Health Care Social Work: Specialty Area Expected to Grow With Shift in Care Model
By Leigh Glenn
For more than 100 years, the need for social workers in health care has been recognized as critical to the care and well-being of patients, their families and communities—where social workers advocate for the redress of structural and systemic issues. The diseases are different now, with fewer incurable illnesses, such as tuberculosis and syphilis, and more manageable, chronic illnesses, like certain cancers and diabetes. But the need is just as important.
Today, nearly 170,000 social workers are employed in health care, according to the Bureau of Labor Statistics. That number is expected to grow with the move away from fee-for-service to value-based care, as models across the health care system emphasize quality and outcomes over volume of medical services.
The importance of health care social workers is obvious to patients and their families, but cost-cutting in the workplace can mean social workers must demonstrate their significance. This needn’t detract from core responsibilities; rather, self-advocacy brings new avenues of value to explore.
For existing social workers and social work students considering health care, today’s changes provide opportunities for professional development and making a difference. Here’s a look at the field, including upsides and challenges.
Learning the Lingo and Processes
Heather Brungardt, MSW, LCSW, LMSW, president-elect of the Society for Social Work Leadership in Health Care, considered nursing and physical therapy before a social policy elective class steered her toward social work. As senior administrative director of Psychosocial Services at Children’s Mercy in Kansas City, Mo., she helps oversee a staff of 300 across eight departments and works with interdisciplinary teams to create tools to help patients.
Within hospitals, says Brungardt, social workers learn most medical-related aspects on the job, including medical terminology, medical records and documentation, and financing and entitlement programs. It’s helpful to embrace new technologies (telehealth video conferencing, texting and various apps), and to understand evolving aspects of records, such as population health analytics, care coordination, psychosocial widgets and other tools.
Regardless of setting—whether hospital or community clinic—social workers are interpreters on interdisciplinary teams, helping patients and their families understand conditions and treatments or, when working with terminally ill patients, illness trajectories. Likewise, social workers help other medical professionals understand the non-physiological aspects of patients, including mental health, family dynamics and socioeconomic status.
Says Brungardt, “… most of a person’s health is not based on physical health—it’s about all the social determinants of health, including poverty, access to education and health care and safety. Also, whether they have mental health or substance-abuse issues or a family member does.”
In the shift toward value-based care, interventions must address the whole patient and be quantifiable. Given fiscal and logistical constraints, Brungardt says, social workers “have to make sure they’re talking to all the different audiences in the health system in a way they can hear,” including the finance folks and the quality assessors. This becomes more important as cost-cutting forces social workers’ traditional functions into nursing.
Social workers excel at mental health screening, where efforts identify patients with mental health concerns, provide appropriate interventions and ensure ongoing access to care, Brungardt says. Suicide risk is an important area—nationwide, suicide is the second-leading cause of death for people ages 10 to 24, according to the Centers for Disease Control—and Children’s Mercy focuses in particular on 12- to 18-year-olds.
Suicide screening started as a pilot program endorsed by the Psychosocial Screening Task Force and, one year ago, spread across all areas within the system, Brungardt says.
Social work staff are encouraged to share research within Children’s Mercy through papers and presentations. But this can apply at any hospital. “Certainly, as I was a new social worker coming out of practicum, any opportunity I saw to help on a project, write a policy, lead a meeting, I took advantage of as a way to learn,” she said.
Long-Term Relationships with Patients
Nephrology social workers typically see dialysis patients three times a week. “This allows you to follow patients and help them on a longitudinal basis, and establish deep connections to your patients and their family members,” says Teri Browne, PhD, MSW, NSW-C, an associate professor and associate dean for faculty and research at the University of South Carolina in Columbia.
Browne, a former chair of the Council of Nephrology Social Workers, got her start as a volunteer rape crisis counselor and then worked in emergency departments. Her MSW field placement took her into hospital settings and her first MSW job was in dialysis, where she worked for 13 years. Nephrology is the one health area where social workers must have a master’s degree, and, as with other areas, increased attention is on patients’ mental health.
