Maramaldi et al. a biopsychosocial perspective on health care. The interdisciplinary functions and patient-centered perspectives currently espoused by the ACA are for social work, essentially a return to the roots of the medical social work more than a century ago. At the turn of the previous century, providers treating low-income and immigrant populations in large urban hospitals—in cities such as New York, Baltimore, and Boston—observed the interactive nature of psychosocial and biological conditions, and attempted to address those issues in part through what we now call social work (Berkman & Maramaldi, 2001). HISTORICAL CONTEXT: WHAT IS OLD IS NEW In her seminal 1915 book on social work in hospitals, Ida Cannon, generally known to be the founder of medical social work (Rehr & Rosenberg, 2006), reflected on her early years when she was invited to Boston by Richard Cabot, who was a Professor of Medicine at Harvard. Her writings related her cross-disciplinary experiences at the Massachusetts General Hospital (MGH) and her training at the Simmons School of Social Work, which were both affiliated with the Harvard Medical School. She posited that the charge of the hospital social worker was to assume the role of “interpreter,” and to bridge the communication gap between patients, families, and other providers. Almost a century later, the Institute of Medicine (IOM) report (2008) on meeting psychosocial health needs for the whole patient underscores the importance of fostering communication. The IOM report states that the entire medical team should work to enhance communication with the patient and family. Patient–provider communication—meaning team members’ listening and speaking with patients—is a critical element of diagnosis, treatment, and discharge. More recently, the ACA (2010) calls for providers to work efficaciously across disciplines to meet patient-centered objectives. The Act has led to the emergence of accountable care organizations (ACOs) aimed at improving quality while containing costs (Fisher & Shortell, 2010; Walker & McKethan, 2012). Given the current demands to shorten hospital stays, the extension of treatment across the continuum of community care, and ubiquitous barriers to patient–provider communication, social work—with its focus on person-in-environment—is ideally suited to facilitate meaningful interactions between patients, families, and interdisciplinary teams. The communication that Cannon described in 1915 was intended to increase what now falls under the rubric of health literacy. For the purposes of this article, health literacy refers to “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (The Patient Protection and Affordable Care Act, 2010, p. 473). The American Medical Association (AMA) Foundation (2008) has estimated Interdisciplinary Medical Social Work 535 that as many as 38% of Americans have limited functional health literacy. Communication strategies, such as encouraging patients to ask questions and verifying their comprehension, have been recommended first steps to enhance health literacy (The Joint Commission, 2007). Social workers on interdisciplinary teams can serve a critical role in addressing the growing national health literacy concerns. Moreover, interdisciplinary teams are ideally positioned to implement effective communication strategies (Kripalani, Jackson, Schnipper, & Coleman, 2007; Oates & Paasche-Orlow 2009). The IOM (2004) suggests that the patient’s diagnosis, treatment, and discharge will be favorably enhanced when interdisciplinary teams facilitate clear consistent communication in a way that is culturally and linguistically relevant for the patient. The spirit of the 2004 report is remarkably similar to Cannon’s 1915 call for social work’s role in promoting communication between patients, families, and providers during hospitalization. From the earliest days of the profession, social work has been uniquely positioned to bring psychosocial considerations into interdisciplinary discourse in acute-care treatment (Berkman, 1996). A century ago, Cannon argued for interdisciplinary collaboration before the term was widely recognized. She stated that the social worker must “have the technical skill of the social expert, and the ability to adapt that skill to the medical institution ... she should also have the power to insist that the social point of view, as well as the medical, receives its due recognition” (Cannon, 1915, pp. 181–182). Starting with diagnosis and the subsequent development of an evidenceinformed treatment plan (Cowles, 2003; Dziegielewski, 2004), expedient optimization of physical well-being of the identified patient through medical intervention is the primary focus of hospitalization (Small et al., 2007). Once patients are medically stable, understanding their home environment and resources is a key element of effective interdisciplinary care, especially when discharge plans are intended to extend treatment into the patients’ community (Bronstein, 2003; Clark et al., 2005; Zimmerman & Dabenko, 2007). Planning for the whole patient, in the context of his/her environment increases well-being, diminishes the likelihood of medical complications, and decreases relapse (Berkman, 1996; IOM, 2008). Family-centered care (American Academy of Pediatrics, 2003; IOM, 2001; Johnson et al., 2008) requires a diagnosis and subsequent treatment to include psychosocial factors such as the patient’s and family’s perceptions of health and illness, cultural beliefs, environmental, and social support factors that may impede compliance with medical regimen (Bronstein, 2003; Zimmerman & Dabenko, 2007). The IOM (2008) report on meeting psychosocial health needs for the whole patient supports communication