Medical Social Work in an Interdisciplinary Health Care Team

Hello, students, there seems to some confusion about the case study. There is no lengthy case study for the paper this week. You only need the information provided to think about how a team would work with the patient, Claire and her family. You will choose a discipline to work with Claire. For example, many students choose oncology, psychiatric, and some have used case management. You need to think about how a specific medical SW discipline would work with Claire and her family.

THE INTERFACE OE HOSPITALS AND CLINICS Chapter 24 Social Work in an Interdisciplinary HIV/AIDS Program Holly H. Dando Charles J. Finlon The Center for Special Studies (CSS) at the Weill Cornell Medical Center of New York Presbyterian Hospital was created by a team of doctors, patients, and volunteers in the late 1980s in response to the growing crisis of the AIDS epidemic. The traditional model using physician and nursing care alone was failing to meet the medical, social, and psychological challenges presented by the disease. Providers sought to create a model that could address the medical needs of a person with HIV or AIDS, as well as problems related to stigma, disability, the psychological effects of impending death, and the recurring need to negotiate complex social entitlement systems. The staff at San Francisco General Hospital had already created a specialized interdisciplinary team model of care in the early days of the epidemic (Jacobs, Damson, and Rogers, 1996) and, because our patient population was demographically similar to theirs, that team model became the basis for our program. Our model gave a central role to those professional services that are considered "ancillary," or subordinate, to medicine and nursing in mainstream health care settings. In a traditional physician-directed system, an individual 229 230 A HISTORY OF AIDS SOCIAL WORK IN HOSPITALS doctor makes outside referrals based on his or her assessment of a patient's needs. In our program, services such as social work, nutrition, and chaplainary are integrated into the patient care system, and practitioners from each of those disciplines provide assessment and service directly to the patient. The program's "democratic structure" emphasizes participation by all relevant disciplines in making a plan for patient care (Jacobs, Damson, and Rogers, 1996). In this model some aspects of patient care are more clearly "owned" by different disciplines than others are. The team's physician will decide which antibiotic to use to treat a patient's infection; the dietician will discuss nutritional supplements; and the social worker will advise patients about insurance and entitlements. More complex questions, however, require the participation of the entire team. Problems such as a patient's difficulty adhering to an antiretrovirai regimen or deciding how to approach end-of-life care discussions with struggling family members are discussed and sometimes argued out by the whole team. This emphasis on communication and shared decision making makes CSS a truly mrerdisciplinary program as opposed to a simple ;»H/f/disciplinary one that might provide the same services but in a less coordinated manner. THE TEAM ' Each patient at CSS is assigned a primary care attending physician and a master's level social worker with New York State certification. If psychiatric care is indicated, the patient is also assigned to one of the program's five psychiatrists. This team remains stable over time and serves the patient in both the outpatient clinic and during hospital admissions. This continuity of care differs from standard programs in which a patient may meet with a different provider at each visit or admission. In most programs, a patient who attends an outpatient medical clinic will not see the social worker from that clinic if admitted to the hospital but will be assigned to whichever social worker serves the area he is admitted to (e.g., surgery, fracture, intensive care, etc.). Our social workers, physicians, nutritionists, and chaplains follow our patients no matter where they are admitted in the hospital. This ensures that providers familiar with the patient are, at the very least, consulting with other specialties and disciplines about the patient's treatment. Such attention can be time consuming but has proven to be worth the effort. Patients express relief at not having to adjust to new staff when they are admitted, and seeing familiar faces can be grounding during a crisis. Working with the same team in both our outpatient clinic and during a hospital admission allows patients and extended family members to build a different kind of long-term relationship with their providers. The trust that develops can give Social Work in an Interdisciplinary HIV/AIDS Program 231 patients the confidence to tackle complex problems in their lives. These issues can then be addressed over time, rather than in the usual single session of crisis counseling. When crisis interventions are needed, the established, ongoing relationship between patient (or family member) and provider increases the intervention's power and likelihood of success. FUNDING Our enhanced specialty care center was made possible partly through public funding from the New York State Department of Health's AIDS