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THE SOCIAL WORK PROFESSION AS A CATALYST OF CHANGE IN HEALTH CARE Julie Miller-Cribbs, MSW, PHD Professor & Director Anne & Henry Zarrow School of Social Work University of Oklahoma

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The problems are serious, but we can do better

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Our physical and mental health are related

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Trauma & violence impact mental and physical health

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Graphic from: http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Childrens-Resilience- Initiative-9-19-12.pdf

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There is tremendous human and economic cost

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Oklahoma is particularly impacted

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POLICY CHANGE & IMPLEMENTATION expanded behavioral health services to 62.5 million Americans. massive expansion of behavioral health services increased demand for mental/behavioral health services in primary care and specialty care dramatic shifts in the delivery of mental health services to primary care Continued development & refinement of short-term and effective interventions Increased understanding of co-morbity, biomarkers, stress and possible interventions Federal Policy Influences Integrated Care Patient Protection and Affordable Care Act (ACA): requires that behavioral care (mental health and substance abuse services) are included, investments in community health centers and funding for behavioral health staff, Medicaid expansion Mental Health Parity and Addiction Equity Act of 2008 final rules requires that behavioral health services are provided at same level as medical and surgical care Federal Policy Influences Integrated Care Patient Protection and Affordable Care Act (ACA): requires that behavioral care (mental health and substance abuse services) are included, investments in community health centers and funding for behavioral health staff, Medicaid expansion Mental Health Parity and Addiction Equity Act of 2008 final rules requires that behavioral health services are provided at same level as medical and surgical care

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INTEGRATED CARE: WHY SOCIAL WORK? Education & Training Values & Ethics Social Work Skills Social work competencies align with integrated care competencies care for the most vulnerable Reducing health disparities Coordinated care Social justice Self-Determination Community engagement Collaboration & teamwork Advocacy Systems & ecological focus Resource mobilizers Research & evaluation Importance of a therapeutic relationship Collaboration Communication skills

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ALIGNED COMPETENCIES SW COMPETENCIES 1.Identify as a professional social worker and conduct oneself accordingly. 2.Apply social work ethical principles to guide professional practice. 3.Apply critical thinking to inform and communicate professional judgments. 4.Engage diversity and difference in practice. 5.Advance human rights and social and economic justice. 6.Engage in research-informed practice and practice-informed research 7.Apply knowledge of human behavior and the social environment. 8.Engage in policy practice to advance social and economic well-being and to deliver effective social work services 9.Respond to contexts that shape practice. 10.Engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and communities. IC COMPETENCIES 1.Interpersonal communication skills 2.Collaboration & Teamwork 3.Screening & Assessment 4.Care Planning & Care Coordination 5.Intervention 6. Cultural Competency & Adaptation 7.Systems-oriented practice 8.Practice-based learning & Quality Improvement 9.Informatics

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EMBEDDED SOCIAL WORK SERVICES

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HISTORICAL ROLE OF SOCIAL WORK IN HEALTHCARE It is an important part of the social workers function to concern herself with the social problems arising directly out of the nature of the medical treatment. Harriet Bartlett

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Ms. Cannon and Dr. Cabot implemented systems to measure social work interventions, to document these interventions in medical charts, to collaborate with medical professionals, furthering the profession of medical social work. Their work promoted the expansion of the social work role in the hospital and the inclusion of the social perspective as a regular part of the medical treatment plan, for instance they began what we know today as "rounds". In a 1930 address Ms. Cannon stated, "The medical social service movement recognized that there should be within the hospital, someone definitely assigned to represent the patient's point of view... And to work out with the physician, an adaptation of the medical treatment in the light of the patient's social condition". To realize this goal, interdisciplinary rounds with social workers were begun, and continue to exists today. Dr. Richard Cabot, a senior physician at Mass General, hired the first social worker in 1905 to provide social work services in the outpatient clinics. In 1906, Dr. Cabot met Ida Maude Cannon and hired her to jointly organize the nation's first hospital-based social work program. Of Cabot, Ida commented, "He was presenting the idea of social service within the hospital where sick patients, although separated from their home and families, nevertheless cannot separate themselves from their personal problems." / /

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20 th century public health overcrowding sanitation and hygiene infectious diseases From How the Other Half Lives by Jacob Riis. Dr. John Snow and his London cholera epidemic map.

