Health Care Social Work
Abstract and Keywords
Health social work is a subspecialization of social work concerned with a person's adjustment to changes in one's health and the impact this has on that person's social network. Social workers in every setting must be ready to assist individuals and families adjusting to illness and coping with medical crises. This entry provides a brief overview and history of health social work and describes the settings and roles where this work is practiced. Significant challenges and opportunities in clinical care, research, education, and policy are discussed. Standards and guidelines for quality practice are then noted.
Keywords: health social work, medical social work, hospital social work, health care, health research, health education, health policy, practice standards and guidelines, pediatric social work, geriatric social work
Health care social work is a subspecialization of social work concerned with a person's adjustment to changes in health and the impact this has on that person's social network. How well or how poorly an individual, his or her family, and social network adapt to and accommodate changes in that person's health status has potentially enormous implications to the wider societal network. The professional heritage of social work recognizes the interconnectedness of these multidimensional forces that influence who we are and how we cope. This “person in the environment” perspective has been at the core of the growth of social work as a profession (van Wormer, 2007). While social workers practice along the continuum of health care today, they began to develop the medical social work specialization in hospital inpatient services.
In 1905, Massachusetts General Hospital in Boston (under the direction of Dr. Richard Cabot) hired the first hospital social worker in the United States. Garnet Pelton worked for only a few months before contracting tuberculosis and was quickly replaced by Ida Cannon, who later founded the first Hospital Social Services Department (Gehlert, 2006). These early pioneers established many of the core responsibilities of health social work, including recognition of the influence of economic and social factors on a patient's physical health and adherence to a treatment plan, documentation of interventions, and a need to “justify” the cost-effectiveness of social work staff to the host institution. The vital role of assessment, the importance of collaboration with the medical team, and the provision of patient education all soon became part of the expanded role of health social work (Rosenberg & Rehr, 1982).
Hospital social work departments spread rapidly throughout the early 20th century in response to economic pressures on the health system by immigration and poverty. Societal strategies to address the prohibitive costs of health care included passage of the Social Security Act in 1935 and support for employer-based health insurance. In 1946, the Hospital Survey and Construction Act (also known as the Hill-Burton Act) was passed to improve the nation's medical infrastructure and to require participating institutions to provide a small measure of “free care” to those most in need. Twenty years later Medicare and Medicaid programs provided major federal monies for health care costs. With the advent of hospital payments based upon diagnostic related groups and the passage of the Health Maintenance Organization Act of 1973, there was a shift from inpatient to outpatient focus, leading to a marked increase in the number of health social workers providing case management and discharge planning services (Clark, 2004). Escalating health care costs, in the 1980s and 1990s, together with a change in ideology toward privatization and managed care under Presidents Reagan and Bush (41 and 43), contributed to the downsizing, mergers, and the closing of many hospitals, and had an adverse effect upon many social work departments (Berger et al., 2003).
Social workers in all settings are called to assist in problem-solving regarding complex health decisions throughout the life span. Questions ranging from reproductive decision-making through end-of-life care and bereavement can be raised by those in prisons, schools, foster care, mental health facilities, and other diverse settings. Social workers in every setting must be competent in grief work and must be ready to assist individuals and families adjusting to illness and coping with medical crises. In order to provide quality care, all specialized health social workers need to translate their generalist social work skill set into the specific skills required in their own individual setting to create an environment of healing and adjustment to illness and disability.
Although there are some regulatory requirements that demand minimum social work duties in some specialties and settings—such as nursing homes or dialysis centers, there is tremendous variety within health social work roles. Community standards vary geographically and by setting. Thus a hospital in a small rural town may have a very different set of expectations for its social work staff than would an urban home health agency. Even within a single institution it is not uncommon for there to be disparity regarding social work responsibilities between units and departments. This is especially true with health services across the life span. Pediatric social workers typically are far more effectively integrated into the service delivery system than is an adult-services social worker even within the same facility (Jones, 2005).
Social Work Roles
If the role of health social work is to thrive in the coming decades, social work leaders will need to escalate their efforts as clinicians, educators, researchers, and policy change agents. Social workers offer education and support to patients and family caregivers as they learn new skills and navigate the complex health-care system. Social workers provide referral information regarding the array of community resources that may be available. Health social workers assess patients for levels of distress and offer interventions such as counseling, cognitive therapy, problem-solving, skills training, and relaxation exercise. They may facilitate support groups and coordinate community outreach programs. Health social workers assist patients as they cope with body image concerns and the impact of illness on sexual functioning.