in family-centered care. It posits that the partnership between the interdisciplinary provider team and the patient/family is the key to identifying, or assessing the psychosocial needs in any given case. Although the focus of 536 P. Maramaldi et al. the report is cancer care, it underscores the importance of medical teams engaging patients, family caregivers, and community-based providers in the development of viable treatment and discharge plans that will sustain health and well-being. This is also consistent with the principles of ACOs to create optimal care plans that are evidence-based and include the patients’ circumstances (Walker & McKethan, 2012). Previous empirical research indicates that the overlap of professional competencies (D’Amour, Ferrada-Videla, Rodriguez, & Beaulieu, 2005; Pike & Wandel, 1991; Satin, 2008) is a key component to interdisciplinary synergy (Newhouse & Spring, 2010). As a result, provider awareness of their function within the array of disciplinary competencies is critical to the creation of a cohesive interdisciplinary team (Baker, Day & Salas, 2006). Interdisciplinary research indicates that team success hinges on the identification of roles, competencies within these roles, and the overlap between roles (Baker et al., 2006; Newhouse & Spring, 2010). CONCEPTUAL FRAMEWORK: INTERDISCIPLINARY COLLABORATION Interdisciplinary collaboration in hospitals occurs among professionally trained specialists representing medicine, nursing, clinical social work, psychiatry (including psychology), nutrition, chaplaincy, and other ancillary disciplines. Interdisciplinary teams assign roles based on disciplinary competence. The hallmark of effective interdisciplinary collaboration is members’ ongoing learning about other disciplines, flexibility and overlapping of roles when competencies permit (Cowles, 2003; Dziegielewski, 2004). By contrast, multidisciplinary teams know other disciplines, plan together, and avoid intrusion on the practice domain of other professions. While competence and identity are developed within one’s discipline on multidisciplinary teams, there tends to be little or no functional overlap between disciplines (Satin, 2008; Schofield & Amodeo, 1999). Satin (2008) frames overlap in interdisciplinary approaches based on spheres of professional competence. Primary competence refers to unique or superior expertise associated with a specific discipline. Secondary competence refers to spheres where one’s discipline provides the expertise, training, and licensure to perform functions that overlap with another discipline’s area of primary competence. Tertiary competence refers to spheres where one has little or no specialized competence; anyone on the team can perform that function. While each discipline may have its own designated primary, secondary, and tertiary competencies, professional competencies overlap, particularly in today’s climate of increased trainings and specializations. Research findings indicating strain between physicians, nurses, and Interdisciplinary Medical Social Work 537 social workers (Cowles & Lefcowitz, 1995; Reese & Sontag, 2001) suggests a need for greater role definition and competency measures. During the current investigation, we observed that even teams with high levels of cohesion and familiarity experienced tension regarding task-allocation and role definitions, often between nurses and social workers in regard to psychosocial issues. Empirical investigations (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000; Netting & Williams, 1996) indicate that psychosocial assessment and intervention are no longer an exclusive domain of social work. There is, however, some agreement that clinical social work’s primary competence is to address psychosocial concerns in the biopsychosocial context (Beder, 2006; Berkman, 1996; Cowles, 2003; Dziegielewski, 2004). To varying degrees, physicians and nurses increasingly recognize that social workers’ primary competence in psychosocial and environmental aspects of cases enhance treatment and improve outcomes (Keefe, Geron, & Enguidanos, 2009; Rock & Cooper, 2000). Existing literature on interdisciplinary medical teams has tended to focus on social workers and physicians views about collaboration (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000), efficacy of differing collaborative styles of physicians and social workers (Abramson & Mizrahi, 2003; Globerman et al., 2003), and social workers’ perspectives regarding their roles in the medical setting (Abramson & Mizrahi, 1996; Cowles, 2003; Kitchen & Brook, 2005; Mizrahi & Abramson, 2000). Few empirical studies have investigated collaborative roles and relationships in the same setting or services (Mizrahi & Abramson, 2000). Published studies that have examined team members’ roles and relationships in the same setting or service focused on hospice, palliative, and geriatric care (Colón & Otis-Green, 2008; Oliver & Peck, 2006; Waldrop, 2006). The study reported here identifies social workers’ perceptions of their primary psychosocial competencies within interdisciplinary medical teams, which—to our knowledge—has not been empirically investigated and published. PURPOSE OF THIS STUDY The purpose of this exploratory study was to document the historically grounded disciplinary competencies of clinical social work within the context of interdisciplinary teams in medical settings. The stakeholder-driven aims of this participatory action research study were to: (1) identify social workers’ perceptions of universal elements of clinical practice on interdisciplinary teams and (2) develop an evidence-based taxonomy of interdisciplinary practice skills and competencies based on the experiences and observations