Every day, health care practitioners learn more about the importance of social determinants of health — “upstream” aspects such as patients’ economic and housing stability, access to nutritious food, and family support — and their crucial role in health outcomes.
Social workers, using their distinctive “person in environment” framework, routinely identify and address these social factors in serving clients — and for more than a century have ensured that health care providers attend to medical and non-medical factors that contribute to health.
A 2019 consensus study by the National Academies of Sciences, Engineering, and Medicine, “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health,” is a significant milestone in the recognition of the value of social factors in health. It recognizes social workers as “specialists in social care” and outlines a roadmap for workforce, information technology, and other changes that are needed to achieve the health care outcomes that continue to be elusive — especially for vulnerable populations.
The 18-member study committee included social workers, nurses and physicians. Study sponsors included NASW, the Council on Social Work Education and numerous schools of social work. Committee members looked at peer-reviewed literature, reports by government and private organizations, websites and presentations given in four public sessions.
The committee found that, in settings where social care activities were addressed, few had gathered evidence supporting the use of social care-related interventions, so it could not make specific, evidence-based, best-practice recommendations.
But members identified five complementary activities that set the framework for a systems approach to using social care to improve health outcomes in clinical practice. These are awareness, adjustment, assistance, alignment and advocacy.
Awareness activities identify patients’ social risks and assets; adjustment focuses on altering care to accommodate social barriers; assistance helps connect patients with resources that can minimize social risks; alignment focuses on existing community-wide social assets and how they can be aligned to support positive outcomes; and advocacy brings together social care and health care organizations in a community to promote policies to address both health and social needs.
Beyond these, the study articulates five goals (with related recommendations) that promise to improve equity as well as outcomes:
- Design health care delivery to integrate social care into health care.
- Build a workforce to integrate social care into health care delivery.
- Develop a digital infrastructure that is interoperable between health care and social care organizations.
- Finance the integration of health care and social care.
- Fund, conduct and translate research and evaluation on the effectiveness and implementation of social care practices in health care settings.
See the full list of recommendations
Where to begin?
The sheer scope of the study’s recommendations implies an “all hands on deck” approach to the integration of social care into health care. That means social workers will need to continue to demonstrate the value they bring to health care settings. Further, they will need to document the outcomes of their activities. Still, the scope begs the question, where does one start?
Long a priority for NASW, social worker compensation will be a key driver of success. In fact, Robyn Golden, LCSW, says compensation is the place to start in implementing the recommendations.
“Financing is the critical piece,” says Golden, one of the study’s committee members and a professor in the Department of Health Systems Management at Rush University in Chicago, as well as associate vice president of Population Health and Aging.
“So many places, we’ve not been included in terms of reimbursement,” she said, because social workers are not considered part of the health care profession.
But where social workers are part of health care teams, those teams have succeeded in identifying and addressing social risk factors that could have hindered positive health outcomes for patients. Physicians and nurses need not be experts in social determinants of health when social workers are involved and know how to speak to patients about where they live, their circumstances at home, which other caregivers may be present, how they get to appointments, whether and what they eat on a daily basis — considerations that may include but go beyond mental health screening, and also may play the most important role in a patient’s well-being.
“Social workers can play a role in teaching others about social determinants,” Golden said.
The financing piece should focus on Medicare and Medicaid, she said. That will raise the question of how medical social care should or should not be, and that points to the need for building evidence about the value of what social workers do in health care settings.
That aspect of the work may be the most challenging. Right now, among many health care professionals, “Social disadvantage is rarely part of systematic screening initiatives,” according to committee member Laura Gottlieb, MD, MPH, associate professor for Family Community Medicine at the University of California San Francisco.
“Maybe I just happened to discover the patient didn’t have transportation — or food — in the course of care, but that’s not typically part of a standardized screening protocol,” she said. “But there’s a movement afoot to increase social risk screening, at least for some high-risk populations.”
While screening for social risk factors in clinical settings is increasing, Gottlieb says, assistance and adjustment interventions are not always increasing concurrently. That’s why it’s important to try to “encourage providers to bring social care up to the level of traditional physical and mental health care to address the whole person,” she said.
One challenge is how to define and then pay for related interventions.
“What social workers do is not well-defined because people’s social barriers to health are not well-defined,” Gottlieb said. “There are so many ways social workers can improve care delivery, but it’s not one intervention — it’s several. How do you pay for that?”
Gottlieb also is part of the Social Interventions Research & Evaluations Network (SIREN), whose mission is to improve health and health equity by advancing research on health care strategies to improve patients’ social conditions. She says more evidence is needed on every component of the NASEM study framework.
“We need to know more both about what interventions work and how to put effective interventions into place,” she said. “The implementation science the committee proposed should examine the payment models, workforce models, and technology infrastructure that can increase adoption.”
