As Health Care Becomes More Complex
Health care delivery models increasingly rely on social workers and social worker case managers because of their specialization in identifying and meeting the needs of patients, post-discharge. Social workers are also healers...
“The aging of the U.S. population, greater incidence of complex health conditions, and the prevalence of multiple chronic conditions highlight the need for a holistic approach to physical and mental health.” (Harkey, 2017)
“The environments in which people are born, live, learn, work, play, worship, and age affect a wide range of health, functioning, and quality-of-life outcomes and risks” (Office of Disease Prevention and Health Promotion, 2016).
“As the "triple aims" of care, health, and cost are addressed across multiple settings and by a variety of disciplines, social workers now play an increasingly important role and will continue to do so in the foreseeable future.” (Harkey, 2017).
Enter the Social Worker
Social workers' whole-person perspective and skill set make them valued members of interdisciplinary health care teams. The social worker brings a patient-centered, holistic view—one that extends well beyond the patient's discharge from an acute care or subacute setting. Social workers enable teams to address multiple factors that influence health and wellness, including the social determinants of health. As a key member of the team, the social worker is often the one relied on most to address how to meet the person's needs back in the community.
Social Worker as Case Manager
Case management is defined as " a professional and collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs. Case management has been a key function of social work since the founding of the profession " (Commission for Case Manager Certification, 2015). As advocates on behalf of patients, case managers are obliged to coordinate care that is safe, timely, effective, efficient, equitable, and client-centered. Without a social worker, it may be virtually impossible for transdisciplinary health care teams to pursue a truly holistic approach.
Social Worker as Healer
The aging of the U.S. population, greater incidence of complex health conditions, and the prevalence of multiple chronic conditions highlight the need for a holistic approach to physical and mental health. Social workers whose practice is rooted in case management are integral to meeting the needs of individuals for whom care and resources must be identified and deployed beyond discharge. The more complex the needs, the more comprehensive the approach should be for creating an optimal case management plan to address the whole person. This case management process is defined by the following nine iterative steps:
- Screening
- Assessing
- Stratifying risk
- Planning
- Implementation/care coordination
- Following up
- Transitional care
- Communicating post transition
- Evaluating
“In the hospital setting, for example, an important aspect of outcomes is improving transitions of care, such as from acute care to subacute or discharge into the community. Improved transitions are key to reducing readmissions in order to avoid penalties and reduced payments from Medicare and other payers because of excessive readmissions within 30 days of discharge” (Watson, 2016).
To Sum Up
Health care delivery models increasingly rely on social workers and social worker case managers because of their specialization in identifying and meeting the needs of patients, post-discharge. For example, with expertise in health care social workers provide support such as helping explain diagnoses and treatment options, as well as helping patients obtain financial assistance.
“Pursuing the triple aims of health care (improving the experience of care, achieving better health of individuals and populations, and reducing the per capita cost of care) puts case management in the spotlight with direct responsibility for undertaking quality measurement and evaluation of the systems of care delivery and the impact on patient care outcomes” (Tahan, Watson, Sminkey, 2016).
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