of clinical social workers. Due to limited resources, the inclusion of other disciplines was beyond the scope of this study. The intent of the second 538 P. Maramaldi et al. aim is to help social work clinicians frame their contributions to teams with the accuracy and rigor required in medical settings. The study answered the research question: What are perceptions of social workers about the disciplinary functions, skills and competencies of clinical social work on interdisciplinary teams in acute care treatment settings? METHODS Participatory action research (PAR), is a collaborative research approach designed to understand and improve on a community’s practices while empowering the population of interest (Glasson, Chang, & Bidewell, 2008). A research partnership is created between a community and researchers to increase knowledge and understanding of a given phenomenon and integrate the knowledge gained to improve outcomes (Israel, Eng, Schulz, & Parker, 2005). The phenomenon of interest in the current study was the perception of socials workers about their disciplinary functions, skills, and competencies on interdisciplinary teams in hospital settings. Our approach was adapted from a nursing study that used elements of PAR, to collect empirical evidence to improve clinical practice (Glasson et al., 2008). We utilized PAR to empower social workers in their community, the hospital setting, to utilize their clinical knowledge to improve their clinical processes and outcomes. Table 1 summarizes the steps that we took in the PAR approach to improve clinical practice. TABLE 1 Summary of Actions Taken in the Participatory Action Research Process Research action Action taken in current study Reflecting Research scientist presented ideas for participatory action research aimed at improving practice. Specific research topics were discussed. Planning Clinical staff overrode researcher and set aims and questions to better reflect stakeholder interests Implementing Extensive review of archival and current literature resulted in decision to develop taxonomy of social work clinical practice in interdisciplinary settings Observing outcomes Social work clinicians, clinical director, and scientist used deductive findings to develop a conceptual model, which was used to frame inductive observations of interdisciplinary practice Feedback During weekly meetings, the research team reviewed individual cases with the aim of identifying universal rather than case specific functions Replanning Clinicians, clinical supervisor, and scientist took findings identified as universal functions back into practice, supervision, and observations seeking to identify new functions until saturation was attained Adapted from Glasson et al. (2008). Interdisciplinary Medical Social Work 539 While the steps in Table 1 are presented in a linear manner, this process was dynamic and interactive. During the planning phase of the PAR process, the clinicians disagreed with the research scientist’s suggestions and provided goals and aims that better reflected their interests. Thus, the goals, aims, and research questions were not dictated by one individual, the research scientist, but by the group most affected by the issue similar to the overall goals of PAR. As a result, the social worker participants and the research scientist reviewed archival and current research on the role of the hospital-based social worker. In reviewing their current practice, the social worker participants concluded that, in general, medical social workers tend not to fully articulate the exact functions that they perform on interdisciplinary teams. Descriptors like “providing support,” “counseling,” and “working with the family” did not capture the full extent of their interdisciplinary clinical practice. The research team decided to develop an empirically driven taxonomy of the universal functions skills and competencies of clinical social work on interdisciplinary teams. Subjects Five members of the core participatory panel investigated the work performed by a total of 37 expert clinical social workers in a large New England teaching hospital for a period of twelve months. The core research panel consisted of three clinical social workers assigned to interdisciplinary teams in Pediatric Services, a senior clinical director, and the social work research scientist. Social work was the only discipline included in the core research panel, which will be discussed as a limitation below. DESIGN Using participatory research methods (Coghlan & Brannick, 2005; James, Milenkiewicz & Bucknam, 2007), the panel participated in every phase of the research study from the development of research questions through the analysis, and finally to the article preparation. The research collaboration was driven by the principles of participatory research (Israel et al., 2005; Glasson et al., 2008). We used deductive approaches by reviewing archival and current published peer-reviewed literature, and inductive approaches by reflecting on practice using a retrospective qualitative case review methodology (Anthony & Jack, 2009; Yin, 2008). For the first phase of the study, five members of the core participatory panel met weekly, reported deductive findings from archival sources and current literature about the role 540 P. Maramaldi et al. of social work in multidisciplinary medical settings. This led to the identification of a conceptual model—interdisciplinary collaboration—and the development of the research questions and methodology. During the second phase, the panel met weekly and engaged in a retrospective, focused debriefing about cases and developed and refined the taxonomy of clinical practice and competencies on interdisciplinary