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21 st century community health Motor vehicle accidents Environmental quality Chronic disease Obesity poor nutrition, inactivity Substance abuse: alcohol, drugs, tobacco

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SOCIAL WORKERS AS ADVOCATES

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THE NEED FOR ADVOCACY IN HEALTH CARE Both healthcare professionals and consumers must engage in advocacy to increase the odds that consumers will receive (Jansson, 2011) funding for care, quality care based on acceptable guidelines, protection of their ethical rights, culturally competent services, access to services in their community, preventive services, and attention to their mental health needs.

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PATIENT ADVOCATES PROTECT AND SUPPORT Social work professionals are in a strategic position to become leaders in promoting the role of patient advocate: by the nature of their values, their commitment to social justice their ability to effectively communicate and engage individuals representing diverse backgrounds their application of the person in environment or psychosocial perspective

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PROMOTI NG POLICY CHANGE

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SOCIAL WORKERS UNDERSTAND SOCIAL DETERMINANTS OF HEALTH I would argue this is one of the strongest contributions social workers can make in interdisciplinary teams, this training makes them uniquely suited to work with vulnerable populations who experience a myriad of conditions that influence physical & mental health

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GROWING APPRECIATION FOR SOCIAL NEEDS Transition from pathology approaches, medical model, to broader approaches that address principles of community health, resiliency

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MODEL SHIFT Traditional or Interdisciplinary Model Community Science Model One or a few disciplines involved, usually one predominating Multiple disciplines, with none predominating Community members or agencies the recipients of intervention Community a full participant Outcomes and measures set by research agenda Community involved in determining outcomes & measures Results disseminated to like-minded professionals Results distributed to communities for improvement and replication

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ACADEMIC DISCIPLINES IN COMMUNITY MEDICINE Health of Persons Lifes basic structures and functions: molecules, cells, tissues, and organisms, and environments The human body in health and disease Methods of medicine: diagnosis, treatment, continuing care, learning and improvement Health of Communities Collective structure and function of human communities The human community: policy, influence, discourse, laws and rules, culture & behavioral change Methods of community health: epidemiology, biostatistics, measurement, system change

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SOCIAL WORKERS ARE NATURAL COLLABORATORS Social workers understand relationships, social competence, emotional intelligence and are often relational leaders

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RELATIONAL LEADERSHIP MIRRORS THE SPIRIT OF CARE PRESCRIBED BY IHC Movement beyond traditional top management leaders and compliance of followers, the power structure is inclusive Partnership/Relationship is central to care Patient- provider Provider & Team Team & Community

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SOCIAL WORKERS CONTRIBUTE TO HEALTH CARE TEAMS Skills & Knowledge Medical Literacy Consultation Liaison skills with medical problems Population Screening Chronic Disease Management Care Management Skills Educating medical staff about integrated care Evidence-Based Interventions Group Interventions Working within the fast-paced, action- oriented ecology of primary care Characteristics & Abilities Responsive Committed to social justice Commitment to the ethical practice of social work Commitment to social change Functional independently and collectively with others Sensitive to relationships Interact positively and instructively with clients

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SOCIAL WORKERS AS COMMUNITY ENGAGEMENT SPECIALISTS

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SOCIAL WORKERS AS SCIENTISTS

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Integrated care approaches: Emerging Evidence & Best Practices

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SOCIAL WORKERS DO PREVENTION, INTERVENTION AND CHANGE SW training is competency based, with significant hours spent in practicum Licensing ensures ethical practice and continuing education Training in behavioral change (MI) Training in cultural competence and adaption of models Person-in-environment Evidence based practice Brief treatment models IC takes advantage of all of the inherent skills and competencies of social work training and professional values & ethics

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SOCIAL WORKERS AS PROMOTERS OF ETHICAL PRACTICES 5 ethical issues of particular importance to integrated health Informed consent Confidentiality Relationships with patients Relationships with colleagues Scope of practice

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THE WAY FORWARD

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THINKING BEYOND SILOS: EDUCATION & PRACTICE

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INTERPROFESSIONAL PRACTICE AND EDUCATION Effective Inter-professional collaborative practice will require Inter-professional education (IPE) Integrated behavioral healthcare cannot move forward without a healthcare work force that is trained in and embraces inter- professional collaboration Our current healthcare system operates predominantly in professional silos Education of healthcare professionals is also done in silos - few students have an opportunity to work together and are not prepared to function as part of a team in an integrated approach to care

