Interdisciplinary Medical Social Work: A Working Taxonomy

Interdisciplinary Medical Social Work: A Working Taxonomy PETER MARAMALDI, PhD, MPH, LCSW Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, Boston, Massachusetts, USA ALEXANDRA SOBRAN, MSW, LICSW, LISA SCHECK, MSW, LICSW, NATALIE CUSATO, MSW, MPH, LICSW, and IRENE LEE, MSW, LICSW Social Work Department, Massachusetts General Hospital, Boston, Massachusetts, USA ERINA WHITE, PhD Candidate, LICSW, MPH Simmons School of Social Work, Boston Children’s Hospital, Boston, Massachusetts, USA TAMARA J. CADET, PhD, LICSW, MPH Simmons College School of Social Work, Harvard School of Dental Medicine, Boston, Massachusetts, USA Findings from a year-long exploratory study aimed at describing universal functions of medical social work with interdisciplinary teams in acute care settings are reported here. A universal taxonomy of interdisciplinary social work skills and competencies was empirically identified through a participatory action research framework. Findings support previous conceptual descriptions of medical social work’s overarching and historical role to help interdisciplinary teams in acute care to consider patients’ home environment, knowledge, beliefs, culture, and resources during assessment, treatment, and discharge planning. The empirically determined taxonomy reported is intended to provide social workers a framework with which to articulate and evaluate their core competencies on interdisciplinary medical teams. KEYWORDS medical social work, interdisciplinary teams, participatory research Received March 10, 2014; accepted March 14, 2014. Address correspondence to Peter Maramaldi, Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, 300 The Fenway, Boston, MA 02115. E-mail: [email protected] 532 Interdisciplinary Medical Social Work 533 THE PROBLEM Although health care in the United States has made tremendous technological gains during the last century, it has also taken on unforeseen dimensions related to distribution and utilization of scarce resources (Berkman, 1996; Rehr & Rosenberg, 2006). Prior to the passage of The Patient Protection and Affordable Care Act (2010), health care was traditionally distributed as a commodity, rather than an inalienable right. Market forces dictated the distribution of resources on both the supply and demand sides of healthcare (Chirba Martin, 2009). Social work has not fared well in resource allocation for a variety of reasons including an erosion of government funding, limited support for social services by insurance companies, and the inadequate demonstration of its potential contribution to health care (Rehr & Rosenberg, 2006). Medical social workers tend to under-articulate their clinical contributions to patients and interdisciplinary teams (Abramson & Mizrahi, 2003; Carrigan, 1978; Globerman, White, Mullings, & Davies, 2003). Descriptors such as “providing support,” “counseling,” and “working with family” do not capture the full extent of the interdisciplinary clinical social work practice. Interdisciplinary curriculum scholars note the importance of standardizing the “objectives, outcomes, and competencies expected for each discipline” (Newhouse & Spring, 2010, p. 315). Thus, our findings offer an empirically determined taxonomy to assist clinical social workers to frame their contributions in operational terms that are easily recognized by other health disciplines and clearly defined for measurement and evaluation. We demonstrate here the potential disciplinary contributions that social work brings to interdisciplinary teams as part of the larger national effort to improve the overall quality of health care. This taxonomy may help clinicians demonstrate their clinical effectiveness and utilize evidence informed interdisciplinary approaches with patients and their families. The recent passage of the Patient Protection and Affordable Care Act (ACA) (2010) indicates that health care quality improvement programs should “assist health care providers in working with other health care providers across the continuum of care” and should work at “engaging patients and their families in improving the care and patient health outcomes” (The Patient Protection and Affordable Care Act, 2010). The law offers a unique opportunity for social workers to participate in teams intended to increase quality while reducing costs. BACKGROUND For more than a century, social workers engaged in interdisciplinary collaboration and practice have worked from a values-based commitment to provide the best available care to vulnerable populations, to develop interventions aimed at health promotion and disease prevention, and to maintain 534 P. Maramaldi et al. a biopsychosocial perspective on health care. The interdisciplinary functions and patient-centered perspectives currently espoused by the ACA are for social work, essentially a return to the roots of the medical social work more than a century ago. At the turn of the previous century, providers treating low-income and immigrant populations in large urban hospitals—in cities such as New York, Baltimore, and Boston—observed the interactive nature of psychosocial and biological conditions, and attempted to address those issues in part through what we now call social work (Berkman & Maramaldi, 2001). HISTORICAL CONTEXT: WHAT IS OLD IS NEW In her seminal 1915 book on social work in hospitals, Ida Cannon, generally known to be the founder of medical social work (Rehr & Rosenberg, 2006), reflected on her early years when she was invited to Boston by Richard Cabot, who was a Professor of Medicine at Harvard. Her writings related her cross-disciplinary experiences at the Massachusetts General Hospital (MGH) and her training at the Simmons School of Social Work, which were both affiliated with the Harvard Medical School. She posited that the charge of the hospital social worker was to assume the role of “interpreter,” and to bridge the communication gap between patients, families, and other providers. Almost a century later, the Institute of Medicine (IOM) report (2008) on meeting psychosocial health needs for the whole patient underscores the importance of fostering communication. The IOM report states that the entire medical team should work to enhance communication with the patient and family. Patient–provider communication—meaning team members’ listening and speaking with patients—is a critical element of diagnosis, treatment, and discharge. More recently, the ACA (2010) calls for providers to work efficaciously across disciplines to meet patient-centered objectives. The Act has led to the emergence of accountable care organizations (ACOs) aimed at improving quality while containing costs (Fisher & Shortell, 2010; Walker & McKethan, 2012). Given the current demands to shorten hospital stays, the extension of treatment across the continuum of community care, and ubiquitous barriers to patient–provider communication, social work—with its focus on person-in-environment—is ideally suited to facilitate meaningful interactions between patients, families, and interdisciplinary teams. The communication that Cannon described in 1915 was intended to increase what now falls under the rubric of health literacy. For