teams. Our deductive findings from archival material and current scientific literature informed our inductive observations. We continued the process of reviewing case exemplars to identify competencies until we reached a point of saturation where no new competencies were identified (Glaser & Strauss, 1967). The PAR process enabled the community of social workers to determine their own competencies and to develop an operational taxonomy that defined their role and functions. Deductive Data Collection We conducted archival research in the Massachusetts General Hospital and the Simmons School of Social Work historical archives with expert librarian assistance. Each of these institutions has extensive medical social work archives dating to the earliest days of Ida Cannon’s work in each setting. Deductive findings from the archival material were remarkably relevant in the context of current clinical practice. The interdisciplinary nature of early medical social work emphasized the enhancement of communication among patients, families, and providers, which informed our inductive inquiry. Inductive Data Collection Using a retrospective clinical case review methodology demonstrated in the nursing literature (Glasson et al., 2008), we reflected on a sample of cases and documented the panel’s perceptions of specific social work functions on interdisciplinary teams. The panel used reflections and observations of their own interdisciplinary clinical work in the form of the clinician stakeholders’ personal case notes, not the formal medical record notations. Case notes were used because they tended to evoke more detailed information about social work functions than the more “sanitized” medical records. More specifically, the actual notes written in the medical record were not used because they tended to be abridged and also devoid of the current study’s focus on interactions with other disciplines. In addition, the notes used for this study were deidentified by each clinician stakeholder prior to the retrospective case review sessions in order to protect the confidentiality of patients as well as medical team members. A total of 43 cases were included in the final analysis. Interdisciplinary Medical Social Work 541 ANALYSIS During weekly research meetings, the core panel engaged in a process of identifying common themes (from the 43 cases studies and archival material) until we reached a point of saturation (Padgett, 1988; Glaser & Strauss, 1967). Case data were presented and discussed by the entire research panel, and then re-documented by the research scientist in summary format. The summary was then cross-checked by the entire panel for accuracy. It is important to note that social work was the only discipline participating in the case reviews due to the pilot nature of this study. Findings Universal elements of social work’s function on interdisciplinary teams were extrapolated from 43 cases reviewed for this exploratory study: rapid 360 degree screening (collection of case information from all available sources), assessment, psychosocial intervention, and referral. These functions may seem obvious and are recognized activities of medical social workers (Berkman, 1996; Cowles & Lefcowitz, 1992; Cowles, 2003; National Association of Social Workers, 1990). However, although limited by a single discipline’s (social work) perception, the findings reported here are empirical and frame social work’s disciplinary utility, skills, competencies, and expected outcomes in an interdisciplinary context. During the process of reviewing cases for common universal themes, we also discovered the importance of including the overt articulation of social work’s disciplinary contributions to the case, and stated expected outcomes to the interdisciplinary team. Adding interrelated expected contributions and outcomes to the taxonomy of social work’s disciplinary function brings social work in line with medicine and nursing on interdisciplinary teams. Much like a physician or nurse routinely state and record a planned procedure and its outcome, social workers can do likewise. Although limited by the pilot nature of this study, we found a level of parity among disciplines to occur in some teams but not others, which further supports inclusion of expected contributions and outcomes to the taxonomy. Social work participants on the panel also reported that the quality of their assessments and the related interventions appeared to be enhanced when they overtly stated the expected outcomes to other team members. As a result, we decided to include both social work contributions and outcomes—as interrelated skills and functions—in the taxonomy, presented in Table 2. Awareness and utilization of these interrelated functions appeared to empower social workers to overtly communicate their role and value to the interdisciplinary team. As discussed earlier, understanding competencies within disciplines is an important aspect of functioning interdisciplinary teams. During the retrospective case reviews, the research 542 P. Maramaldi et al. TABLE 2 Taxonomy of Social Work Functions on Interdisciplinary Teams Social work functions Brief description 360 Degree Screening Rapid assessment to identify risk Assessment Explanation of case across interdisciplinary perspectives as the bridge between the patient/family and the team Intervention Actions taken to enhance health and well being Referral Best attempt to connect case with community resources needed to carry interventions across continuum, beyond the hospital Expected Outcome Ensures patient focus, enhances accountability and quality, and contributes to evidence informed practice Contributions to Interdisciplinary Team Reiteration of social work’s unique