Social Workers — Vital to Multidisciplinary Hospital Teams
Social Work Today
By Kim Schuetze, ACSW, CCM
Vol. 4 No. 3 p. 32

Hospital-based social workers have an important role to play as part of multidisciplinary teams that include physicians, nurses, respiratory and physical therapists, psychologists, dietitians, and other caregivers. By identifying the needs of the patient and/or the patient’s family, hospital-based social workers bring core skills of nonjudgmental assessment, advocacy, and the ability to find appropriate solutions. This is not an ancillary strategy that is undertaken as a solo project. Rather, social workers strive to be highly effective members of teams that draw upon the strength and unique contribution of all parties, from a variety of professional backgrounds.

“For social workers working as part of teams, one of the challenges is to be a leader, even if they don’t carry that title. Social workers must enhance their leadership skills; they must be able to lead and be comfortable with it,” observes Kathleen M. Wade, PhD, MSW, ACSW, director of social work, University of Michigan Hospitals, and assistant dean of hospital social work, University of Michigan School of Social Work. “There are times, however, when social workers feel like the least important people on the team. That’s not true. Getting them to believe it is the challenge.”

Social workers must recognize that the value they bring to the team is equal to the clinical or rehabilitative skills that others possess. Their case management skills, obtaining both internal and external resources for the patient and/or the family, complement the clinical/medical efforts. While skill sets and care delivery differ from discipline to discipline, there is a common bond that unites and focuses the team: patient care. When teams base their attitudes and actions on this premise, conflicts can be resolved, compromises reached, and decisions made.

Working As a Team
“The physicians, nurses, and medical/clinical staff care deeply about all aspects of the patient,” says Deborah Campbell, RN, BSN, CCRN, the clinical manager for the pediatric intensive care unit at Kosair Children’s Hospital in Louisville, KY. “But, we are so focused and busy running from one thing to the next that we are unable to meet all of the patient’s needs outside of the basic clinical, medical, and nursing needs. Without the entire team working with us—including the social workers, who are an integral part—we are only taking care of part of that patient.”

Hospital-based social work has served as a model for other practice areas that now incorporate a team approach. “We know that many of the social work problems we deal with are so complex that one discipline alone cannot be as effective as all the disciplines coming together. We are beginning to see this in more and more settings, and we can thank hospital-based social work for getting us thinking along those lines,” says Karen M. Sowers, PhD, MSW, dean of the University of Tennessee College of Social Work. “From a bio-psycho-social model, social workers take a holistic view. So, who better to facilitate the disciplines coming together than social workers?”

Multidisciplinary teams in hospitals function differently, depending on the setting, the kinds of patients treated, and what team members have grown accustomed to over the years. In my personal experience, I have been part of a multidisciplinary team in the intensive care unit at Kosair Children’s Hospital for the past four years. The only freestanding, full-service children’s hospital in the region, Kosair serves children from Kentucky and neighboring states.

Our team spans the various medical and rehabilitative disciplines: physicians, nurses, respiratory and rehabilitative therapists (including physical, speech, and occupational), dietitians, psychiatry, cardiovascular, diabetic and pulmonary nurse educators, and social workers. With such a diverse team, any number of specialties can be brought in for any given patient’s needs.

As part of the team, I am welcome to make the medical rounds each day, though I typically do not because of the time involved. Rather, I join the rounds at specific times when a child or family is in need of my services. My colleagues and I may not see every patient, but we rely on referrals from physicians, nurses, or families.

By contrast, at Kindred Hospital in Louisville, a licensed, long-term acute care hospital, social workers do assessments of every patient within the first week of admission to identify the needs and concerns of the patient and/or family. “A family might come to us with particular concerns or Adult Protective Services may be involved,” explained Maureen Chambers, MSW, CSW, director of the social work department at Kindred Hospital. “We handle any number of issues.”

End-of-Life Care
One issue that is frequently dealt with by the Kindred Hospital team is termination of life support, a process that is physician-generated but that also involves nursing, respiratory therapy, and social workers. While Chambers and her colleagues handle the required paperwork, the services of these social workers encompasses so much more, including seeing to the emotional needs of both the family and staff.

“A couple of years ago, as we were talking about patient care, someone commented, ‘We give a lot of care at the beginning of life. Why not at the end?’ That’s when I spoke up. We, as social workers, are the ones providing the intensity of service at the end of life,” Chambers explains. “We are the ones who are facilitating the paperwork and guiding the family through the process and educating them. And, we are in the room holding their hands as they sit with the patient.”

The “intensity of service” that Chambers describes means staying with the family beyond normal working hours, extending into nights and weekends if necessary. It also includes one-on-one intervention to address the basic needs—something as simple as ensuring tissues are available and lowering the patient’s side bedrails. “I never want a family to say, ‘The last thing I remember was that I had to reach for my mother’s hand through a bedrail,’ or, ‘I couldn’t even get a tissue.’ We pull in chairs and pull down bedrails. The lasting impression for the family should be one of support.”

Treating Patients and Their Families
Hospital-based social workers recognize that while the patient is the focus of the medical attention, it is often the entire family that needs to be treated. A patient’s health issues extend into family systems. Problems may range from financial to social—from a lost job or lack of transportation to a sick child whose parent is in jail. As a social worker who provides case management services, my job is to help identify solutions.

“Adam” was a 10-year-old patient at Kosair whose adoptive mother lived in another town. She stayed with him for a few days and then had to go home. Immediately, Adam’s behavior became atrocious; he refused to eat and urinated on the floor. One of the nurses contacted me to help get the boy’s adoptive mother to return to the hospital.

