The Medical Social Worker: Following patient interactions in the healthcare system
About the Author: Janina Kwilos has worked in the field of social work since 1987. She has a Bachelors degree in Psychology and a Masters of Social Work, both from SDSU. Additionally, she holds a certification as a community college instructor from UCSD. Her interests include; travel, reading, film, languages, technology, cooking, and yoga. She has lived in five countries and is strongly influenced by her Lithuanian background.
Medical social work began at Massachusetts General Hospital in 1905 with Ida Cannon. In a 1930 address she aptly described the role of medical social workers: "The medical Social Service movement recognizes 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".
This article will follow the patients’ pathway through the healthcare system. It is important to keep in mind that patients being treated for medical problems can also have psychiatric diagnoses, multiplying the complexity of their situation. Interventions are always performed in the context of proper legal and reporting procedures.
This is the entry point into the hospital for many patients. Some unexpected event requires immediate attention. Social work in this environment entails assessing psychosocial needs in relationship to the presenting problem. The patient pathway can lead to treatment and discharge, admission to an observation unit or inpatient admission.
A typical scenario is a patient presenting with a diabetic crisis. This is often due to patients not having the ability to afford their medications. Providing resources for food assistance or information on low-cost healthcare at a community clinic may be a resource that can stabilize the patient and prevent re-hospitalization. A large number of the patients seen in the emergency room are seniors who face the struggles of aging and facilitating placement for rehabilitation is a frequent need following falls.
Other scenarios where social work service is vital are patients who come in with obvious signs of neglect or abuse and mandatory reports need to be completed. Patients sometimes expire in the emergency room and comforting the families and providing information on making final arrangements is necessary. People with substance abuse disorders are very high users of emergency care. These patients are often homeless, physically debilitated and not at a point where they want to change their lifestyle. Providing information on shelters and community resources is a common activity. Victims of domestic violence need information on where to get restraining orders, placement in a battered women’s shelter and notification of law enforcement.
A large number of patients use the emergency room to get help for psychiatric problems. People who have attempted suicide, had a panic attack or have psychotic symptoms all present frequently. Patients can be placed on involuntary holds until they can be dispositioned. Many have physical problems that will need to be treated before they can move on to getting psychiatric care. Many of these patients need education about their conditions and information on where to get outpatient care as the emergency room is just a stop gap measure.
This is a specialty service provided by certified hospitals. There are regional trauma programs that determine where trauma patients will be taken. Some of the patients seen in this service may be life-flighted in by helicopter from a remote area. These patients are very critically injured and will require intensive treatments such as surgeries and life support. Trauma patients may need to be in the intensive care unit or some can be well managed on the acute care trauma unit or observation floors. Please refer to these sections as they describe the continuing care these patients receive.
Social workers attempt to gather information and locate and inform family. If patients expire, being with the family when they arrive and view their loved one is important. Family members are often in such a state of shock they cannot function so crisis intervention is a major role.
These units provide care to patients who are critically ill. The patients are most often under sedation so the social work intervention is often with families and collateral contacts.
A frequent need is helping to identify patients. Family members need to be located and informed. Advance directives need to be found. Family conferences orchestrated by social workers and headed by physicians are held so families can get the information they need to make decisions. We coordinate with palliative care to clarify the goals of treatment. Social workers provide support and education and help families work toward a realistic view of the situation. We work to repair poor family dynamics so that families can function in the crisis without their problems interfering with patient care. We provide information on final arrangements and grief resources. Sometimes we are alerted that the patient we have received has a dependent spouse at home that they cared for and we have to quickly evaluate for their safety and care. Some patients are suddenly snatched from very productive life roles and are suddenly unable to take care of their finances, businesses and dependents. We provide information on conservatorships, power of attorney, legal referrals, disability benefits and provide employer notifications.
Patients who will be evaluated for 24 hours or less will be admitted to an observation unit. Social workers in these units have very limited time to assess patients and provide services.
Often patients receiving stress tests for cardiac symptoms are admitted to this type of unit. If the medical tests are negative and the symptoms are determined to be stress related, resources and counseling and stress management may assist the patient to improve their coping. Facilitating placements is a frequent role as well as setting up follow-up appointments and services. Many psychiatric patients make a brief stay in this type of unit while the severity of their symptoms is evaluated. They will either transition to inpatient care or get resources for outpatient care.
Acute Care Floors
These floors house medical and surgical patients. Their needs are linked to whatever their disease process is.
A cardiac patient may have a bad heart due to methamphetamine abuse and need education and information about substance abuse programs. Many patients need help to establish a primary care physician for their ongoing care. Patients with pulmonary illnesses can be extremely anxious and can benefit from counseling and education and referrals for outpatient psychiatric care. One of the unique inpatient services is oncology. This service often sees patients returning over time as they battle their disease. They need help applying for disability benefits, counseling to help them cope with the anxiety of their illness and help to plan for their future. Their families need support and education to help them cope with their role as caregivers. We encourage and assist our patients to complete advance health care directives so that they have thought about what their wishes are and we have surrogate decision makers designated when the need arises. Patients on these floors need information about resources related to their health needs. Some lack transportation to medical appointments, some cannot afford medications and some need assistance at home with activities of daily living. We attempt to link them to services that will enhance their ability to stay well and prevent readmission.
Social work is a mandated service for transplant patients. There is a need to evaluate patients being considered for transplant to see if they have the ability and resources to care for themselves and the transplanted organ.
