Personal Growth and Professional Growth and Engagement

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=wshc20

Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: https://www.tandfonline.com/loi/wshc20

Social workers in integrated health care: Improving care throughout the life course

Lisa de Saxe Zerden MSW, PhD, Brianna M. Lombardi MSW, PhD & Anne Jones MSW, PhD

To cite this article: Lisa de Saxe Zerden MSW, PhD, Brianna M. Lombardi MSW, PhD & Anne Jones MSW, PhD (2019) Social workers in integrated health care: Improving care throughout the life course, Social Work in Health Care, 58:1, 142-149, DOI: 10.1080/00981389.2019.1553934

To link to this article: https://doi.org/10.1080/00981389.2019.1553934

Published online: 20 Dec 2018.

Submit your article to this journal

Article views: 28592

View related articles

View Crossmark data

Citing articles: 19 View citing articles

Social workers in integrated health care: Improving care throughout the life course Lisa de Saxe Zerden MSW, PhDa, Brianna M. Lombardi MSW, PhDb, and Anne Jones MSW, PhDa

aThe University of North Carolina at Chapel Hill School of Social Work, Chapel Hill, NC, US; bUniversity of Pittsburgh School of Social Work, Pittsburgh, PA, US

ABSTRACT Great strides have been made in highlighting the strengths of the social work profession as a workforce vital to improving the health and well-being of individuals, families, and communities. Neverthe less, substantially more work is needed to advance education, practice, and research involving social workers’ potential and their contributions to improved care throughout the life course. This special issue offers exemplars of the power of social work in inte- grated settingswith the capacity to address the scopeof behavioral health, psychosocial, and physical health care needs. In today’s rapidly evolving heath care context, integrated care represents a promising direction for the future of health services, and may be leveraged to improve population health across the life course. Papers selected for this special issue focused on two themes: (a) defining the expanding roles and functions social workers fulfill in integrated health settings, and (b) identifying organizational and system factors that affect social workers’delivery of interventions in integrated health models. This special issue further articulates the added-value of social workers on health care teams and the result- ing improved outcomes for patients, families, and communities. Through increased evidence, such as the knowledge gained from this special issue, it is our hope that the profession continues to advance the boundary-spanning roles and capabilities of social workers in integrated health settings—both in the hospital and in community-based settings.

KEYWORDS Integrated health care; social worker roles and functions; health and behavioral health

The impetus for this special issue on grew out of an invitation to participate in a National Academies of Sciences, Engineering, and Medicine forum on Promoting Children’s Cognitive, Affective, and Behavioral Health and an accompanying Perspectives Paper released by the National Academy of Medicine (Boat et al., 2016). While immensely satisfying to be invited to discuss how the social work profession is preparing the workforce to improve care for children and families, it was also evident the potential of social work practice was relatively unexplored, despite great potential for impact. Great strides have been made in highlighting the strengths of the social work

CONTACT Lisa de Saxe Zerden [email protected] The University of North Carolina at Chapel Hill School of Social Work, 325 Pittsboro Street, CB#3550, Chapel Hill, NC 27599-3550, US

SOCIAL WORK IN HEALTH CARE 2019, VOL. 58, NO. 1, 142–149 https://doi.org/10.1080/00981389.2019.1553934

© 2018 Taylor & Francis

profession as a workforce vital to improving the health and well-being of individuals, families, and communities (Fraher, Richman, de Saxe Zerden, & Lombardi, 2018; Rishel, 2015; Stanhope, Videka, Thorning, & McKay, 2015; Zerden, Lombardi, Fraser, Jones, & Garcia Rico, 2018). Nevertheless, sub- stantially more work is needed to advance education, practice, and research involving social workers’ potential and their contributions to improved care throughout the life course.

The articles within this special issue of Social Work in Health Care offer exemplars of the power of social work in integrated settings with the capacity to address the scope of behavioral health, psychosocial, and physical health care needs. The articles in this issue clarify the roles and practice realities of social workers in integrated health care settings while providing macro system recommendations to support social work and integrated health mod- els of care. Authors Reno, Beaujolais, and Davis state in their article, “Integrated care represents a promising direction for the future of health services, and may be leveraged to improve population health across the life course” (this issue, p. 1): As the guest editors of this special issue, we could not agree more.