contributions across professional competencies Competencies Needed Clinical skills and knowledge needed to perform functions team discovered the importance of identifying the competencies needed to contribute and plan outcomes in specific case exemplars. Including the category of competencies needed to perform the interrelated functions was also important to differentiate between core clinical social work competencies and advanced specialty training. The inclusion of competencies brings social work into greater parity with other disciplines that require advanced certifications and advanced training in specific areas of medical service. As a result, we found it important to include competencies as part of the taxonomy. The final taxonomy, therefore, included expected outcome, contributions to the interdisciplinary team, and clinical competencies needed. A case exemplar demonstrates the utility of the taxonomy. Case Exemplar In preparing this article, we discovered a lack of consistent and established protocol for publishing clients’ narratives and stories in psychological, psychiatric, and psychoanalytical journals. In the face of ongoing debates about protecting human subjects in articles such as this, we decided to follow the lead taken in psychiatric literature, to protect patient confidentiality by disguising subjects’ identity (Person, Cooper, & Gabbard, 2005). We went beyond de-identification and also altered some potentially identifying features of the case exemplar reported here (Estroff, 1995). Therefore, the case presented in the findings is a composite representation of several patients. Conveying the case in this manner is considered an ethical approach to upholding patients’ privacy (Clifft, 1986; Kantrowitz, 2006; Person et al., 2005). Therefore, while each of the interventions presented below are taken directly from the 43 actual cases reviewed, any resemblance to real individuals, living or dead is purely coincidental. Social work was the disciplinary competency best suited to meet the patient’s need in the composite case presented here. While social work Interdisciplinary Medical Social Work 543 performed its duties in this case, the interdisciplinary team was able to focus on its respective roles and other case responsibilities. The following is an example of a crisis intervention case where the primary competence is social work: An unconscious 16-month old African-American girl in respiratory distress with a high fever was rushed to the hospital by ambulance. She was accompanied by her mother, father, and aunt, who explained they had left the patient’s three siblings in the care of a neighbor. The medical trauma team worked in vain to resuscitate the child. She was pronounced dead shortly after arrival in the Pediatric Intensive Care Unit (PICU). The team turned their focus to the child’s mother, shifting primary competence from medicine and nursing to social work. Social work approached the case with the child’s mother as the identified patient. 360 SCREENING The rapid collection of case information from multiple sources is the universal purpose of screening. The objective is to rapidly identify risks for detrimental or complicating conditions, and to determine if further assessment and intervention is needed. Traditional screening includes the observation of the patients’ affect, appearance, family interactions, and in some cases, the administration of standardized assessment instruments. In the interdisciplinary context, we found screening most efficacious when it also included information from multiple disciplines on the interdisciplinary team level—meaning that mechanisms allowed representatives of each discipline to contribute initial impressions of the case. In this case, social work integrated the PICU team’s impressions of the mother into the screening. To accomplish this, social work approached members of the team representing medicine and nursing. The screening indicates that the mother is in a state of shock, has concerns about her other children who were left with a neighbor, and is at risk for acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). ASSESSMENT Social work provided a biopsychosocial assessment that included the influence of cultural and health beliefs of patients and providers. Social work incorporated assessment data from the primary perspectives of each discipline involved with the case. These assessments were brief descriptions that illuminate pertinent facts and a range of clinical impressions that might provide context and direction for an interdisciplinary intervention. Based on an interdisciplinary team meeting, a psychosocial assessment, conducted by social work and supported by nursing and medicine, indicates 544 P. Maramaldi et al. that the mother is in a state of crisis. She is exhibiting distress, confusion about the circumstance surrounding her child’s death, and demonstrates an inability to focus on next steps. She blames herself for the infant’s death stating, “she would still be here if I called 911 sooner, my God what have I done?” The mother identifies her three remaining children and family members as resources to help her. Her sister, who accompanied her, is hysterical and loudly praying. The father appears to be in a daze and is extremely quiet, not engaging in the interview. INTERVENTION Psychosocial interventions are intended to modify the physical or psychosocial state of the patient. By integrating a range of disciplinary perspectives, coordinated psychosocial interventions target the patient and/or family to promote recovery and sustain health. Interdisciplinary interventions are customized to fit the cultural beliefs and intellectual capacity of patients and families. Social work