the purposes of this article, health literacy refers to “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (The Patient Protection and Affordable Care Act, 2010, p. 473). The American Medical Association (AMA) Foundation (2008) has estimated Interdisciplinary Medical Social Work 535 that as many as 38% of Americans have limited functional health literacy. Communication strategies, such as encouraging patients to ask questions and verifying their comprehension, have been recommended first steps to enhance health literacy (The Joint Commission, 2007). Social workers on interdisciplinary teams can serve a critical role in addressing the growing national health literacy concerns. Moreover, interdisciplinary teams are ideally positioned to implement effective communication strategies (Kripalani, Jackson, Schnipper, & Coleman, 2007; Oates & Paasche-Orlow 2009). The IOM (2004) suggests that the patient’s diagnosis, treatment, and discharge will be favorably enhanced when interdisciplinary teams facilitate clear consistent communication in a way that is culturally and linguistically relevant for the patient. The spirit of the 2004 report is remarkably similar to Cannon’s 1915 call for social work’s role in promoting communication between patients, families, and providers during hospitalization. From the earliest days of the profession, social work has been uniquely positioned to bring psychosocial considerations into interdisciplinary discourse in acute-care treatment (Berkman, 1996). A century ago, Cannon argued for interdisciplinary collaboration before the term was widely recognized. She stated that the social worker must “have the technical skill of the social expert, and the ability to adapt that skill to the medical institution … she should also have the power to insist that the social point of view, as well as the medical, receives its due recognition” (Cannon, 1915, pp. 181–182). Starting with diagnosis and the subsequent development of an evidenceinformed treatment plan (Cowles, 2003; Dziegielewski, 2004), expedient optimization of physical well-being of the identified patient through medical intervention is the primary focus of hospitalization (Small et al., 2007). Once patients are medically stable, understanding their home environment and resources is a key element of effective interdisciplinary care, especially when discharge plans are intended to extend treatment into the patients’ community (Bronstein, 2003; Clark et al., 2005; Zimmerman & Dabenko, 2007). Planning for the whole patient, in the context of his/her environment increases well-being, diminishes the likelihood of medical complications, and decreases relapse (Berkman, 1996; IOM, 2008). Family-centered care (American Academy of Pediatrics, 2003; IOM, 2001; Johnson et al., 2008) requires a diagnosis and subsequent treatment to include psychosocial factors such as the patient’s and family’s perceptions of health and illness, cultural beliefs, environmental, and social support factors that may impede compliance with medical regimen (Bronstein, 2003; Zimmerman & Dabenko, 2007). The IOM (2008) report on meeting psychosocial health needs for the whole patient supports communication in family-centered care. It posits that the partnership between the interdisciplinary provider team and the patient/family is the key to identifying, or assessing the psychosocial needs in any given case. Although the focus of 536 P. Maramaldi et al. the report is cancer care, it underscores the importance of medical teams engaging patients, family caregivers, and community-based providers in the development of viable treatment and discharge plans that will sustain health and well-being. This is also consistent with the principles of ACOs to create optimal care plans that are evidence-based and include the patients’ circumstances (Walker & McKethan, 2012). Previous empirical research indicates that the overlap of professional competencies (D’Amour, Ferrada-Videla, Rodriguez, & Beaulieu, 2005; Pike & Wandel, 1991; Satin, 2008) is a key component to interdisciplinary synergy (Newhouse & Spring, 2010). As a result, provider awareness of their function within the array of disciplinary competencies is critical to the creation of a cohesive interdisciplinary team (Baker, Day & Salas, 2006). Interdisciplinary research indicates that team success hinges on the identification of roles, competencies within these roles, and the overlap between roles (Baker et al., 2006; Newhouse & Spring, 2010). CONCEPTUAL FRAMEWORK: INTERDISCIPLINARY COLLABORATION Interdisciplinary collaboration in hospitals occurs among professionally trained specialists representing medicine, nursing, clinical social work, psychiatry (including psychology), nutrition, chaplaincy, and other ancillary disciplines. Interdisciplinary teams assign roles based on disciplinary competence. The hallmark of effective interdisciplinary collaboration is members’ ongoing learning about other disciplines, flexibility and overlapping of roles when competencies permit (Cowles, 2003; Dziegielewski, 2004). By contrast, multidisciplinary teams know other disciplines, plan together, and avoid intrusion on the practice domain of other professions. While competence and identity are developed within one’s discipline on multidisciplinary teams, there tends to be little or no functional overlap between disciplines (Satin, 2008; Schofield & Amodeo, 1999). Satin (2008) frames overlap in interdisciplinary approaches based on spheres of professional competence. Primary competence refers to unique or superior expertise associated with a specific discipline. Secondary competence refers to spheres where one’s discipline provides the expertise, training, and licensure to perform functions that overlap with another discipline’s area of primary competence. Tertiary competence refers to spheres where one has little or no specialized competence; anyone on the team can perform that function. While each discipline may have its own designated primary, secondary, and tertiary competencies, professional competencies overlap, particularly in today’s climate of increased trainings and specializations. Research findings indicating strain between physicians, nurses, and Interdisciplinary Medical Social Work 537 social workers (Cowles & Lefcowitz, 1995; Reese & Sontag, 2001) suggests a need for greater role definition and competency measures. During the current investigation, we observed that even teams with high levels of cohesion and familiarity experienced tension regarding task-allocation and role definitions, often between nurses and social workers in regard to psychosocial issues. Empirical investigations (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000; Netting & Williams, 1996) indicate that psychosocial assessment and intervention are no longer an exclusive domain of social work. There is, however, some agreement that clinical social work’s primary competence is to address psychosocial concerns in the biopsychosocial context (Beder, 2006; Berkman, 1996; Cowles, 2003; Dziegielewski, 2004). To varying degrees, physicians and nurses increasingly recognize that social workers’ primary competence in psychosocial and environmental aspects of cases enhance