Institute. The institute permits hospitals identified as designated AIDS centers (DACs) to receive a higher rate of reimbursement for services in exchange for creating enhanced programs to serve the needs of people with HIV and AIDS. These public funds are supplemented by a dedicated group of private fund-raisers tJirough an event called the "Fete de Famille," which was organized by this group in conjunction with the hospital's development department. These additional funds have made many wonderful projects possible, such as purchasing refrigerators for each inpatient room on our designated AIDS unit and the provision of TV and phone service for all patients in our program who become hospitalized. These services are normally provided at considerable cost to the patient. The generosity and commitment of our donors also allow us to provide emergency cash grants for patients in need, as well as supporting research projects and staff education programs. STAFFING The center's staff has grown significantly since the program's inception in 1989. Our cuirent charge nurse began at the center that year, working as a home care specialist performing patient assessments and coordinating services between agencies and insurers. She recalls that the program originally held one outpatient clinic per week and was staffed by three part-time physicians, two social workers, several volunteers, and one other outpatient nurse. By 1996, the clinic was holding seven clinics each week and staff had grown to include two home care nurse specialists, eight master's level social workers, a medical director, four full-time general internists, sixteen part-time physicians (including subspecialists such as dermatology and rheumatology), two full-time and four graduate staff psychiatrists, three ambulatory care nurses, twenty-two floor nurses, eleven nurses' aides, a registered dietician, an occupational therapist, a volunteer coordinator, a chaplain, a part-time research coordinator, an emergency medical technician/van operator, and a medical/surgical technician, in addition to a full complement of administra- 232 A HtSTORY OF AtDS SOCIAt. WORK IN HOSPITAtJ tive staff (Jacobs, Damson, and Rogers, 1996). The following year we opened a freestanding clinic in another part of the city and almost doubled our staff. Our current clinical staff now includes nine full-time internists, five psychiatrists, and twenty social workers between the two sites. Staffing changes over the years have reflected changes in the epidemic. For example, although overall caseloads have remained about the same (about ninety patients per social worker), inpatient caseloads have gotten smaller (between zero and five per social worker at any given time) due to the increasing numbers of patients who avoid hospitalization through improved treatment options. We therefore have fewer floor nurses and, as less time is spent on discharge planning, we have returned to using only one home care specialist to assist our social workers. We have also eliminated some positions such as our occupational therapist and volunteer coordinator because these services became less important as patients' needs changed. We have, conversely, increased our outpatient clinic staff to care for the growing numbers of ambulatory patients we see. While other AIDS programs in the city have been forced to reduce social work staff due to budget cuts, we have continued to grow due to solid funding and our administration's firm belief in the importance of providing social work service. Social workers, following patients both in and out of the hospital, now make up more than 30 percent of our staff. Each of ourMSWs has approximately ninety patients on his or her caseload—relatively reasonable compared to the 250 to 400 patients followed by social workers in some other hospital-based HIV clinics in New York City. Manageable caseloads maintain morale and reduce the incidence of burnout, but having a large proportion of social workers on staff also has other advantages. Social work's holistic perspective adds balance to the medical model that quite naturally flourishes in hospitals. Our doctors and nurses are able to view problems—and patients—more systemically because of our social workers' influence. It's also less daunting for a social worker to question an unrealistically simplistic interpretation ofa patient's behavior when there are others with similar viewpoints sitting in the daily case conference. COMMUNICATION Team care without regular and direct communication can lead to fragmentation and duplication of services, so the CSS model incorporates daily patient case conferences. At the end of the clinic session, all providers involved in patient care meet to discuss every patient seen in the outpatient clinic that day. Once a week we also have a full team case conference discussing the inpatients followed by our program. This latter meeting also in- Social Work in an tnterdisciplinaryhttV/AIDS Program 233 eludes the floor nurses caring for our patients. At both inpatient and outpatient conferences we present and discuss new diagnoses, medications, and social and psychological problems, and care plans are made and agreed upon by team members. There is an enormous benefit to the providers in having their work reviewed by their peers in this way. Helpful suggestions, comments, and