As an example, Gottlieb notes that recently many electronic health record vendors have begun to incorporate social risk data modules that further open the door to bridging health care systems and community organizations. But whether and how they improve health outcomes is under-examined.
Part of the challenge is health care’s rapid evolution.
“To focus only on impact and ignore implementation will mean missing many opportunities,” Gottlieb said, so those in the field need to operate on both fronts.
She encourages social workers to sign up for SIREN’s newsletters and to examine the network’s evidence library to ensure new initiatives are based on the growing body of effectiveness and implementation science literature.
A Blessing, A Curse
Both the education and training of social workers means that by the time they enter the field, grasping and appreciating the “whole person” context isn’t something they think twice about. It’s the same with various interventions. But because the person-in-environment framework is so ingrained in social work practice as to be instinctive, that also makes it less likely to stand out as distinctive. It’s those types of interventions that need to be defined and documented if social workers are to demonstrate the value they bring to health care.
Committee member Tamara Cadet, PhD, MSW, MPH, associate professor of social work at Simmons University in Boston, says that while Simmons has certain specialized classes in health care for social work students, the social determinants of health are in many ways part of every class.
“A practitioner has to be aware of what the facilitators and barriers are to providing care and there are times when it is in fact SDOH that can ease the access,” she said.
Cadet had hoped she would be wrong about the lack of documentation and evidence around social care and its value. “Thinking about and doing something about SDOH is just what social workers do, so the idea that we would write about them versus depression, anxiety and other diagnoses would never occur to folks.”
She agrees with Golden about the need for reimbursement through Medicare and Medicaid. “If we look at goal one to include social care workers as integral members of the team, is that feasible if there is not reimbursement?”
Yet, she also recognizes that social workers have to do a much better job “explaining and clarifying” their roles so that health care providers understand the value social workers bring.
“There still seems to be a population of health care providers that are not really sure what social workers do,” Cadet said. “For me, this is a call to action: We know what we do and we need to share this with others in whatever mechanism that we have access to.”
Even the documentation need not be too great a stretch. For example, social work students are taught to set goals with clients, and at the end of their time together to write which goals they achieved and how. This can be done in a way that doesn’t violate patient privacy, such as by sharing X, Y and Z clients were made aware of the transportation resources available to them, perhaps were even assisted in securing transportation, and can now get to their appointments to help them manage their diabetes or depression.
That kind of more informal documentation “may not be enough eventually,” says Cadet, “but it’s more than what we have right now.”
If agencies and health care organizations are overburdened, it may be more of a challenge to document social workers’ interventions, link them to outcomes and share that information. But allocating time and energy for the work is important.
“The ideal situation is having both a health care provider and social worker working together internally on increasing awareness (Goal 1),” says Cadet, “having another group of folks working on Goal 2 (advocacy), and yet another group working on Goal 5” (social work research and working on their intervention projects in addition to working with practitioners who are not researchers but are doing the work).
Even in grants, for example, scope and language will need to change. Simmons, which has federal grants from the Health Resources and Services Administration to help move social work students into primary care settings, will want to know how many students were trained and how many went into primary care after graduation. They were not asked to focus on patient outcomes, but that will probably be one question in the next grant they write, says Cadet. “How do we institutionalize this stuff?”
Even since her work on the study, Cadet is making changes in her approach, including a greater emphasis on SDOH in her classes. She describes observing an advanced health care class conducted with medical students from Tufts University in which the social work students were to be part of medical teams and had to interact with medical school students three to four times a day.
Initially, says Cadet, the students were timid. But when it was emphasized to them that they were the psychosocial experts who could lead, they took charge of the process.
“I get very excited when it makes sense to them,” she said. And they are probably sick of her, she quips, because she continues to prompt them: “‘Tell me why you’re doing this and what you hope your outcome will be,’” in language that is not “socialworky.”
Going Forward: How NASW Members Can Get Involved
Since the release of the Integrating Social Care study in September, NASW has begun to incorporate recommendations around scope of practice and compensation — priorities for the profession — into its advocacy efforts, including its support of the Improving Access to Mental Health Act (S. 782/H.R. 1533) as well as the Social Work Reinvestment Act. NASW also is sharing information about the study recommendations and policy implications with numerous stakeholders, including Congress and federal regulators.
NASW will offer several sessions about the study recommendations at its national conference in June and also is encouraging chapters to include programming about the study in their events.
NASW members can ensure the study helps shape policy, practice and professional development in the following ways:
- Get informed about the study through NASW national or state and local chapter events.
- Urge lawmakers to support the proposed legislation and any other bills that are pro-social worker.
- Urge state licensing boards to revise policies, as needed, to expand social worker scopes of practice when they are overly restrictive.
- Conduct or contribute to further research that demonstrates the value of social care and the return on investment.
- Write op-eds on the crucial need for social care and the role social workers play in providing it. (NASW can provide templates for this).