treatment and improve outcomes (Keefe, Geron, & Enguidanos, 2009; Rock & Cooper, 2000). Existing literature on interdisciplinary medical teams has tended to focus on social workers and physicians views about collaboration (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000), efficacy of differing collaborative styles of physicians and social workers (Abramson & Mizrahi, 2003; Globerman et al., 2003), and social workers’ perspectives regarding their roles in the medical setting (Abramson & Mizrahi, 1996; Cowles, 2003; Kitchen & Brook, 2005; Mizrahi & Abramson, 2000). Few empirical studies have investigated collaborative roles and relationships in the same setting or services (Mizrahi & Abramson, 2000). Published studies that have examined team members’ roles and relationships in the same setting or service focused on hospice, palliative, and geriatric care (Colón & Otis-Green, 2008; Oliver & Peck, 2006; Waldrop, 2006). The study reported here identifies social workers’ perceptions of their primary psychosocial competencies within interdisciplinary medical teams, which—to our knowledge—has not been empirically investigated and published. PURPOSE OF THIS STUDY The purpose of this exploratory study was to document the historically grounded disciplinary competencies of clinical social work within the context of interdisciplinary teams in medical settings. The stakeholder-driven aims of this participatory action research study were to: (1) identify social workers’ perceptions of universal elements of clinical practice on interdisciplinary teams and (2) develop an evidence-based taxonomy of interdisciplinary practice skills and competencies based on the experiences and observations of clinical social workers. Due to limited resources, the inclusion of other disciplines was beyond the scope of this study. The intent of the second 538 P. Maramaldi et al. aim is to help social work clinicians frame their contributions to teams with the accuracy and rigor required in medical settings. The study answered the research question: What are perceptions of social workers about the disciplinary functions, skills and competencies of clinical social work on interdisciplinary teams in acute care treatment settings? METHODS Participatory action research (PAR), is a collaborative research approach designed to understand and improve on a community’s practices while empowering the population of interest (Glasson, Chang, & Bidewell, 2008). A research partnership is created between a community and researchers to increase knowledge and understanding of a given phenomenon and integrate the knowledge gained to improve outcomes (Israel, Eng, Schulz, & Parker, 2005). The phenomenon of interest in the current study was the perception of socials workers about their disciplinary functions, skills, and competencies on interdisciplinary teams in hospital settings. Our approach was adapted from a nursing study that used elements of PAR, to collect empirical evidence to improve clinical practice (Glasson et al., 2008). We utilized PAR to empower social workers in their community, the hospital setting, to utilize their clinical knowledge to improve their clinical processes and outcomes. Table 1 summarizes the steps that we took in the PAR approach to improve clinical practice. TABLE 1 Summary of Actions Taken in the Participatory Action Research Process Research action Action taken in current study Reflecting Research scientist presented ideas for participatory action research aimed at improving practice. Specific research topics were discussed. Planning Clinical staff overrode researcher and set aims and questions to better reflect stakeholder interests Implementing Extensive review of archival and current literature resulted in decision to develop taxonomy of social work clinical practice in interdisciplinary settings Observing outcomes Social work clinicians, clinical director, and scientist used deductive findings to develop a conceptual model, which was used to frame inductive observations of interdisciplinary practice Feedback During weekly meetings, the research team reviewed individual cases with the aim of identifying universal rather than case specific functions Replanning Clinicians, clinical supervisor, and scientist took findings identified as universal functions back into practice, supervision, and observations seeking to identify new functions until saturation was attained Adapted from Glasson et al. (2008). Interdisciplinary Medical Social Work 539 While the steps in Table 1 are presented in a linear manner, this process was dynamic and interactive. During the planning phase of the PAR process, the clinicians disagreed with the research scientist’s suggestions and provided goals and aims that better reflected their interests. Thus, the goals, aims, and research questions were not dictated by one individual, the research scientist, but by the group most affected by the issue similar to the overall goals of PAR. As a result, the social worker participants and the research scientist reviewed archival and current research on the role of the hospital-based social worker. In reviewing their current practice, the social worker participants concluded that, in general, medical social workers tend not to fully articulate the exact functions that they perform on interdisciplinary teams. Descriptors like “providing support,” “counseling,” and “working with the family” did not capture the full extent of their interdisciplinary clinical practice. The research team decided to develop an empirically driven taxonomy of the universal functions skills and competencies of clinical social work on interdisciplinary teams. Subjects Five members of the core participatory panel investigated the work performed by a total of 37 expert clinical social workers in a large New England teaching hospital for a period of twelve months. The core research panel consisted of three clinical social workers assigned to interdisciplinary teams in Pediatric Services, a senior clinical director, and the social work research scientist. Social work was the only discipline included in the core research panel, which will be discussed as a limitation below. DESIGN Using participatory research methods (Coghlan & Brannick, 2005; James, Milenkiewicz & Bucknam, 2007), the panel participated in every phase of the research study from the development of research questions through the analysis, and finally to the article preparation. The research collaboration was driven by the principles of participatory research (Israel et al., 2005; Glasson et al., 2008). We used deductive approaches by reviewing archival and current published peer-reviewed literature, and inductive approaches by reflecting on practice using a retrospective qualitative case review methodology (Anthony & Jack, 2009; Yin, 2008). For the first phase of the study, five members of the core participatory panel met weekly, reported deductive findings from archival sources and current literature about the role 540 P. Maramaldi et al. of social work in multidisciplinary medical settings. This led to the identification of a conceptual model—interdisciplinary collaboration—and the development of the research questions and methodology. During