If someone is homeless or a substance abuser, these problems jeopardize the success of the procedure. Patients can work toward being listed for transplant by getting recommended evaluations and treatments, applying for benefits that will give them the necessary income to provide for their care and conscientiously following the recommendations of the transplant team. Patients awaiting transplant can benefit from counseling to help them cope with the uncertainty of their health condition. Planning such as completing advance directives can take place. Following transplant, patients are also seen to assess coping and plan for ongoing care needs. There are support groups run by social workers to help patients get ongoing health education and support. Transplant workers coordinate with collateral agencies such as dialysis. For example, a patient’s compliance with dialysis will impact whether they can be listed for kidney transplant.
LVAD (Left Ventricular Assist Device)
Patients being evaluated for this intervention receive the same type of evaluation as heart transplant patients. It is vital to know if the patient has the means and ability to comply with a very regimented lifestyle. The device can serve as a bridge to transplant or it can be “a destination device” with no plan to move forward with a transplant. These patients are generally over the age of 65 and have been living with chronic heart failure and deteriorating health. There are support groups run by social workers to help patients get ongoing health education and support.
This role is mostly filled by registered nurses but some social workers also specialize in the area. Case managers facilitate transition to the next level of care or home as well as providing utilization review.
Typical interventions include arranging specialist appointments, getting insurance authorizations, scheduling outpatient treatments such as dialysis, having patients evaluated by extended care facilities, ordering equipment, arranging home health services, and providing information on services available for private pay such as caregivers, meal services or emergency alert systems. Case management is a very marketable skill. There are certifications available through professional organizations and also continuing education programs. Case management offers some unique opportunities such as telecommuting (in some circumstances) and is a role that is often available per diem which allows for a flexible work schedule.
Once patients have completed their treatments and surgeries, they are ready to move on to restoring function. Patients may go to an acute rehab which is an intense program for patients who have the physical stamina to participate in 3 hours of therapy a day. Typical patients would be accident victims and stroke survivors.
Social workers here work on disability benefits, provide counseling to help patients cope with the life changing events they have experienced and plan for ongoing care needs. Services to families include providing resource information and counseling.
Frailer patients get rehabilitation in skilled nursing facilities where the pace of therapy is less intense and there is time to rest sufficiently. A good example of this patient population is an elderly person who fractured a hip. In a skilled nursing facility a social worker could have the role of a case manager as well as providing counseling, resources and support.
As patients recover and head home their physician may order a home health social worker with or without other disciplines (depending on insurance benefits).
Sometimes there are specific referrals that need to be followed up on, safety assessments made or assessment of psychological coping. Patients are often so eager to get home that they overestimate their abilities and once home struggle to manage their activities of daily living. Referrals to programs like meal services can ensure that patients have adequate nutrition. Sometimes caregivers are needed and information or referrals can be provided. Caregiver stress can be addressed.
Social workers in dialysis centers have a stable patient population that is seen over time. Dialysis is typically done 3 times per week.
This patient population struggles with chronic health issues such as diabetes, hypertension, and resulting problems of poor vision, cardiac problems, and neuropathy. They need assistance with disability benefit application, resources, counseling, and referrals for medical care. Helping patients comply with their treatment regimen is vital. As mentioned earlier, the dialysis social worker coordinates with transplant social workers for a thorough evaluation of transplant suitability.
Child Health Women’s Services or Maternal
Services for women may be housed in a distinct specialty hospital or be a separate department in a general hospital. The population includes long-stay patients such as women who need to be monitored and on bed rest to brief stays for labor and delivery. Many of the services are similar to what has been described already.
Patients need to be assessed for mental disorders and provided with treatment and resources for continuing care. Domestic violence screenings are necessary along with mandated reports. Substance abuse issues need to be evaluated and babies born addicted referred to protective services. While most patients in this population are not facing a life threatening problem, their infants might. Helping couples adjust to having their baby in intensive care for weeks or months is an ongoing need. Infant demises are occasions for grief work and referrals for any needed ongoing support or care.
Occasionally, women will have critical events during childbirth and need to be placed on life support or in intensive care. Helping loved ones adjust to such unforeseen circumstances gives ample opportunity for crisis work. There are some joyful events such as working with adoptive parents and surrogates. There are opportunities to interface with the legal system during the adoption agreements.
Social workers also do group work in this setting both for health education, support groups and aftercare groups.
Overall, medical social work is a wonderfully challenging field. Working in this field for 30 years I still come across unique situations that require creative problem-solving. It is a field where one can work and learn to varying degrees. Some people like a stable day-to-day role such as evaluating scheduled patients like transplant candidates. Others thrive in the high energy trauma service which is very unpredictable. There are committees, such as ethics, which are thought provoking and provide an opportunity to interface with other disciplines. Working as a member of a multidisciplinary medical team provides great learning opportunities and chances for care team collaboration. The professional organizations for social work specialties such as transplant, oncology, and others are additional arenas to explore for growth and collegial support. The field offers the ability to transfer between services which can relieve boredom or help to avoid burnout. Work schedules vary and can offer flexibility that enhances quality of life. Witnessing the resilience of the human spirit and body is rewarding.
- A Focus on Adverse Childhood Experiences: Interview With Dr. Julie Miller-Cribbs, Director of the University of Oklahoma Anne and Henry Zarrow School of Social Work