Owing to changing hospital structures and financing, hospital social workers are shifting their focus of service (Browne, 2006). They may be asked to be on-call for nights and weekend coverage and may be found in emergency departments, critical care units, and in specialty areas such as burn or transplant units. Pediatric health social workers are integral team members in neonatal and pediatric intensive care settings. Specialty centers such as dialysis clinics are staffed with nephrology social workers. Social workers have a vital role with patients who have especially complex needs, such as those with developmental disabilities or other serious comorbidities. There are social workers in all aspects of the military health system both within and outside the United States—with the Veterans Administration being the leading employer of social workers. In addition, health social work innovators are crafting new roles in emerging areas such as cancer survivorship and genetics. Recent breakthroughs in understanding the human genome have opened the door for health social workers to develop leadership roles in the field of genetic counseling.
Geriatric social workers can be found in long-term care facilities. Home health and hospice programs have social workers providing home visits for assessment and counseling services. These social workers also assist patients as they cope with the long-term impact of chronic illnesses such as Alzheimer's disease. Health social workers are found in rehabilitation centers where they coordinate concrete services in addition to counseling patients as they adjust to limitations in function.
Diverse communities may rely on their health social worker to help with the coordination of concrete services, provide assistance in obtaining medications, arranging for medical interpretation services, and to assist the facility in providing culturally congruent care. All social workers are mandated abuse reporters and may coordinate the care provided to victims of physical violence, child abuse, dependent adult abuse, and sexual assault. In addition, health social workers may be the front-line determiners of mental illness and substance abuse and become involved in complex coordination of care delivery and have a responsibility for continuity of care across settings to ensure a durable discharge.
At the macro level, social workers are involved in a variety of institutional leadership capacities. They can be found on many hospital committees and may have administrative responsibilities within different departments (social work, discharge planning, human resources) and specialized programs (palliative care teams, volunteer programs, or bereavement services). Continued pressure on U.S. health care by growing numbers of uninsured and underinsured individuals, ever-increasing pharmaceutical costs, a growing elderly population, expanding technologies, fear of repeated terrorist attacks and potential pandemics as well as recurring natural disasters all threaten to overwhelm a fragmented and what many believe to be an already unsustainable system. Social workers have a historic role as advocates for health-care reform.
Quality health care is driven by the goals of the patient and family, and social workers play a vital role in translating these goals to the members of the health care team (Abramson & Mizrahi, 2003).
The provision of quality health care requires a team of competent and compassionate professionals dedicated to addressing the multidimensional concerns of patients and their families, but patient and provider dissatisfaction with the current delivery of care is well documented (Institute of Medicine, 2007; SUPPORT Principal Investigators, 1995). There is a disconnect with the kind of care most people say they want and what is actually offered to them, and this discrepancy escalates as patients face the end of life.
As hospitalizations grow ever shorter, patients are discharged with increasingly complex health care needs. In addition, as staffing levels have fallen crisis management becomes, too often, the standard level of intervention. Social workers are called to assess and assist patients who may be depressed, anxious, confused, and fearful. They have developed and used tools and instruments to assess functional status and make appropriate referrals.
Social workers may take a leadership role in transitioning their facility to adopt and implement a more family-centered approach to care. Health social workers play a role in institutionalizing and facilitating family conferences (for example, in assisting in establishing policies for which different professionals should be involved, when the family conference should occur and reoccur). Health social workers are often the care provider best positioned to support family caregivers.
Health social workers in every setting are called to recognize the importance of teamwork. Teams exist along a continuum from unidisciplinary (a team composed of several members within a single discipline), to multidisciplinary (typically a reactive model with ad hoc membership that uses a consultation format), to interdisciplinary (members are identified as working together proactively, but often without shared leadership and decision-making authority), to transdisciplinary (where members create a shared team mission, benefit from role overlap, and have integrated responsibilities, training, and leadership). This transdisciplinary model requires staff to have competence in collaboration and an appreciation of the diverse social, psychological, spiritual, and cultural concerns that impact care delivery (Simpson, 2003; Speck, 2006).
Third-party payers have demanded the adoption of evidence-based practice. Outcome data to support the variety of social work interventions currently available are needed so that effective and efficient use of resources can be justified. Innovative research is necessary to make the multifaceted roles of health social work more transparent and accountable (Kramer et al., 2005).
Health social workers are too often underutilized regarding patient accrual to clinical trials. Social workers can normalize the research process as well as provide education and support for study protocols. Social workers are especially needed to advocate for studies that reflect the needs of diverse populations. Health-related quality-of-life research is especially suited to social workers in the medical field and can be accomplished through transdisciplinary collaboration.
Health social workers have a responsibility to be health educators. Patients rely on social workers to offer anticipatory guidance and problem-solving skills regarding management of their illness and its treatment. New social workers rely upon seasoned veterans for supervision and mentorship. Communities and institutions rely on social workers to offer information regarding how to offer culturally congruent care. Medical colleagues rely upon social workers to assist with understanding the complex bio-psychosocial-spiritual impact of illness upon a patient and family system. Social workers may be the first professionals that patients turn to regarding questions about the use of complementary or alternative treatments. Health social workers have a strengths perspective that gives them an opportunity to focus not just upon illness and loss but also upon empowerment and wellness (Csikai & Raymer, 2003).