the second phase, the panel met weekly and engaged in a retrospective, focused debriefing about cases and developed and refined the taxonomy of clinical practice and competencies on interdisciplinary teams. Our deductive findings from archival material and current scientific literature informed our inductive observations. We continued the process of reviewing case exemplars to identify competencies until we reached a point of saturation where no new competencies were identified (Glaser & Strauss, 1967). The PAR process enabled the community of social workers to determine their own competencies and to develop an operational taxonomy that defined their role and functions. Deductive Data Collection We conducted archival research in the Massachusetts General Hospital and the Simmons School of Social Work historical archives with expert librarian assistance. Each of these institutions has extensive medical social work archives dating to the earliest days of Ida Cannon’s work in each setting. Deductive findings from the archival material were remarkably relevant in the context of current clinical practice. The interdisciplinary nature of early medical social work emphasized the enhancement of communication among patients, families, and providers, which informed our inductive inquiry. Inductive Data Collection Using a retrospective clinical case review methodology demonstrated in the nursing literature (Glasson et al., 2008), we reflected on a sample of cases and documented the panel’s perceptions of specific social work functions on interdisciplinary teams. The panel used reflections and observations of their own interdisciplinary clinical work in the form of the clinician stakeholders’ personal case notes, not the formal medical record notations. Case notes were used because they tended to evoke more detailed information about social work functions than the more “sanitized” medical records. More specifically, the actual notes written in the medical record were not used because they tended to be abridged and also devoid of the current study’s focus on interactions with other disciplines. In addition, the notes used for this study were deidentified by each clinician stakeholder prior to the retrospective case review sessions in order to protect the confidentiality of patients as well as medical team members. A total of 43 cases were included in the final analysis. Interdisciplinary Medical Social Work 541 ANALYSIS During weekly research meetings, the core panel engaged in a process of identifying common themes (from the 43 cases studies and archival material) until we reached a point of saturation (Padgett, 1988; Glaser & Strauss, 1967). Case data were presented and discussed by the entire research panel, and then re-documented by the research scientist in summary format. The summary was then cross-checked by the entire panel for accuracy. It is important to note that social work was the only discipline participating in the case reviews due to the pilot nature of this study. Findings Universal elements of social work’s function on interdisciplinary teams were extrapolated from 43 cases reviewed for this exploratory study: rapid 360 degree screening (collection of case information from all available sources), assessment, psychosocial intervention, and referral. These functions may seem obvious and are recognized activities of medical social workers (Berkman, 1996; Cowles & Lefcowitz, 1992; Cowles, 2003; National Association of Social Workers, 1990). However, although limited by a single discipline’s (social work) perception, the findings reported here are empirical and frame social work’s disciplinary utility, skills, competencies, and expected outcomes in an interdisciplinary context. During the process of reviewing cases for common universal themes, we also discovered the importance of including the overt articulation of social work’s disciplinary contributions to the case, and stated expected outcomes to the interdisciplinary team. Adding interrelated expected contributions and outcomes to the taxonomy of social work’s disciplinary function brings social work in line with medicine and nursing on interdisciplinary teams. Much like a physician or nurse routinely state and record a planned procedure and its outcome, social workers can do likewise. Although limited by the pilot nature of this study, we found a level of parity among disciplines to occur in some teams but not others, which further supports inclusion of expected contributions and outcomes to the taxonomy. Social work participants on the panel also reported that the quality of their assessments and the related interventions appeared to be enhanced when they overtly stated the expected outcomes to other team members. As a result, we decided to include both social work contributions and outcomes—as interrelated skills and functions—in the taxonomy, presented in Table 2. Awareness and utilization of these interrelated functions appeared to empower social workers to overtly communicate their role and value to the interdisciplinary team. As discussed earlier, understanding competencies within disciplines is an important aspect of functioning interdisciplinary teams. During the retrospective case reviews, the research 542 P. Maramaldi et al. TABLE 2 Taxonomy of Social Work Functions on Interdisciplinary Teams Social work functions Brief description 360 Degree Screening Rapid assessment to identify risk Assessment Explanation of case across interdisciplinary perspectives as the bridge between the patient/family and the team Intervention Actions taken to enhance health and well being Referral Best attempt to connect case with community resources needed to carry interventions across continuum, beyond the hospital Expected Outcome Ensures patient focus, enhances accountability and quality, and contributes to evidence informed practice Contributions to Interdisciplinary Team Reiteration of social work’s unique contributions across professional competencies Competencies Needed Clinical skills and knowledge needed to perform functions team discovered the importance of identifying the competencies needed to contribute and plan outcomes in specific case exemplars. Including the category of competencies needed to perform the interrelated functions was also important to differentiate between core clinical social work competencies and advanced specialty training. The inclusion of competencies brings social work into greater parity with other disciplines that require advanced certifications and advanced training in specific areas of medical service. As a result, we found it important to include competencies as part of the taxonomy. The final taxonomy, therefore, included expected outcome, contributions to the interdisciplinary team, and clinical competencies needed. A case exemplar demonstrates the utility of the taxonomy. Case Exemplar In preparing this article, we discovered a lack of consistent and established protocol for publishing clients’ narratives and stories in psychological, psychiatric, and psychoanalytical journals. In the face of ongoing debates about protecting human subjects in articles such as this, we decided to follow the lead taken in psychiatric literature, to …