“For example,” says Browne, “Medicare now requires that all dialysis social workers screen patients for depression and quality of life.”
Interested MSW students should try to get a field placement in a dialysis center as the best way to learn. There, among other activities, they may intervene to address identified concerns; assess issues of spirituality or religiosity; do motivational interviews to help patients cope with restrictive diets and fluid regimens; work with dietitians to help patients get nutritional supplements or renal-appropriate meals; help patients get listed for kidney transplants; and help patients plan travel and travel dialysis.
Sometimes, NSWs are involved in crisis situations in their clinics, including threats of violence from patients, and they also help medical colleagues on the team deal with those. Plus, spending so much time with patients who then die means NSWs not only have to deal with grief themselves, but to help others on the team.
Transplant social workers assess recipients and donors for psychosocial suitability to receive a kidney or donate one, Browne says. They also help transplanted patients with hospital discharge needs, and post-transplant medication needs.
Nephrology’s major challenges: high caseloads and “inappropriate clerical tasks,” Browne says, such as arranging travel dialysis and billing. Two for-profit companies own and operate most U.S. dialysis centers and profit emphasis can drive cutting labor costs at the expense both of patient care and staff well-being. Too-high caseloads are being addressed through state staffing-ratio laws, with the ideal ratio of patients to NSWs at 75:1, according to research by the Council of Nephrology Social Workers (CNSW), part of the National Kidney Foundation. Without such limits, NSWs may slide toward burnout and leave nephrology.
Nephrology social work may also feel professionally isolating when there is one NSW in a dialysis clinic, says Browne. To help, CNSW has an active listserv connecting NSWs with their local chapters and others in the field, she says.
In legislation and regulation, nephrology social work is at a paradoxical crossroads, Browne says. Department of Health and Human Services leaders support new technologies, such as artificial kidneys and wearable dialysis, plus legislation to protect living donors’ workplace rights and life insurance. They also want to lengthen transplant recipients’ Medicare immunosuppressant coverage, which expires after three years.
But the latest proposed changes, says Browne, gut short-term plan coverage of dialysis and deny coverage altogether for living donors. Changes regarding pre-existing conditions could limit services to people with diabetes and hypertension, where meaningful intervention can delay or reverse kidney disease.
Such changes reinforce the need for health care social workers to advocate at the state and federal levels and to encourage patients and their families to do so as well. Advocacy is part of the social work code of ethics, Browne says. Without it, end-stage renal disease patients might still be subject to panels like those that selected who would receive dialysis—as they were before 1973—because there would be no automatic coverage under Medicare and there would be no master’s requirement for nephrology social workers.
Because You Never Know…
The need for activism and advocacy and mending broken links in the health care system is so great that health care social workers may find their true calling in health policy.
That’s what happened with Leigh Greene, a master’s candidate in Social Service Administration at Case Western Reserve and a 2018-2019 NASW Foundation Verne LaMarr Lyons Memorial MSW Scholar. Greene could not have predicted working as director of minority health for Youngstown, Mahoning County, Ohio, where she focuses on infant mortality, helping new parents, preparing future moms and dads, and helping clients advance their education, secure transportation, and even gain access to nutritious food in what is a “food desert.” The area has been hit hard by automaker and manufacturing losses, with the effects rippling out to allied businesses and others.
For more than 23 years, Greene worked in the family business—a nursing home founded by her grandmother to address health inequities among mostly African-American elders and continued by her mother; both were nurses. She was grandfathered into social work licensure in 1992, and there, she directed social services. When the business was sold into a large health system in 2010, Greene took some time off, then became a navigator for the then-new Affordable Care Act before being tapped, in 2014, to head minority health for Youngstown. Through the scholarship, part of the Healthcare Education and Leadership Scholars (HEALS) program, she is focusing on a concentration in Community Practice for Social Change.
As part of the HEALS Policy Summit, she went to Washington, D.C., where she learned how to better advocate for policy change at the highest levels—through training in communication with policymakers—and to measure change.