Social work and health care: then and now

Since the turn of the 20th century, social workers have been involved in the health care of individuals and communities. The title of books for social workers published more than 100 years ago such as Social Work in Hospitals: A Contribution to Progressive Medicine (Cannon, 1913) or Social Work: Essays on the Meeting-Ground of Doctor and Social Worker (Cabot, 1919), capture the essence of how the profession has connected social and environ- mental conditions to physical health outcomes. Today’s literature is equally compelling in emphasizing the importance of the social determinants of health and the significant role social workers play in addressing people’s complex and often intersecting needs. The connection between physical health and social conditions is illuminated by the Los Angeles County Department of Public Health (2013, p. 4) suggestion that, “A population’s health is shaped 10% by the physical environment, 20% by clinical health care (access and quality), 30% by health care behaviors (themselves largely deter- mined by social and physical environments), and 40% by social and eco- nomic factors.”

As health systems shift away from fee-for-service reimbursement to value- based payment models, these systems will have new incentive to renew their focus on addressing the social determinants of health to improve population health – the health outcomes for a group of individuals. Social workers are already helping health systems achieve this goal. This special issue further articulates the roles, scopes of practice, and added-value of social workers on

SOCIAL WORK IN HEALTH CARE 143

health care teams and the resulting improved outcomes for patients, families, and communities.

Along with a growing appreciation for the influence of the social determi- nants of health, health systems are meeting patients’ behavioral health needs more than ever through models of integrated behavioral health care. Collaborative teams, commonly inclusive of a social worker, screen for, assess, and treat behavioral health problems within traditional physical health care settings, addressing both the stigma of seeking mental health services and improving access to behavioral health services. The link between physical and behavioral health is well acknowledged, underscoring the imperative to address all components of an individual’s well-being to improve “whole health.” Social work is one of the largest trained groups of professionals able to provide evidence-informed behavioral health treatment and the profession is growing in its expertise in integrated behavioral health. For example, the Health Resources and Services Administration’s federal investment in 2014 and again in 2017 to train and expand the behavioral health workforce for practice in integrated settings is further confirmation of the synergies that exist for the social work profession and integrated models of care to help improve health outcomes (Kepley & Streeter, 2018). The focused education and clinical training of social workers in integrated behavioral health aligns with the projected demand for workforce growth; over the next 5 years, a 22% increase is expected for social workers in health care settings (U.S. Department of Labor, 2018).

Now is the time for social work to clearly articulate its role and to demonstrate the individual, interpersonal, interprofessional, and organizational benefits of skilled professionals who can effectively address the complex needs of patients in a rapidly transforming health care environment. Papers selected for this special issue focused on two themes: (a) defining the expanding roles and functions social workers fulfill in integrated health settings, and (b) identifying organiza- tional and system factors that affect social workers’ delivery of interventions in integrated health models.

Social work roles and functions in integrated models of care

Given the varied skill set of social workers, these professionals perform a variety of functions in integrated health settings. Indeed, social workers’ training and knowledge of psychosocial risk factors for health, as well as their expertise in behavioral health screening, assessment, and use of evidence- based interventions makes social workers uniquely qualified to assist in the treatment of the “whole person” in integrated care settings (Andrews, Darnell, McBride, & Gehlert, 2013; Stanhope et al., 2015). Social workers frequently support patients and their families as they navigate complex health systems, coordinate multifaceted care plans, provide patient psychoeducation on health and wellness, address behavioral health through a variety of

144 L. D. SAXE ZERDEN ET AL.

treatment modalities, facilitate connections to needed non-medical resources, and advocate for patients across care teams to improve overall access of care (Fraser et al., 2018).