Seizing Interdisciplinary Opportunities in the Changing Landscape of Health and Aging: A Social Work Perspective.

Purpose of the Study: This paper is a revision of the Kent Award Lecture given at the Annual Meeting of the Gerontological Society of America held in New Orleans, Louisiana, in November, 2010. Design and Methods: This paper looks at the evolution in geriatric social work assessment and outcomes research and concludes with observations of the changing landscape in health and aging. Results: Since the 1960s, the policies and the context of health care delivery have changed many times as have geriatric health screening and assessment of patients in need of social health care services. Research on social–behavioral and environmental factors critical in measurement of outcomes of health care has progressed significantly as theories of care and the research technologies that allow us to study these factors have become more sophisticated. Implications: Researchers from multiple disciplines need to study the questions which can build the evidence necessary for empirically supported social policy direction. Opportunities in interdisciplinary geriatric assessment and measurement Seizing Interdisciplinary Opportunities in the Changing Landscape of Health and Aging: A Social Work Perspective Barbara J. Berkman, DSW/PhD* Columbia University School of Social Work, New York, New York. *Address correspondence to Barbara J. Berkman, DSW/PhD, Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027. E-mail: [email protected] Received March 11, 2011; Accepted May 06, 2011 Decision Editor: Rachel Pruchno, PhD An earlier version of this article (“Changing landscape in health and aging: Seizing the opportunity”) was presented as the 2009 Donald P. Kent Lecture on November 21, 2010, at the 63rd Annual Scientific Meeting of the Gerontological Society of America, New Orleans, LA. of outcomes, which are presented to researchers today, are highlighted. Key Words: Assessment, Multidisciplinary, Outcomes, Social-Behavioral Donald Kent believed, and practiced his beliefs, in the importance of linking research on aging to practice and policy. He wrote eloquently on policy issues and the need for researchers from multiple disciplines to study the questions that can build the evidence necessary for empirically supported social policy direction (Kastenbaum & Sherwood, 1972; Kent, 1964). It is my hope that this paper will bring renewed meaning to his words. Since the 1960s, when my academic trajectory began, the policies and the context of health care delivery have changed many times as have geriatric health screening and assessment of patients in need of social work services in the hospital and other health care settings. In addition, research on the social–behavioral and environmental factors critical in measurement of outcomes of health care has progressed significantly as theories of at Briscoe Library on October 2, 2013 http://gerontologist.oxfordjournals.org/ Downloaded from 434 The Gerontologist care and the research technologies that allow us to study these factors have become more sophisticated. Research by social workers has been conducted in this arena for 40 years, with practice-based research efforts linked to the ever-changing realities of our health policies, care systems, patients, and providers. This paper looks at the evolution in geriatric social work assessment and outcomes research from my personal perspective and concludes with observations of the changing landscape in health and aging. Opportunities in interdisciplinary geriatric assessment and measurement of outcomes, which are presented to researchers today, are highlighted. The 1960s An appropriate place to begin is the 1960s, a time when the number of social workers in hospitals was growing exponentially in response to an increasing need for the services they offered. John F. Kennedy, who exuded youth and energy, was elected President in 1960. The country was elated when we walked on the moon, and there were also impassioned public disagreements over the appropriateness of our engagement in the Vietnam War. And when President Kennedy was assassinated in 1963, as horrible as that was, the transition to Lyndon Johnson was relatively uneventful (Ebert, 1986). However, the mid-60s was a time of the civil rights movement and growing public calls for creating a society that offered equity for all, particularly minorities, the poor, and the elderly patients. President Johnson responded to this growing public concern with his “unconditional war on poverty,” with access to health care being a major initiative. In 1965, the Older Americans Act was passed, establishing the Administration on Aging and state agencies to address, in part, the social service needs of older people. In 1966, Medicare and Medicaid legislation was passed, giving support to teaching hospitals with an emphasis on the health of older adults and of the poor. President Johnson’s Great Society social programs, which focused on community action and education, became inseparable from medical care (Starr, 1982). Social work began to be viewed as a significant part of health service delivery in the academic medical center and as a necessity for identifying and dealing with inadequacies related to social, behavioral, and environmental issues, which affect patient’s health care outcomes. With the advent of Medicare and Medicaid, assessment of older hospitalized adults who were at risk for problems, which could negatively affect their health care outcomes, became extremely critical. Hospital floors were increasingly crowded with older patients whose discharges were being delayed because of the complexity of their health care and home care needs. Social work services were vital for such patients, but a deterrent to service delivery was the hospital social work casefinding system. Traditionally, this was a system that was dependent on referrals from doctors and nurses. Those patients whom they believed needed social work service were often referred during the last days of their long lengths of stay when their discharge planning was in crisis (Rehr & Gordon, 1967). The average length of stay of those patients who were referred to social workers was 39 days compared with 18 days for other older patients (Berkman, Rehr, Siegal, Paneth, & Pomrinse, 1971). In addition, there were concerns that because of the referral system, social work might be missing the most vulnerable of the older patients, specifically minorities and the poor (Gordon & Rehr, 1969). Hospitals needed a means of earlier valid identification and assessment of whom, among the increasing numbers of elderly vulnerable inpatients, would benefit from receiving social work services earlier in their hospitalizations. Thus, a major question for social work research was to identify characteristics of elderly hospitalized patients who had social–behavioral problems (e.g., difficulties in family relationships or in ability to follow posthospital care plans) and/or environmental problems (such as unsuitable housing) that might negatively affect the outcome of their health care and who could be helped by social workers. This study had not been done before, and in 1967, supported by a grant from Health, Education, and Welfare, Berkman and colleagues (1971) began recording daily admission data on 5,280 older patients admitted to Mt. Sinai Hospital in New York City, with a focus on the 520 patients referred to social work services . These data were basically sociodemographic and found that 12 factors accounted for only 12% of the variance in who were referred and who were not. However, the most significant variable was extended lengths of stay, and the major question became whether there were social, psychological, and environmental factors, which could be identified early in a patient’s length of stay, which were associated with long hospitalizations. Vol. 51, No. 4, 2011 435 The 1970s By 1970, the halcyon days of available resources for health care service delivery were waning. The Vietnam War had drained federal monies and in the mid-70s, 10 years after Medicare and Medicaid came to be, there was an unprecedented rise in health care expenditures (Blendon, 1986). With a weakened economy, the war on poverty disappeared. President Richard Nixon spoke about a crisis in costs of health care (Starr, 1982). Medical care was under scrutiny, and regulation was the “only game in town.” Other deficiencies were also reported as the United States “had higher infant mortality rates and lower life expectancies than most Europeans” (Starr, 1982, p. 382). By 1972, Medicare and the Joint Commission for Accreditation of Hospitals (JCAH) both required utilization review of the necessity of admission, duration of stay, readmissions, and professional services utilized (United States. Congress, Senate, 1972). The major health care issue was costly lengths of stay. Social work researchers believed that patient- and family-related social, behavioral, and environmental factors recorded in social work records would predict patients at high risk for extended lengths of stay and who needed social services. And so, in the early 70s, a series of studies to test those assumptions were conducted (Berkman & Rehr, 1973, 1974; Rehr & Berkman, 1973). These social work–specific research efforts identified some important social–behavioral factors. Stress related to becoming a dependent patient, psychological issues in adjusting to illness and hospitalization, and problematic social relationships were important factors in identifying high-risk patients. But still, these factors explained very little of the variance in who did, or did not, need social work services. By the late 70s, many health professionals were beginning to try to explain the reasons