typically takes primary competency in psychosocial interventions—although nursing increasingly demonstrates secondary competence in this area. Such an inclusive approach is especially beneficial to patients when interventions include referrals to other medical services. Social work, as the discipline with primary competence to address psychosocial concerns in the biopsychosocial context, consults with nursing and medicine to confirm the child’s death. Medicine determines that the death is the direct result of meningitis and not due to a previous illness or condition. Social work integrates the information from medicine and nursing. After the medical team spoke very briefly with the family, social work attempted to engage the family to provide the same information with less rush. The father and aunt decline help, stating that the doctor already spoke to them. The mother is amenable to talk with the social worker, who happens to be a young Caucasian female. Interventions with the mother include crisis intervention to help her understand that the child’s death did not occur as a result of anything that she did or did not do. Crisis intervention is comprised of various techniques such as validating the mother’s emotions, acknowledging her reactions as appropriate and necessary, and explaining that her symptoms are indicative of ASD and PTSD, which are expected after experiencing a traumatic event such as a child’s death. Additional interventions with the mother include providing psycho-education about trauma-response/acute stress, imparting techniques to regain a sense of control over her environment, and preparing her for probable reactions for herself and her children over the next several days. The social worker was careful to incorporate cultural values and beliefs by identifying the mother’s personal sources of support, including her faith system, and acknowledging her husband’s comment that “we have our own way (culture)” to cope with the death of a child. Interdisciplinary Medical Social Work 545 Interventions with the interdisciplinary team include notifying the team of the assessment and crisis intervention with the mother, explaining the role of social and cultural factors in the case, encouraging the team (taking secondary competence) to reiterate the social work interventions and to clarify any medical information in a communication tailored to the family’s current state. In effect, the social worker coaches the physician by explaining the family and cultural dynamics and then communicates the suggested psychosocial intervention to the mother. REFERRAL Social work acts as the liaison for referrals between the acute care team, outpatient services, and community resources with a goal of ensuring the best long-term outcome for the identified patient and her or his family. We found that in providing interventions and making referrals, medical social workers are superbly situated to ensure that the entire team communicates in a manner that has cultural and linguistic relevance for the patient and family. This function is especially important when acute care teams communicate with the patents’ home and community resources. Short-term strategies include social work referring the mother for a psychiatric consult based on recommendations from nursing and medicine, to the chaplain for spiritual support, to the child life specialist for approaches with siblings, and to the local hospice for bereavement support. The longterm strategy is for social work to refer the mother for follow up mental health services in her home community with the intent of preventing the onset of ASD or PTSD. EXPECTED OUTCOMES By stating the expected outcomes of a psychosocial intervention or referral that extends beyond discharge, the team considers the patient and family in the context of their culture and home environment. Quality assurance in health care must exceed structure and process to include outcomes (Maramaldi, Berkman, & Barusch, 2005). We found that the social work clinician’s work was enhanced during assessment, intervention, and/or referral by stating expected outcomes. This also heightens accountability, which is similar to standards set by other disciplines. The expected outcomes include: accelerating the mother’s return to a state of equilibrium, diminishing the acute symptoms of ASD, preventing or diminishing the severity of PTSD symptoms, enhancing self-efficacy to seek psychological services when needed, providing the family with adequate, culturally appropriate coping mechanisms, and linking the mother and family with community resources. 546 P. Maramaldi et al. CONTRIBUTIONS TO THE INTERDISCIPLINARY TEAM The benefit to the interdisciplinary team is the synergy created from each discipline’s enhanced understanding of the case. Specifically, the physicians and nurses on the team have medical knowledge, while the social workers can report on the patient’s understanding and beliefs about the medical condition, the home environment, resources, and support to ensure well-being after discharge. Furthermore, when medical social workers take the lead role on psychosocial issues, other team resources are able to focus on their areas of primary competency, such as medical and nursing services. Not only do social workers allow other interdisciplinary team members to focus on their specific work role but social workers possess a unique skill set that enables them to treat the psychological crisis. Just as social workers are not trained in medicine, physicians and nurses are not highly trained in psychosocial interventions or culturally competent crisis negotiation. In this case, the benefits to the interdisciplinary team include: team members have an understanding that