As is evident from the diversity within this special issue, social work practice in integrated settings is rapidly expanding and cuts across diagnoses (e.g., Parkinson’s disease, depression), patient populations (i.e., pediatrics, adolescents, and adults; Cohen, Gonzáles-Ramos, & Gonzáles, this issue; Ewald, Lahey, Vail, & Golden. this issue; Lynch, Greeno, Teich, & Jeekin. this issue; Ross et al., this issue), and among the most vulnerable populations of the health care system. For example, Xiang, Zuverink, Rosenberg, and Mahmoudi (this issue) examine the population of health care super-utilizers, a term that refers to individuals whose complex physical, behavioral, and social needs are not well addressed because of current fragmented health care and social care systems. Two papers in this special issue focus on social worker roles in coordinating complex health services and managing care plans. First, Ross et al.’s (this issue) article clarifies the tasks associated with care coordination by social workers across a large urban pediatric hospital setting. The authors describe the benefit of social workers providing care coordination and articulate how the functions of a care coordinator are especially critical for populations with chronic, complex conditions. Second, Xiang and colleagues (this issue) evaluate of the Bridge Model for Super Utilizers (Bridge-SU) and offer an in-depth example of the positive impacts of social worker-led care management interventions on hospital readmission rates, length of stay, and costs for inpatient super-utilizers. In addition, the authors describe how social workers as part of interprofessional teams are particularly well suited to serve as leaders for the implementation of inter- ventions in multifaceted health systems.

The core values of social work support the role of social workers on integrated care teams to be advocates for patients. This special issue includes a qualitative study by Bell, Doss, Myers, and Hess (this issue), whose work focused on ways to include the voice of parents – as partners with primary care providers – to comprehensively address externalized behavioral health issues of their children. Bell et al.’s study was conducted in a Southwestern federally qualified health center as part of a larger study focused on integrat- ing parent-management training programs into pediatric health settings.

Training the next generation of social workers to fulfill multiple roles and functions on integrated care teams is supported by considerable efforts to develop rigorous interprofessional course work, enhanced field placements, and service-learning projects (Zerden, Jones, Brigham, Kanfer, & Zomorodi, 2017; Zomorodi, Zerden, Alexander, Nance-Floyd, & Byerley, 2017). Developing standardized competencies to create a shared training plan among social workers in integrated care settings can assist in refining the expanding, evolving role of social work. Davis et al.’s (this issue) study on the

SOCIAL WORK IN HEALTH CARE 145

Social Worker Integrated Care Competencies Scale measures trainees’ knowl- edge and skills around integrated care competencies while offering adminis- trators a systematic way to asses knowledge acquisition.

Organizational and system factors to support social workers in integrated care

Increased attention to the organizational and system factors that support integrated models is urgently needed to support social workers in their rapidly emerging and expanding roles on integrated care teams. For example, deliver- ing optimal integrated care first requires that social workers understand the various, complex models deployed in practice. Lynch, Greeno, Teich, and Heekin’s (this issue) article provides readers with a comprehensive overview of integrated delivery models that support the integration of physical and behavioral healthcare in pediatric primary care settings. Given the persistently high rates of behavioral diagnoses that contribute to the care- and cost- burden for individuals, families, health care systems, and public and private insurers (Boat, Land, & Leslie, 2017; National Academies of Science, 2015), the work of Lynch and colleagues underscores a critical point: To meet the needs of those with behavioral health disorders and mitigate long-term sequelae, it is vital to deploy a comprehensive and integrated service framework that addresses the physical and social determinants of health.

Social workers might have unique barriers and facilitators to practice on interprofessional, integrated care teams. Identifying mechanisms to support social workers can maximize the profession’s effectiveness on teams, and in turn, support enhanced patient care. The study conducted by Reno et al. (this issue) identified which factors affect social workers’ capacity, as a front-line workforce, to successfully provide integrated care across multiple health settings. Further, Reno and colleagues offer a conceptual framework of intersecting themes related to organizational structure, personal and inter- personal dynamics, and practitioner knowledge with the potential to impact the uptake and receptivity of integrated models of care. By preparing and sustaining a future workforce with the capacity to collaborate with other health care providers, patients, and families – health systems will provide high-quality and holistic care that can harness the strengths of the social work perspective.