for extended lengths of hospital stay and early preventable readmissions (Rothberg, Pinto, & Gertman, 1980; Sang-O, Lyons, & Payne, 1979; Sherman & Flatley, 1980; Westphal, Frazier, & Clinton Miller, 1979). Social work researchers realized that the perspective of a single discipline was not fruitful. What was needed were data from medicine and nursing. However, the practice in the hospital at that time was not collaborative. The professions were not there yet. And so, utilizing a broader database, through medical and social work records, social workers identified that severity and chronicity of illness were critical factors and were, of course, related to extended length of stay, complex patient posthospital needs, and the need for social work help (Berkman, Rehr, & Rosenberg, 1980). But these efforts did not account for a great deal of the variance in differentiating which elders were “at risk” and which were not. Instead of the originally reported 12%, these factors accounted for 28% of the variance, but there was still a high false-positive rate in the screening process. Two thirds of the time, our screening was inaccurate, and social workers did unnecessary time-consuming assessments on patients and families who did not need social work help. The 1980s By the 1980s, Ronald Reagan was President, and cost control was an even greater driving force. So the country enacted a number of cost containment measures, one of which, in 1983, was a prospective payment system through which hospitals received a fixed payment on the basis of a medical diagnosis. Diagnoses were grouped in categories called Diagnostic-Related Groups (DRGs). The diagnostic specificity (e.g., Diseases and Disorders of the Respiratory System, Diseases and Disorders of the Circulatory System) was recognized as a critical variable in determining reimbursement rates and in reviewing costly hospitalizations and readmissions. Specific disease categories were significant as biomedical factors, which could not be ignored in our thinking about length of stay and discharge planning. In addition to meeting government mandates to control rising costs, quality assurance mechanisms were being implemented to address issues around quality of care. In 1980, the JCAH standards on quality assurance mandated that discharge planning should be initiated through early determination of need, such as use of early screening for high social risk patients (JCAH, 1980). By 1982, most hospitals had formed utilization review committees to monitor lengths of stay, readmissions, and quality of services delivered. These committees were frequently composed of hospital-based professionals such as nurses, physicians, and social workers who had similar research interests and skills and had been picked by their departments to collaborate on utilization reviews. There was a uniform interdisciplinary objective—to address the mandates for reducing length of stay and readmissions while protecting quality of care for older patients. 436 The Gerontologist It was also during this time, in the 80s, that I joined the social work department at Massachusetts General Hospital (MGH), an affiliate of Harvard Medical School, and I became one of the founders of the MGH Institute of Health Professions. The philosophy of the Institute’s education for their students who were to be nonphysician health care providers (i.e., dieticians, nurses, physical therapists, and social workers) was interdisciplinary in that they believed that certain key knowledge elements should be taught across the board with disciplines learning together. And it was also during this same time period that I joined the interdisciplinary practice and research efforts, which were being conducted by members of the Harvard Medical School’s Division on Aging (Berkman, Campion, Swaggerty, & Goldman, 1983; Campion, Jette, & Berkman, 1983). Concomitantly in the mid-80s, in their efforts to establish valid floor staffing patterns based on DRGs and disease-specific patient needs, nursing at MGH began to use the computerized Medicus Nursing Productivity and Quality Patient Care Classification (NPAC) data system, which was very sophisticated for the times. Nursing and social work researchers realized that multidisciplinary data inputs were essential to the study questions they were pursuing, and they believed that in order to improve the measurement of health care outcomes, disease-specific studies, as were available through the DRG classification system, were necessary. Now, new research avenues opened. Collaboration began between social work and nursing colleagues who started to study standardized functional data available on the NPAC system as well as additional social work and medical data. Studies of assessment and outcomes of discharge planning for elderly cardiac patients, a high-risk group in need of multiple services for posthospital care planning, were undertaken. The assessment data derived from one such study reduced the false-positive screening rate of cardiac patients needing social services from 65% to 26%—a very important step as social work staff time was becoming a precious resource (Berkman, Millar, Holmes, & Bonander, 1990). Again in collaboration among social work, medicine, and nursing, research focused on the rehospitalization of elders with cardiac disease reported that the rapidity of physical and functional deterioration was key assessment indicators predicting early recurrent rehospitalization (Berkman, Millar, Holmes, & Bonander, 1992). And so, by the end of the 80s, the research perspective at MGH had now clearly become interdisciplinary in terms of education and patient care as well as multidisciplinary in relation to the data systems needed to answer significant patient care outcome questions. This model was biopsychosocial. In brief, the interdisciplinary contributions in the 80s were efforts that created a very exciting and fruitful research environment. The 1990s In the 1990s, we saw the dissolution of the Soviet Union, and President Bill Clinton was a dominant political figure. The United States experienced its longest period of economic expansion, and we began to have widespread use of computers and the Internet. The early research work of the 60s set in motion a research direction that basically remained the same for over thirty years. What changed by the 1990s was the health care policy and practice context of the research, the technological capabilities, and the firm conviction held by many researchers of the necessity of interdisciplinary collaboration in assessment and outcome research in clinical health. The fee-for-service payment system began to be under scrutiny, and a managed care capitation payment system was initiated (Shortell, Gillies, & Devers, 1995). And the use of managed care organizations for the administration of medical benefits was a growing trend (White, Simmons, & Bixby, 1993). Prior to this time, our health care system had been based on a paradigm of unpredictable acute disease. In the 1990s, increasing numbers of elderly patients were living longer with multiple chronic health problems. In the new health care paradigm characterized by chronic illness, there was awareness that chronic illnesses and their progression are determined by multiple factors, such as an individual’s physical, social, and psychological status as well as genetic endowments, cultural backgrounds, and health care accessibility issues (Berkman, 1996). The focus of care became primary care with an emphasis on disease prevention and health promotion (Pawlson, 1994). It was recognized that positive health care outcomes could only be effectively achieved with collaborative practice among multiple disciplines. There was a surge of interest in new models of hospital-based short-term care as well as models of long-term care, home care, and community care. Short-term collaborative practice teams were Vol. 51, No. 4, 2011 437 effectively used by physicians and nurses in hospital intensive care units. And the substantial evidence of the benefits of collaborative care in improving depression outcomes in primary care was reported (Richards et al., 2006). The accepted value of collaborative care in primary care was also clearly evidenced in the 1997 National Institute of Mental Health call for proposals for demonstration projects, which would prevent suicide among elderly patients in primary care, a trial which was to test a “collaborative care” model involving nurses and social workers with physicians in primary care practices working together to better manage chronic conditions and improve identification of older patients in need of treatment for depression (National Institutes of Health, 1997). A prime example of collaborative long-term care beginning in the 90s was the Program of All-Inclusive Care for the Elderly (PACE). Originally authorized in the Omnibus Reconciliation Act of 1986 as a demonstration program, in 1997, PACE became a regular part of Medicare targeting individuals who meet Medicaid nursing home eligibility criteria. Through the use of a multidisciplinary team approach, PACE integrates social and medical services primarily through a combination of adult day health care and home care (Eng, Pedulla, Eleazer, McCann, & Fox, 1997). And another excellent example of collaborative long-term care was the Social/Health Maintenance Organization (S/HMOII) demonstration, implemented in 1996 in Nevada. It presented a unique coordination approach for collaborative care services, such as case management, personal attendant care, transportation, day care, and social services (Kane & Homyak, 2003; Kane, Homyak, Bershadsky, Lum, & Siadaty, 2003; Newcomer, Harrington, & Kane, 2002). Educational multidisciplinary health care training projects were also introduced in the 90s. For