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ASPECTS OF SOCIAL WORK ARE INCORPORATED INTO TRAINING OF OTHER HC PROFESSIONS A shift in attitude toward the relationship between physician and patient- stressing collaboration, the importance of positive interactions, and the role that all contributing parties serve in meeting the patients goals. Interpersonal Communication Process Vs. Outcomes Systems Based Practice

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IPE EXAMPLE: EPIC & SUMMER INSTITUTE http://www.ouhsc.edu/epic/Home.aspx http://www.ou.edu/tulsa/community_medicine/2013.html

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INTERPROFESSIONAL EDUCATION IMPLICATIONS Intentional creation of interdisciplinary groups Experiential elements facilitate co-learning, communication practice Professional meaning & world caf: perspective taking Teams, dialogue, relationship orientation Experiencing community in teams, finding solutions as teams Prototypes create opportunities for team work (compromise, negotiation, project management, perspective taking) Emphasis on collective learning, and appreciative inquiry

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STUDENT PERCEPTIONS OF THE LEARNING ENVIRONMENT: SI Learning Culture Important Elements Relationships Socialization Experiential activities Community Health Principles Awareness of Underserved Transdisciplinary Work Problems and Solutions Appreciation of Other Profession Products of learning: reflection, change & inspiration Self-Reflection Broaden Perspective Inspiration/Motivation Commitment Attitudinal Shift Key learning for participants, from analysis of multiple years of qualitative data Sometimes re: people in poverty (most common) but sometimes re: working with or understanding OTHER professions

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INTERDISCIPLINARY PARTNERSHIPS SI participants learn to appreciate other disciplines and value experiences and opportunities for interdisciplinary collaboration and teamwork Data also revealed important lessons related to communication the SI experience allowed for interdisciplinary conflict resolution related to professional bias to occur I learned how other professions play important roles in the process of giving care to people in the community. "I have learned that other professions need to better communicate with each other in order to help the community as a whole. Egos need to be left aside, and people need to focus on the "bigger picture," which is healthcare for all in the community." "The impact they have on our community. I learned what their roles are in clinics and how we each depend on the other to make the process work best for patients. Communication is key."

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EPIC DATA: STUDENT FEEDBACK It is difficult to get people with different backgrounds to work together I need to learn when to speak up Importance of communication Importance of listening Everyone in the group has important, valuable knowledge to contribute. Listening is very important to make sure details are heard. Process of students communicating with each other. How certain professions always gave debriefing, might be interesting to see other disciplines giving overview of concerns Giving and receiving feedback Learning the dynamics between disciplines How to work with various professions I learned that different disciplines overlap but can easily work together Learning to let go of stereotypes Social work is very, very helpful!

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DEVELOPING INTERDISCIPLINARY CORE COMPETENCIES

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AN INTRODUCTION TO THE IMPORTANCE OF INTERPROFESSIONAL WORK How do you communicate with other professions in a interprofessional setting? How to account for multiple perspectives in understanding a problem, finding a solution? How do we move to a community model? How de we engage communities in our discussion of problems and solutions?

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SOCIAL WORK OPPORTUNITIES Social workers practice Developing models, providing expertise in IC teams Lending expertise in community work & engagement Lending expertise in bio-psycho-social model and relevance to health of individuals and communities Advocacy on all levels (patient, policy, AND for the PROFESSION) Social work education Student practicum engaging with whole communities and across disciplines in primary care settings Collaborative work across disciplines to create innovative curriculum, common competencies in community health & integrated care Focus on relationship of physical/mental health in coursework Social work research Science of community wellness, lending expertise in community based participatory and action research

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RESOURCES & REFERENCES Council on Social Work Education, Social Work and Integrated Behavioral Health Project http://www.cswe.org/CentersInitiatives/DataStatistics/IntegratedC are.aspx http://www.cswe.org/CentersInitiatives/DataStatistics/IntegratedC are.aspx Core Competencies for Integrated Behavioral Health and Primary Care http://www.integration.samhsa.gov/http://www.integration.samhsa.gov/ The place of social work in public health 1996 http://www.socialwelfarehistory.com/programs/the-place-of-social-work-in-public-health/