As I became involved in the case, I learned the details of Adam’s life. His birth mother had abused him. He suffered emotional and psychological problems, and his adoptive mother had abandoned him—or so it appeared. When I called the adoptive mother, I learned she had been ill and was briefly hospitalized herself. She was trying to arrange for someone to care for her other children while she recuperated.

Until his mother could come, we needed to devise another strategy to help Adam. Psychiatrists prescribed a behavior modification program, rewarding him with games when he behaved correctly. Dietitians prepared foods that he liked. Nurses did their charting in his room so he wouldn’t be alone. Working together, we were able to do what we could with the situation at hand: trying to meet Adam’s needs while his mother was away.

One of the most important contributions that social workers bring to hospital teams is a nonjudgmental attitude. In Adam’s case, it would have been easy to assume his mother had “abandoned him,” but that did not turn out to be the case.

Social Workers and Case Management
Assessing the needs of patients and their families and finding the appropriate resources in a timely and cost-efficient manner are part of another role that I fulfill—that of a case manager. Acting as an advocate for the patient and family is reflective of my roles as case manager and social worker. The two roles are distinct, yet intertwined. As my professional credentials reflect (I am an ACSW and a certified case manager), I see myself as a social worker who also provides case management services.

With its focus on the needs of the patient and commitment to obtain the resource at the right time, case management has a uniquely individual approach. As the healthcare system continues to operate under the glaring scrutiny of cost containment, case management is one of the few areas that remain personalized. Thus, my case management services are enhanced by my professional role as a social worker, where patient advocacy is a top priority.

“Social workers are going to advocate for the patient, and at times, we may stand on the other side of clinical issues,” says Chambers. “To do that, social workers need to be confident about themselves and their skill set. For example, if I know that a patient is being restrained, I want to know why. I want to know for sure that there are legitimate reasons for the restraints, such as keeping a patient from dislodging life-sustaining medical lines/tubes.”

Case management skills also involve obtaining access to the right resources at the right time. When it comes to social or community needs, the resources may be a phone call away: transportation to bring a patient to follow-up appointments, food or utility bill relief, or low-cost counseling. Seeking external resources—if, when, and where they exist—is an extension of a social worker’s team approach. We cannot provide the services ourselves, but to the best of our ability, we can help patients and their families obtain the help they need, when they need it. And, when the resources do not exist, we must advocate for change on a broader, societal level.

“Advocacy is part of our [social work] code of ethics—to advocate for better conditions for all people,” Sowers observes. “We do that on a macro level dealing with policy and legislation and on a micro level with patients.”

Building a Team
As advocates and liaisons, social workers operate well in a team environment. Facilitating services, we naturally reach out to others. Thus, in a hospital where various aspects of patient care are coordinated and deployed, the team approach seems natural. Yet, not every hospital has a fully functioning multidisciplinary team.

Unfortunately, there are hospitals that tend to view social workers as only “resource getters and discharge planners,” Sowers says. “That’s short-sighted because social workers have so much more to offer.”

Social workers who are not part of a fully functioning multidisciplinary team should not give up the ideal of operating in a team environment. They can foster change by being good team players. For example, whenever a case is discussed, social workers should be prepared to make a meaningful contribution. That doesn’t mean they need to have an immediate answer for every question or a solution to every situation. But, it does mean making a commitment to investigate the problem, research potential solutions, and then report back in a timely fashion.

Communication among all parties is the difference between having a team in theory and one in practice. Many hospitals may claim to have a multidisciplinary team, but it is the day-to-day function of the team that determines whether or not it is effective. Do the various disciplines communicate with each other? Do they respect and value the unique contributions of each party? The multidisciplinary label is not enough; it must be demonstrated through practice.

Respect can become an issue. In the traditional hierarchy of a hospital environment, social workers may not think they are given the same respect as the medical/clinical personnel. The best strategy is to do respectable work in a predictable and proactive manner. No one likes to have to prove themselves, particularly when they possess the experience and expertise in their field. But, it is a fact of life in the real world of many hospitals.

Patient care is the unifying factor for all teams, even splintered ones. “The more you can work together in a collaborative way within the context of everyone’s unique skills, the better your patient care is,” says Wade. “People need to check their egos at the door and recognize what others can do. That approach adds to the depth of the team. Patient care is really served.”

Over time, mutual respect and sensitivity grow into a heightened awareness. Wade recalls her work with HIV/AIDS patients when the social workers asked for a moment of silence after the reading of the names of patients who had died. The doctors, she recalled, at first were uncomfortable and eager to fill up the silence with talk. But, after a few months, the physicians were the ones asking that the names be read and the moment of silence be observed.

“In time, there was a blurring of boundaries,” Wade adds. “The doctors were asking about patients who lived in third-floor walkups and social workers were inquiring about pain management.”

For members of a multidisciplinary team, this is perhaps the most vivid sign of success. Team members become so acutely aware of each other’s areas of expertise that they anticipate the questions that will be asked—and ask them on behalf of others. Distinctions among professional backgrounds, educational degrees, and even status at the hospital fall away. All that remains is a group of colleagues, equal in respect and contribution, focused on patient care.

— Kim Schuetze, ACSW, CCM, is a hospital social worker at Kosair Children’s Hospital in Louisville, KY. She also serves on the Commission for Case Manager Certification.
For more information about the Commission for Case Manager Certification, please visit www.ccmcertification.org.