the family’s presentation was an expected response to a trauma; an understanding that the mother is receptive to seeking further treatment if indicated; team members with primary competence in medicine who have the ability to completely focus on child’s medical care in order to clearly state the cause of her death; team members who learn about social work’s primary competencies in assessment, crisis intervention, psychosocial intervention, coordination of care, including reinforcing the importance of the mother (families) taking referrals from any team member as needed. This is especially important in teaching hospitals where residents and fellows rotate through services for relatively short periods of time. It is important for house staff and trainees to understand social work’s disciplinary focus on the entire family in the context of their home community environment. COMPETENCIES NEEDED The inclusion of competencies needed to perform on interdisciplinary teams is an inductive finding that helps focus on discrete clinical skills. There is a general shift in social work toward a competency-based outcome approach in which performance is measured via a predetermined set of practice behaviors (Council on Social Work Education, 2012). The identification of skills may inform the selection and continuing education of clinical social workers on interdisciplinary teams. In this case, the identified competencies needed included: knowledge and application of appropriate crisis intervention approaches, supportive counseling techniques, knowledge of developmentally appropriate children’s reactions to death, understanding of the Diagnostic and Statistical Manual of Mental Disorders (DSM), appropriate interventions for ASD and PTSD, an Interdisciplinary Medical Social Work 547 understanding of cultural and religious beliefs, and the ability to link patients and families to hospital- and community-based resources. LIMITATIONS The pilot study reported here focused exclusively on the perceptions of social workers within interdisciplinary teams. Research based on actual collaborative experiences between members of the interdisciplinary medical team is needed to capture how members of the team work with one another (Mizrahi & Abramson, 2000). Additional research will be required to include the perspectives from other disciplines such as, nursing and medicine (Keefe, Geron, & Enguidanos, 2009). In addition, other medical disciplines did not participate in the case reviews as we developed the social work taxonomy. The process of developing the taxonomy would have benefited if a physician and a nurse participated in the weekly case reviews. This limitation is most salient where we included “expected outcome” in the taxonomy to go beyond process, in order to articulate the value added by social work. An additional limitation to this small pilot project was the absence of a feedback loop on the taxonomy with the social work participants outside of the research panel. We intend, in future projects, to pilot this taxonomy with stakeholders beyond a single institution. While piloting the taxonomy in multiple hospitals was beyond the scope of the current study, we anticipate that the initial taxonomy will become a springboard for the development of future social work taxonomies, competencies, and measures. DISCUSSION Although the current study was limited to developing a universal taxonomy, we conceptualized it with the hope that it will provide formative evidence for future investigations evaluating interdisciplinary practice. During the course of the study, the utility of the standardized taxonomy was evident. Although we did not measure outcomes, the research panel reported that the taxonomy helped them articulate their function on interdisciplinary teams. The taxonomy also provided the social workers with a sense of improved clinical functioning within interdisciplinary teams. Finally, the clinical director in particular found it useful—in her role as a supervisor—to identify clinical competences in the context of benefits to the interdisciplinary team. Although this study is limited by the exclusive focus on social work and the single study site—albeit a large department in a teaching hospital— we sought to identify universal rather than idiosyncratic elements of clinical social work practice. This taxonomy provides the foundation with which to 548 P. Maramaldi et al. further examine interdisciplinary collaboration between social workers and other medical professions. Future research should include other disciplines, including nursing and medicine. When individual team members are committed to include other perspectives into their own clinical formulations, the overlap between disciplinary roles becomes the norm. As a result, interdisciplinary collaboration becomes part of the structure of the team’s function, which produces a synergy that provides more efficacious treatment for the patients and families. In addition, the team benefits from a broader perspective of the patient, family, and community. Social workers’ advanced psychosocial training and ecological perspective (framing the patient in environment) makes them ideally positioned to act as interpreters of health information being communicated between patients and the interdisciplinary team. Interdisciplinary interventions work only if there is an institutional commitment to provide a structure for cross-disciplinary communication. Social work should develop and assert organizational structures to facilitate and sustain communication among teams and patients. We hope the taxonomy will help social workers articulate their clinical role within interdisciplinary teams. 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