The contributions by Ewald, Lahey, Bail, and Golden (this issue) offer an excellent example of efforts underway in a large urban academic medical center that articulate how a social work-led team addressed depressive symptoms in adolescent and adult patients by connecting patients to care and support in both the hospital setting and outpatient primary care clinics. Similar to Lynch et al.’s (this issue) contribution, the Ewald et al. article

146 L. D. SAXE ZERDEN ET AL.

highlights macro levers necessary to scale up and sustain to more fully utilize social workers as essential members of collaborative care teams.

Next steps for social work education, research, and practice in integrated care

Attendees at the 2016 National Academy of Medicine meeting represented leadership from many health disciplines, including social work (a paper summarizing a workshop on preparing the healthcare workforce was later released by the National Academies of Sciences, Engineering, and Medicine, 2017). The consensus across the multiple health disciplines was that the health field as a whole needs to do more to enhance care. As part of the meeting and subsequent committee work, the National Academies of Science Board of Children, Youth, and Families identified multiple levers for change (Figure 1) that could enhance integrated care. Although these change levers were primarily provided for integrated pediatric care, the recommendations are translatable to a range of integrated health settings. Indeed, as the articles in this special issue reflect, the role of social work in integrated care occurs across a spectrum of ages, geography, and practice setting variability beyond pediatrics. The levers identified in Figure 1 are easily applied across the life course and are necessary and applicable to the findings and lessons learned highlighted in this special issue.

Ultimately, we are confident this collection of articles advances efforts to (a) clearly articulate the expanding roles and functions social workers fulfill in integrated health settings, and (b) identify organizational and system factors that impact social workers’ delivery of interventions in integrated health models. It is our hope that the social work profession continues to advance the boundary-spanning roles and capabilities of social workers in

Levers to Improve Behavioral Health Training

A. Adopt program themes that enhance clinical training settings and content

1. Recognize the social determinants of health

2. Build on family strengths to promote wellness and resilience across the life course

3. Foster parenting knowledge and skills

4. Promote cognitive and behavioral health, starting in infancy and throughout the life course

5. Recognize and mitigate risks for healthy behavioral development

6. Identify and intervene early for problem behaviors in non-stigmatizing settings

7. Recognize chronic disease as a risk factor for behavioral disorders

8. Work effectively within an interprofessional team; partner with community supports

B. Employ training modalities (e.g., online courses, simulations), that surmount limitations of faculty and services.

C. Develop faculty who foster innovative behavioral education and training.

D. Evaluate model programs and disseminate learnings.

E. Create funding streams for broadly implemented interdisciplinary training in behavioral health.

F. Harness the power of certification and accreditation organizations to shape training.

G. Align local, state, and national promotion of programs, policies, and resource allocation.

H. Educate and train health professionals early to address behavioral health.

Figure 1. Levers to improve behavioral health training.

SOCIAL WORK IN HEALTH CARE 147

integrated health settings – both in the hospital and in community-based settings. Additional work is needed to support the synergy between social work educational programs and practice settings to ensure the future and current workforce are prepared and ready for the practice realities of today’s health care landscape. Ensuring an adequately prepared workforce includes efforts to train social workers interprofessionally and collaboratively given that social workers, patients, and families do not exist in siloes. To further bolster the interprofessional aspect of social work, continued research is needed on the scope of practice, outcomes associated with health care delivered by teams that include social workers, and the return-on- investment for hiring a social worker. Last, the impact of social workers in integrated health care on improving health throughout the life course needs to be disseminated broadly. Increasing the public’s and heath fields’ aware- ness of the impact social workers have on health comes is critically important not only as internal evidence for the profession but also, and perhaps more importantly, as compelling evidence for stakeholders at all level of health systems and service provision. Sharing this evidence interprofessionally is a key step in demonstrating the value-added of social workers in integrated health settings as integral throughout the life course.

