Understanding the Social Work Role in Integrated Care — Taking a Seat at the Table
On integrated care teams, it is vital for social workers to identify, understand, and advocate for their role.
Social workers have long fought for their seats at any number of tables. With a wide scope of practice knowledge and skills, they recognize—and have worked for others to recognize as well—that their abilities are valuable to an array of care teams. This is particularly true in health care—an ever-evolving field that is increasingly looking to include professionals outside of what may be thought of as the standard team.
“The health care domain—that domain is changing very rapidly,” says Barbara Brandt, PhD, associate vice president of the University of Minnesota’s Academic Health Center and director of the National Center for Interprofessional Practice and Education. “The whole field is moving away from health care to health.”
This is evident in the rising number of integrated care teams across the country. Primary care offices and other health care settings increasingly aim to include, among other professionals, behavioral health care workers on their teams. In fact, according to a study released in November 2018 from the University of Michigan School of Public Health Behavioral Health Workforce Research Center (HWRC), nearly 44% of primary care physicians are colocated with behavioral health providers. This means that they are not only on the same team but also physically in the same office.
As integrated care continues to grow, social workers are tasked, yet again, with ensuring that they have a place on those teams and, even more, with identifying what that place means. To be most effective, social workers must enable themselves and their colleagues to recognize and understand the value of a social worker.
One of the guiding forces is the Health Resources and Services Administration (HRSA). Through its Bureau of Health Workforce, it has, among other initiatives, established six national HWRCs, which in part aim to “collect, analyze, and report health workforce program data to the National Center for Health Workforce Analysis and to the public.”
HRSA also created the Behavioral Health Workforce Education and Training (BHWET) program. This program helps colleges and universities train and develop the behavioral health workforce.
Thanks in part to the existence of the HWRCs, researchers have been able to examine the role of social workers on integrated care teams through a variety of studies. One recent study in particular relied on BHWET participants to help pinpoint what social workers are doing and what more they might be able to do.
Toward a Better Understanding
• a systematic review aimed at identifying the function of social workers on interprofessional teams in primary care settings, as well as the whole teams’ impact; and
• a pilot study similarly aimed at identifying social workers’ functions.
This third step surveyed 395 MSW students and MSW field placement instructors, all of whom were a part of BHWET programs. The surveys looked to identify what social work–specific tasks the respondents were performing in their roles, as well as how the respondents felt as a part of the integrated care team.
Of the 25 tasks named in the survey, respondents did an average of 15 weekly. These tasks included team-based care, motivational interviewing, warm hand-off, and medication management. Of note, however, was the fact that certain tasks didn’t seem to be well utilized.
Take, for example, SBIRT (Screening, Brief Intervention and Referral to Treatment). “There’s been a lot of emphasis through SAMHSA [Substance Abuse and Mental Health Services Administration] and others to train on SBIRT, but this was one of the things that was not commonly understood or used,” says Lisa de Saxe Zerden, PhD, MSW, senior associate dean for MSW education and an associate professor at the University of North Carolina Chapel Hill School of Social Work. “We need to work to align what is taught in school with the practice realities MSWs face once they graduate.”
Erica L. Richman, PhD, MSW, a research analyst at the Program on Health Workforce Research and Policy at the Cecil G. Sheps Center for Health Services Research and adjunct clinical assistant professor in the School of Social Work at the University of North Carolina Chapel Hill, agrees. “One of the things I remember was that most of the people in health care or placed in health care settings learned most of what they had to do in their job on the job,” she says.
As for how social workers felt on the integrated care teams: “There were some things that were missing,” Lombardi says. “But overall, social workers reported feeling supported, felt they had space, and felt valued on the team. It was more positive than we were expecting.”
However, even with the majority feeling valued, a significant portion (near 40%) did not, indicating room for improvement.
It is true that respondents indicated that they had been trained on many of the 25 listed tasks. “This is a special population,” Lombardi acknowledges of the individuals surveyed. All were at schools with the BHWET grant. “But the good news is that overall social work students were trained in the vast majority of the tasks.”
However, there were gaps and, as Zerden pointed out, a slight disconnect between what was being taught in the classroom and what models were being applied in the field.