questions are integral to this process. Communication between disciplines is also fostered through weekly meetings to discuss administrative issues, answer current questions, and plan for the future. All staff are also invited to participate in biweekly support groups facilitated by an outside social worker at each site. In these groups team members can share their experiences and gain meaning about this profound and difficult work in an atmosphere of trust and empathy. The groups began before the introduction of highly active antiretroviral therapy (HAART) when so many of our patients were suffering horrific deaths. Often abandoned by their families, they were wasting away, incontinent, demented from brain infections, and disfigured by Kaposi's sarcoma lesions. Team members clearly suffered the effects of secondary traumatic stress. Now that more of our patjents are living longer, it is sometimes easier to deny the effects of job-related stress. Although they present less dramatically, trauma and stress continue to pervade our work. Patients still die isolated from loved ones and supported only by our staff. Our ambulatory patients also present repeatedly with substance abuse relapses, adherence failures, and unremitting social problems, making our work seem futile and increasing our risk for burnout. Having a safe place to vent frustrations and remind one another of past successes is needed as much now as it was in 1994. In addition to support, social workers receive regular supervision through the hospital's social work department. Each unit meets separately on alternate weeks for group supervision with the director of the department, and several times a year both units meet together for a combined group supervision. New social workers also receive individual supervision during their first year of employment. Working with nineteen other social work colleagues allows many opportunities for informal support and peer supervision as well. COMMITTEES Topics such as substance abuse, adherence, and patient education are discussed and explored by staff in a committee format as well. When an area of patient care is identified as particularly complex or compelling, staff is encouraged to form a committee to examine the issues and create a plan of action. An example of the efficacy of this plan is the development of an AIDS education committee. At the outset of the epidemic, our staff members noticed that other departments, often due to staff ignorance or "AIDS phobia," 234 A HISTORY OF AIDS SOCIAL WORK IN HOSPITALS occasionally treated CSS patients differently. We therefore invited other hospital departments who treated AIDS patients, such as pediatrics, the hemophilia clinic, and gynecology, to participate in a committee dedicated to educating the hospital as a whole on AIDS and its attendant issues. Working with managers of all hospital departments, we were able to schedule inservice education seminars. Committee members prepared material appropriate for each audience and, after providing basic HIV/AIDS education, were able to answer questions from staff in areas such as security, nutrition, laundry, escort, laboratory, and registration. Evaluation questionnaires indicated that staff enjoyed and benefited from these meetings. The committee's goal to improve conditions in our hospital by educating our colleagues was met during the many years this committee was in session. More recently, we have formed a committee to coordinate our developing relationship with an HIV clinic in Sagamu, Nigeria. Staff from many disciplines come together biweekly to sort and pack donated medications for patients at that clinic. We are also developing teaching modules for the Nigerian patients and staff and arranging for reciprocal visits to increase learning opportunities for both programs. RECENT GROWTH In the late 1990s, Gay Men's Health Crisis (GMHC), the oldest and largest AIDS service organization in the country, moved to a newly renovated building and decided to lease a part of their ground floor space to an HIV/AIDS care provider. After reviewing submissions from other designated AIDS centers in New York City, they offered the space to our program, and in October 1997 the David E. Rogers Unit of the Center for Special Studies opened at GMHC. Dr. Rogers was an early champion of the cause of AIDS treatment and an inspiration to many of us who worked with him when he was on staff as the Walsh McDermott University Professor of Medicine and Psychiatry at Cornell Medical School. The providers at the Rogers Unit continue to follow their patients both in and out of the hospital, commuting to the main campus as needed. Our original clinic, at the hospital's Sixty-Eighth Street campus, was named for one of our most active donors, Glenn Bernbaum. Between the two units, the Center for Special Studies now cares for over 2,000 patients. CLINIC STRUCTURE Each unit holds six clinic sessions per week, during which their care teams see twenty to thirty patients per session. Appointments are scheduled Social Work in an tnterdisciplinary HtV/AIDS Program 235 as in a private practice where providers see patients at specific times rather than the typical "clinic" scheduling in which patients are booked for one block of time and seen on a first-come, first-served basis. All patients receive and sig