“In my employment in public health, I often have to give briefs to members of city council, city health board members, city officials and community leaders,” she says.
Health care social workers can expect much slower change at the macro level than working one-on-one with patients, says Greene. Yet, much of that change stems from educating individuals in the community through outreach events and work with community health workers. This may mean, as in Greene’s realm, developing a video for young fathers, “Dads Do Matter;” lead testing at citywide baby showers; support groups for moms; and PSAs and brochures on child spacing and safe-sleep practices.
“The upside for me is to provide community education either through events or workshops and then having those community members leave empowered through knowledge gained or being connected to resources,” says Greene. “I really see the field evolving in the path of advocating on a large scale. Social workers are the wheel in the advocacy movement. We can bring research, evaluation, testimony, amongst other assists, to work toward policy change. …Whether we are in a clinical setting or a political stage, the field of social work is going to be a necessity in addressing the social ills of our society.”
Bringing her grandmother’s and mother’s passion to the wider community, Greene has touched into ongoing conversations about racism and cultural competency training for area stakeholders. Regardless of socioeconomic status, the health outcomes for African-American moms-to-be and their infants are affected by unseen structural and systemic racism. “Social workers are going to have to be conscious of the barriers that prevent their clients from receiving needed health care,” Greene says.
When That Time Comes
Almost every aspect of social work involves change, transition and, often, loss and grief, which is why social workers are generally well-positioned to work with terminally ill patients.
Today, some 80 percent of hospitals with 150 or more beds provide some aspect of palliative care, says Shirley Otis-Green, MSW, MA, ACSW, LCSW, OSW-C, FNAP, palliative care consultant and founder of Collaborative Caring, based in Toluca Lake, Calif. Otis-Green sees transition, change and loss as the overarching link between the first part of her career—working with children in distress and then foster care—and now—working with people with terminal illnesses.
Palliative care social workers can grow professionally and make a difference, yet few health social workers are trained in palliative care. Just this January, a guidebook, Palliative Care: A Guide for Health Social Workers, came out. Otis-Green helped to write the foreword and believes palliative care approaches should be part of any health social worker’s education, because palliative care applies to so many aspects of life with which social workers are involved, including mental, spiritual and existential concerns.
In the early 1990s, after earning her MSW, Otis-Green moved to Los Angeles, where there was an opening in oncology. She did clinical work, program development and research and education. An oncologist who wanted to create a team approach to pain management and end-of-life care consulted with her, then asked her to join the team.
Today, the National Cancer Institute recognizes that team approach as ideal: From the moment a patient is diagnosed with a serious illness, an interdisciplinary team addresses stress and quality-of-life impacts. Health care social workers help manage patients’ needs in key areas—family, work and school—and help with logistics, including moving from inpatient to outpatient care, from intensive care to a nursing home, as well as with the maze of financing and insurance.
Palliative care’s biggest challenge is that, like much of the medical field, it’s part of a broken, fragmented system in need of a holistic overhaul, says Otis-Green. Patient-to-social worker ratios are often out of line, which inhibits social workers’ ability to be proactive.
For example, Otis-Green says, too often when a side effect or symptom is anticipated—say someone with advanced-stage lung cancer will lose 10 to 20 percent of their body weight—referrals, such as to a dietician, are delayed until the symptom manifests. A mindful approach would mean referring much sooner. Initial assessments—which social workers can guide—help ferret out such concerns.
Palliative care social workers daily get to see how people face death, and that’s a big responsibility. Otis-Green recommends that social workers new to palliative care have a mentor and be a mentor. That may be a physician, nurse or fellow social worker on-site, or, if their unit is not well resourced, a social worker somewhere else. In addition, being part of a bereavement support group can help instill a sense of humility.
Otis-Green also recommends committing to excellence, because social workers are dealing with life and death, may not have a do-over and their actions have enormous consequences for generations.
Resources
Health Care Social Workers: Improving Your Health (brochure)
Social Work Practice: Health
Find a social worker and other resources athelpstartshere.org