References

Andrews, C. M., Darnell, J. S., McBride, T. D., & Gehlert, S. (2013). Social work and implementation of the affordable care act. Health & Social Work, 38(2), 67–71. doi:10.1093/hsw/hlt002

Boat, T. F., Land, M. L., & Leslie, L. K. (2017). Health care workforce development to enhance mental and behavioral health of children and youths. JAMA pediatrics, 171, 1031–1032. doi:10.1001/jamapediatrics.2017.2473

Boat, T. F., Land, M. L., Leslie, L. K., Hoagwood, K. E., Hawkins-Walsh, E., McCabe, M. A., & Sweeney, M. (2016). Workforce development to enhance the cognitive, affective, and beha- vioral health of children and youth: Opportunities and barriers in child health care training. Washington, DC: National Academy of Medicine. doi:10.31478/201611b

Cabot, R. C. (1919). Social work: Essays on the meeting-ground of doctor and social worker. Cambridge, MA: Houghton Mifflin.

Cannon, I. M. (1913). Social work in hospitals: A contribution to progressive medicine. Philadelphia, PA: Russell Sage Foundation.

Fraher, E. P., Richman, E. L., de Saxe Zerden, L., & Lombardi, B. (2018). Social work student and practitioner roles in integrated care settings. American Journal of Preventive Medicine, 54, S281–S289. doi:10.1016/j.amepre.2018.01.046

Fraser, M. W., Lombardi, B. M., Wu, S., Zerden, L. D., Richman, E. L., & Fraher, E. P. (2018). Integrated primary care and social work: A systematic review. Journal of the Society for Social Work and Research, 9, 175–215. doi:10.1086/697567

Kepley, H. O., & Streeter, R. A. (2018). Closing behavioral health workforce gaps: A HRSA program expanding direct mental health service access in underserved areas. American Journal of Preventive Medicine, 54(6S3), 190–191. doi:10.1016/j.amepre.2018.03.006

148 L. D. SAXE ZERDEN ET AL.

Los Angeles County Department of Public Health. (2013). Social determinants of health: How social and economic factors affect health. Los Angeles, CA: Author. Retrieved from http:// publichealth.lacounty.gov/epi/docs/SocialD_Final_Web.pdf

National Academies of Sciences, Engineering, and Medicine. (2015). Mental disorders and disabilities among low-income children. Washington, DC: National Academies Press.

National Academies of Sciences, Engineering, and Medicine. (2017). Training the future child health care workforce to improve behavioral health outcomes for children, youth, and families: Proceedings of a workshop—In brief. Washington, DC: National Academies Press. doi:10.17226/24789

Rishel, C. (2015). Establishing a prevention-focused integrative approach to social work practice. Families and Society, 96, 125e–132e. doi:10.1606/1044-3894.2015.96.15

Stanhope, V., Videka, L., Thorning, H., & McKay, M. (2015). Moving toward integrated health: An opportunity for social work. Social Work in Health Care, 54, 383–407. doi:10.1080/00981389.2015.1025122

U.S. Department of Labor, Bureau of Labor Statistics. (2018). Occupational outlook handbook. Retrieved from https://www.bls.gov/ooh/community-and-social-service/social-workers. htm#tab-6

Zerden, L. D., Lombardi, B. M., Fraser, M., Jones, A., & Garcia Rico, Y. (2018). Social work: Integral to interprofessional education and integrated practice. Journal of Interprofessional Education and Practice, 10, 67–75. doi:10.1016/j.xjep.2017.12.011

Zerden, L. D. S., Jones, A., Brigham, R., Kanfer, M., & Zomorodi, M. (2017). Infusing integrated behavioral health in an MSW program: Curricula, field, and interprofessional educational activities. Journal of Social Work Education, 53(sup1), S59–S71. doi:10.1080/ 10437797.2017.1288595

Zomorodi, M., Zerden, L. D., Alexander, L., Nance-Floyd, B., & Byerley, J. S.; the Healthcare PROMISE Team. (2017). Impact of an interprofessional population health course and clinical immersion experience: Students and practice outcomes. Journal of Interprofessional Education and Practice, 9, 91–94. doi:10.1016/j.xjep.2017.08.008

SOCIAL WORK IN HEALTH CARE 149