example, in 1995, the John A. Hartford Foundation (JAHF) funded its Geriatric Interdisciplinary Team Training Program with the understanding that if health care professions were to continue to follow strict disciplinary lines, they would leave students unprepared for implementing patient care plans in an interdisciplinary setting (JAHF, 2007). However, the issue not yet addressed was that we would never achieve validity in our health care outcomes research without the input of standardized data from the perspective of multiple disciplines. The 2000s In this first decade of the 21st century, we have experienced serious challenges as well as historic milestones. There have been horrific events; 9/11, the wars in Iraq and Afghanistan, Hurricane Katrina, and a global recession. But our first African American President was elected, and the continuing yearly debates (for almost 50 years) regarding health care reform resulted on March 23, 2010, with President Obama signing into law the Patient Protection and Affordable Care Act (PPACA; United States. Congress, Senate, 2010). The practices of the 90s have had a significant impact on health care practice in the first ten years of the century and have influenced many of the provisions in the PPACA. The landscape of delivery of care to older adults has been evolving rapidly with the majority of patients receiving their medical care in ambulatory primary care settings (Westphall, Mold, & Fagnan, 2007). Disease prevention and health promotion are receiving more recognition with older adults because research has shown that adults who engage in evidence-based self-management programs can remain healthy longer than those who do not (Tilly, 2010). Considerable efforts in the 1990s addressed quality and costs in Medicare, and teams became an important feature of health care delivery in acute and long-term care and in primary care. In the PPACA, interdisciplinary health teams are envisioned as a means to enhance quality while lowering health care costs. For example, starting this year, there is a new division within the Centers for Medicare and Medicaid Services known as the Center for Medicare Innovations, which is charged with establishing innovative methods of furthering the quality/cost initiative (Segal, 2010). One of the pilot programs being tested is “medical homes,” with its concept of a personal physician leading a team of practitioners and allied health professionals who are responsible for the health care of patients with chronic illnesses. In this model, community-based “health teams” are to be established as integrated primary care practices within community areas served by the hospital. Evidence-based practice was also a growing movement in the 90s and is now being utilized in many community-based organizations serving older adults (Whitelaw, 2010). Valid outcome measures are critical to the development of evidence-based interventions as well as to the evaluation of the component parts of programs in aging services. 438 The Gerontologist For example, outcomes representative of the work of many disciplines should be included in the assessment of the effectiveness of the varied components in a health promotion program. An example of this is diabetes management, which offers a number of services such as nutrition guidance, physical exercise programs and counseling (Rahman & Applebaum, 2010). The evolution of clinical assessment measures in health and aging has influenced the attention given to clinical health outcomes measures in the new health care reforms act. The PPACA mandates evidence-based changes aimed at improving the quality of health care, and so the Patient-Centered Outcomes Research Institute is now being created (H.R. 3590-625). Among this, Institute’s responsibilities are identifying: national priorities for research with an emphasis on chronic conditions, gaps in evidence in terms of clinical outcomes, and practice variations and health disparities in terms of delivery and outcomes of care. These objectives are very significant for our practice and research with older adults. The question is how should these responsibilities be interpreted if they are going to prove fruitful? First, in examining clinical health outcomes, it is not clear, based on the language of the bill, if, or how, the new Institute will conceptualize interdisciplinary health outcomes research. Health outcomes have, too frequently, been defined narrowly, focusing on traditional clinical indices, which measure elements within the biological component of the biopsychosocial model. It is time to go beyond traditional physiological data to include psychological, social, and behavioral data in the assessment of patient needs and clinical outcomes. Significant among such research efforts has been the work of the Society of Hospital Medicine’s (SHM) Hartford Discharge Planning Improvement Initiative. SHM’s Project Boost Implementation Guide is used to identify patients with complex discharge needs. Such needs are to be addressed prior to discharge, or patients are considered at high risk for adverse clinical events. The Guide suggests attention to caregiver support issues as well as to language and cultural factors, which are necessary to bolster patient’s understanding and acceptance of services, such as home health care (Williams et al., 2010). Measurement of outcomes in older adults is frequently, if not always, affected by the complex multidimensionality of their physical, psychological, and social challenges. Measuring outcomes of interventions usually should not be limited to a single factor or dimension. The high rates of cooccurring health and mental health conditions among chronically ill older adults complicate the assessment of outcomes for determining the effectiveness of interventions. As an example, older adults experiencing cognitive impairment may simultaneously confront significant psychological, social, and physiological impairments, and measuring outcomes of treatment activities may require an array of measures across multiple domains during both the assessment process and after the intervention (Berkman & Kaplan, in press). The multidimensional factors that are critical in determining patient care outcomes must be defined and corresponding priorities for research developed. Without the presence of multiple disciplinary practice perspectives, critical biopsychosocial–behavioral factors may be understated or overlooked and the validity of the outcomes compromised. The other major focus of the Patient-Centered Outcomes Research Institute is to address health disparities. Disease risk factors, as well as responses to treatment, caregiving, and overall quality of life, may be affected by race, ethnicity, gender, and socioeconomic status (Berkman, Silverstone, Simmons, Howe, & Volland, 2000; MacKenzie, 2000; Maramaldi & Cadet, in press; Yee, 1997). As many researchers have demonstrated, issues of health disparities, in terms of both delivery of services and differential patient preferences, need to be “front and center” when examining clinical outcomes. Since 1997, managed care plans administered by Medicare have been reporting quality of care measures utilizing the Health Plan Employer Data and Information Set. In early studies, disparities in health care quality between black and white patients were reported. Data from 1997 to 2003 indicate that Black and White elders enrolled in Medicare-managed care plans showed improvements on a number of clinical performance measures (Trivedi, Zaslavsky, Schneider, & Ayanian, 2005). And although many are committed to developing culturally sensitive approaches to service, particularly troubling is the lack of culturally sensitive outcome measures, which are necessary to develop evidence-based practices. The heterogeneity and demographic changes in the older adult population are associated with health care and service delivery challenges that demand more effective outcome measures that will deepen our understanding of the interactions between health Vol. 51, No. 4, 2011 439 and culture, such as the effects of cultural beliefs on self-care practices and acceptance of health services (Berkman & Kaplan, in press). Researchers must commit to working toward these needed outcome measures or our data will lack validity. When social–behavioral and cultural factors are included in assessment of patient needs, and appropriate interventions to address these needs are put in place, then clinical patient outcomes are significantly improved. Our assessments and outcomes research must reflect these important dimensions. In light of current health care reforms, which are significant in design, potentially significant in effects, and probably subject to a number of sizeable alterations in health care legislation and oversight, collaborative research in geriatrics and gerontology on outcome measures is more essential than ever. The Gerontological Society of America can be a significant base for interdisciplinary collaborative action in this arena. To do this, professionals must leave comfortable discipline-specific research silos and seize the opportunity to work together on developing and improving biopsychosocial health care outcome measures and making clinical health research as valid and as relevant as possible. References Berkman, B. (1996). The emerging healthcare world: Implications for social work practice and education. Social Work, 41, 541–551. Berkman, B., Campion, E., Swaggerty, E., & Goldman, M. (1983). Geriatric consultation team: Alternate approach to social work discharge planning. Journal of Gerontological Social Work, 5, 77–88. doi:10.1300/ J083V05N03_07 Berkman, B., & Kaplan, D. (in press). Outcomes measurement and gerontology: What we’ll need as the United States grows older. In J. Magnabosco, …