In addition, social workers serve an important role in demystifying the medical process and helping patients navigate the system of care and access insurance and medication. Social workers are involved in education regarding community resources and, in turn, must educate these local resources of the needs of patients (Rhiner, Otis-Green, & Slatkin, 2004).
As long as there are disparities in access to quality health care, social workers have a professional and ethical obligation to advocate for change. Age, gender, racial, ethnic, cultural, social, and economic factors continue to disproportionately influence the delivery of medical care (Freeman & Payne, 2000). Impoverished rural communities may lack access to basic medical care. Data demonstrate that there are many barriers to achieving adequate pain and symptom management. Those living in high-crime districts may find that pharmacies in their neighborhood are reluctant to carry many pain medications for fear that stocking such medications may make them more of a target (Anderson et al., 2002). Persons of color, those who speak a language other than English, those with low literacy, those who are elderly, those who lack insurance, and those who are female are less likely to receive appropriate pain medications (Lasch, 2002). Concerns about substandard medical care for those who are incarcerated or otherwise disenfranchised are unpopular, but health social workers have a historic mandate to advocate for social justice.
Health social work leaders are needed to give voice to the escalating concerns of those most vulnerable. They are needed as community organizers, lobbyists, and governmental leaders with the courage and vision necessary to advocate for national and global health reform.
Standards and Guidelines
There is a consensus that the health care system in the United States is in need of improvement, but less agreement regarding what should be done to address these multifaceted problems. Guidelines have been developed to address specific areas of concern. In recognition of the particularly compelling needs of those facing the end of life there have been several prominent Institute of Medicine reports—Approaching Death: Improving Care at the End of Life (1997), Crossing the Quality Chasm (2001), When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families (2002)—that offer outlines for needed change and argue for a more holistic focus of care. The National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (2004) lists eight domains of care, each of which argues for a multidimensional team approach to the provision of care. These guidelines have since been adopted by the National Quality Forum (National Quality Forum, 2006). Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs (2007) provides compelling evidence for the role of health social work in offering quality care.
Disease-specific organizations such as the National Comprehensive Cancer Network have adopted clinical practice guidelines that address the bio-psychosocial-spiritual concerns of patients. The Distress Guidelines in particular are useful in standardizing health social work assessments and interventions.
Leading social work organizations such as the National Association of Social Workers and the Association of Oncology Social Work have also developed guidelines and standards of practice useful for health social workers. Beyond laying out best practices guidelines, these professional organizations have utilized Web-based curricula designed to offer health social workers core information regarding roles and responsibilities.
Currently, the majority of health social workers practice in settings that follow a traditional medical model for the provision of care. This means they are illness-focused and services are physician-driven. There is a clear hierarchy of roles, and even interdisciplinary teams often consist of only a physician and a nurse.
Despite increasing awareness of the benefits of holistic care, many community clinics have no social worker services available. Most hospital social workers are conscious of their vulnerability in a host environment that may view their contributions as “optional” with the majority of patients receiving only minimal interactions with a social worker. Although there are certain commonalities across institutions regarding the role of a health social worker, there can be great variety in what specific tasks are provided. This lack of standardization regarding who is likely to see a social worker and what services this social worker is likely to provide contributes to the challenges facing health social work in the 21st century.
The challenges faced by the discipline of health social work are further exacerbated by a troubled U.S. health care delivery system. Continued pressure on U.S. health care by growing numbers of uninsured and underinsured individuals, ever-increasing pharmaceutical costs, a growing elderly population, expanding technologies, fear of repeated terrorist attacks, and potential pandemics as well as recurring natural disasters all threaten to overwhelm a fragmented and what many believe to be an already unsustainable system. Social workers must be poised to advocate for health care reform.
Ideally, there would be a synergistic evidence-based system of health care wherein clinical practice needs informed research, which in turn provides the evidence that influences the ultimate delivery of patient care. These data then become the basis for policy decisions that further influence practice and the system repeats in continuous performance improvement cycles. For this model to be maximally effective, all health social workers must be competent in each of these interconnected areas.
Health social workers must consider the ethical implications of everything they do. Assisting people who struggle with questions about advance directives, the discontinuation of life-support, physician-assisted termination of life, or abortion requires self-reflective practitioners who empathically consider the perspectives of another's suffering. Health social work offers not only many challenges but also opportunities in the future. A skilled clinician has the privilege of interacting with patients and their families at times of enormous vulnerability. Times of medical crisis create windows of opportunity for competent and compassionate social work leaders who will demonstrate their range of knowledge, skills, and values across the continuum of health care and across the life span.
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