Additionally, Zerden, Lombardi, and Richman’s work illustrates that the tasks used by social workers do not align with what providers are able to bill for. While health care is moving toward a value-based model, most settings continue to rely on a fee-for-service model. If incoming social workers don’t understand what that means, they might not be able to bill for their services or demonstrate their financial value to the team.
“In addition to being trained as direct practitioners, social workers also need to be thinking about and trained on aspects that are not direct practice—understanding billing, understanding how policy affects their job—and continued training. We need to make sure that we understand how other health disciplines are trained,” Lombardi says. This too has been incorporated into classrooms through the BHWET program, but more can be learned.
Perhaps the best setting for that learning is in the field, with field instructors. If that is the case, MSW programs need to ensure that they have a cadre of field instructors able to provide not only direct practice supervision but also administrative instruction and guidance.
However, historically, most health care professionals have been taught solely about their profession and their potential skill set. “Traditionally, we have been teaching in silos,” Brandt says. “Social work often isn’t included in the health professions. They are across the campus in a separate school.”
Fortunately, programs such as the BHWET program help merge the silos through preparation and education, and there is evidence of increasing emphasis on understanding one’s future teammates. “Many schools now make sure that right off the bat, they start teaching about what the other health professions do,” Brandt says. This is something that has begun happening at the University of North Carolina, Zerden notes. In fact, she is involved in several interprofessional courses across the health affairs that now include MSW students.
Such education is an important first step but it does not completely eliminate the likelihood of role confusion. Considerable overlap is possible among team members and that can lead to tension, which leads to a lesser quality of service. This is most evident for social workers in the care management role—a position that has traditionally been filled by nurses and/or social workers.
“There is this kind of tension between social work care management and nursing care management,” Lombardi says. “Health systems are just used to having nurses on the team, but the skill set of both can be invaluable.”
When both a nurse and a social worker are on the integrated care team and have a similar role or are unclear on their roles, this has the possibility of creating a “turf war.” “So let’s clarify what we do,” Richman says. “Social workers are not trained to be nurses. If we clarify roles and responsibilities—what we should and should not be doing—the turf [war] will go away.”
Of course, this is easier said than done. “It takes grit and tenacity, something common to social workers, to be able to say, ‘This is what I do, and you need my skills to help,’” Zerden says.
It also takes know-how. Social workers need to know what they do. They must be able to not only describe their skills but name them as well. In “Toward a Better Understanding of Social Workers on Integrated Care Teams,” many respondents failed to recognize the tasks they perform weekly. Take, for example, problem-solving therapy. “Some of the people said, ‘No, I don’t do that.’ But they would describe what they do, and they do problem-solving therapy,” Richman says.
The other thing social workers need to identify is themselves. “Call yourself a social worker when you can,” the team encourages. “If you’re hired as a care manager, also be a social worker. Be proud of it.”
It can be uncomfortable to do this, but it’s worth it. “When I was an MSW student, we went up to Sacramento for a lobby day activity, and we talked about title protection,” Zerden says. “I remember thinking this was a low priority. I wanted to talk about the people we were there to serve.
“I’ve come so far from that. Title protection and being called a social worker is fundamental. You can’t care for someone else unless you are well and cared for yourself.” Similarly, you can’t be an effective and good social worker unless you can effectively advocate and support your profession.
More research and dissemination of that research must be done as social workers become an increasingly present part of health care teams.
At present, Zerden says, there is a focus on reaching as many professionals as possible with their findings. “We are really on a conference circuit. We need to get others to understand social workers.”
Additionally, “[We need] to have a 360-degree view of social workers on care teams,” Lombardi says. “We’ve looked at the literature; we’ve asked social workers what they’re doing. What does the outside team report that social workers are doing?”
And, much like health care teams, the research needs to be interprofessional. “You publish in your journals; you talk to yourselves. But that’s not unusual to social work,” says Brandt, who notes that most professions continue in their silos as they conduct and disseminate research. She emphasizes that scholarship across professions must occur for best results—just as in health care.
“No one professional,” Brandt says, “can have all the knowledge to take care of a patient or community. By combining knowledge and problem solving together, you get a better outcome.”
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.