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

2

Comprehensive Assessment

Tolulope I. Moses

Master of Social Work, Walden University

SOCW-6111: Clinical Social Work Practice

Dr Kristie Abbs

October 2021

Comprehensive Assessment

Introduction

The Cortez family is made up of David, Miguel and Paula. In this comprehensive assessment, the client will be Paula. Miguel is Paula’s son, but she had to give up custody of the son due to her medical state, and as a result, she has been isolated from her family since she has been experiencing both emotional and physical abuse from them. Paula has been diagnosed with Hepatitis C, HIV, bipolar disorder and circulatory problems (Plummer et al., 2014). In this assessment, she becomes pregnant and is forced to decide in keeping the baby or aborting it. In this paper, therefore, two assessment models will be used to identify the client’s strengths as well as analyze two multidisciplinary approaches and the social worker’s mode in her case.

Paula’s Assessment Models.

The two assessment models that will be discussed in accordance with Paula Cortez’s case are as follows.

Psychosocial assessment. Paula is a 43-year-old woman living with HIV. She left her family in Columbia to come and live in the US. Paula has one child, Miguel, and she is divorced from the child’s father, David. Despite her financial challenges, Paula has both physical and mental illnesses (Plummer et al., 2014). She also has a history of not following the medical prescriptions to the letter. The client has a high school education, which helped her acquire a college degree, and she is also fluent in English and Spanish. Due to Paula’s health conditions, her ability to commute to work and do other daily activities has been constrained. She is diagnosed with Hepatitis C, HIV/Aids, and bipolar disorder (Plummer et al., 2014).

Strength-Perspective Assessment. Paula Cortez is a 43-year old Latina woman living in New York City. To help her be employable in the near future, Paula has a high school education as well as a college degree and is well acquainted with painting (Plummer et al., 2014). The client uses her painting skills to express her creative side by painting various fashionable designs that express her view of the world. Despite the brain infection that limited her mobility and paralyzed her dominant hand, Paula overcame that and learned to use her non-dominant hand in her creative arts. Above that, she received assistance from professionals to stabilize her state of mind and help her strive to achieve her desired goals.

Areas of Strength in Paula’s Case as per the Cowger Article

In this case, Paula portrayed various emotional and physical strengths; she also exhibited interpersonal skills and the ability to have positive thinking, a part of the multidimensional assessment (Cowger, 1994). Above that, Paula experienced external strengths from family, community groups, medical professionals and other organizations and institutions. Despite the medical predicament that Paula is in, she avoids rush decisions when contemplating on aborting or keeping the baby; instead, she thought it out carefully and had to keep the pregnancy even after getting doubts and scepticism from some medical professionals who thought that either Paula or the baby would not survive. Her good interpersonal skills made Paula a likeable person, hence why most medical practitioners at the hospital always wanted to be around her.

Perspective-Multidisciplinary team.

The medical professionals where Paula received treatment thought it wise for her to get rid of the pregnancy because of her medical conditions that might lead to giving birth to an unhealthy baby. Besides that, they also argued that Paula might get more health complications if she kept the pregnancy and gave birth. Additionally, the doctors believed that since she was paralyzed on her dominant hand and was also getting weak, she could not be in a position to take care of a newborn.

From the assessment above, the social worker did not exhibit any bias but displayed a (1.01) commitment to the client as per the NASW code of ethics (Simpson, 2020). Additionally, the social worker was supposed to ensure that Paula received adequate health care that she required and other social services such as in-home child care assistance, baby crib and other items, WIC, and Medicaid. Generally, besides the doctors’ advice and recommendations for Paula to terminate the pregnancy, the social worker was supported in Paula’s case, and in the long run, this helped her come into well-thought decisions to keep her pregnancy and give birth.

The model used by social Workers in the Assessment.

In Paula’s case, the social workers seem to be using the collaborative approach in their assessment. The social workers use various assessment models to understand the difficult and somehow complicated situations, such as what Paula is going through, to create an understanding and friendly environment between the professionals and the client (Berg‐Weger, 2019). A comprehensive client assessment was also utilized to understand important details about the client, such as asking about Paula’s mental status and health, physical health and capabilities, cognitive ability, and prior psychiatric related diagnosis.

Potential for Bias When Choosing an Assessment Model

While professionals always strive to choose the most suitable assessment models without any bias, there is a possibility of potential bias in some instances. For instance, potential bias during diagnosis may focus on the problem a client faces and then end up providing a treatment plan that is not well backed up by sufficient data. In other instances, there could be some bias in other assessment models where the clients have self-reported their diagnosis questions inaccurately, and if the doctors or the practitioners do not do proper diagnosis, then the treatment offered might not be evidence-based. Additionally, choosing only one assessment model might lead to bias since some instances might require both environmental and psychosocial assessment. For instance, Paula’s case requires an emphasis on the client’s strengths instead of self-diagnosis of the mental problems or reported medical problems. Therefore, a single approach will not be appropriate in most instances to avoid bias.

Strategies to avoid the potential for biases.

As a social worker, I will ensure that the biases mentioned above do not occur by employing a couple of following strategies. First, I will emphasize understanding what the client is going through both physically, mentally and emotionally. This way, I will employ various assessment models to avoid focusing on a single issue or, rather, just the reported pain points from the client. To ensure that the client gets appropriate attention, I will connect her to other good therapists and counsellors who will help her make informed decisions based on her health conditions before deciding whether to keep the baby or terminate the pregnancy. Being a strong and zealous woman, Paula has exhibited self-determination that needs to be maintained and protected by receiving a lot of encouragement from various people around her. This can be achieved by encouraging her to collaborate with a multidisciplinary team to offer proper care for her various medical needs. Above that, Paula needs to be helped to overcome and learn how to deal with stigma, especially if people become aware that she is HIV positive. Also, based on her history of not completing or adhering to medical prescriptions, as a social worker, I will notify her of the potential risks involved in not completing her prescriptions or not following them.

References

Berg‐Weger, M. (2019). Social Work Practice with Individuals and Families.

Cowger, C. D. (1994). Assessing client strengths: Clinical assessment for client empowerment. Social Work, 39(3), 262–268.

Plummer, S.-B., Makris, S., & Brocksen, S. M. (2014). Sessions: case histories.Baltimore, MD: Laureate International Universities Publishing. Cortez Family (p23-25)

Simpson, J.E. (2020). New theories for social work practice: ethical practice for working with individuals, families and communities. Journal of Social Work Practice, 35, 112 – 114.