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Social Workers on Transdisciplinary Teams: Pursuing the 'Triple Aims' With a Holistic Approach

By Jane Harkey, RN-BC, MSW, CCM, and Michael Demoratz, PhD, LCSW, CCM

There has never been a doubt that social workers play an important role on health care teams as critical collaborators with physicians, nurses, professional case managers, and other clinicians, as well as in their role as patient advocates engaged with the extended family/friend/community support system. How the social worker's role is perceived, however, may differ from setting to setting and team to team. In order to pursue the "triple aims" in health care outcomes—better care, reduced costs, and healthier populations—(Berwick, Nolan, & Whittington, 2008) and to optimize the health care team as a fully functioning transdisciplinary team, there must be a full appreciation of how social workers contribute meaningfully to a holistic care plan.

Transdisciplinary team members work across their individual disciplines and clinical expertise. They come together around a shared focus on the patient's health issues, therapeutic goals, and desired outcomes. Even when a transdisciplinary team is in place, however, some clinicians and other health care colleagues may perceive the social worker's role in a limited capacity. The social worker may be viewed as the professional to consult mostly when a patient is covered by Medicaid and/or there's a lack of financial or other resources. Likewise, they may think the social worker is the person to call on only when there is upset within a patient's family/support system, or if the patient has received a serious diagnosis and "needs someone to talk to." While social workers can contribute skills and expertise in these areas, such scenarios don't define the full extent of their roles on transdisciplinary teams.

In order for the complete scope of their roles to be recognized by the transdisciplinary team, social workers need to advocate for themselves, their profession, and their expertise. Where necessary, social workers must correct any confusion or misperceptions about how they can help the team deliver patient-centric care. When social workers are utilized to the full extent of their skills, the transdisciplinary team becomes more effective and truly patient-centric in its whole-person approach.

The social worker, like the professional case manager, contributes to the alignment of the transdisciplinary team around all of the needs of the individual: physical, mental, emotional, and psychosocial. With in-depth expertise in psychosocial issues and strong communication skills, social workers can be especially effective in helping to educate and empower patients, regardless of a person's background, economic level, or health status.

Full patient engagement and a high degree of empathy allows social workers to relate to individuals who need support and resources as they adjust to a "new normal." This new normal can occur after an accident or illness that is life changing, even if the individual eventually achieves a full recovery. Social workers also bring insights from these patient interactions back to the transdisciplinary team to further team members' understanding of the person's physical, mental, and emotional state.

The contributions of the social worker to the transdisciplinary team, as well as to the patient and family/support system, show how the role of the social worker is congruent with case management. Social workers exhibit the same holistic perspective that is shared by professional case managers who come from a variety of disciplines, including nursing and social work. (According to Commission for Case Manager Certification data, about 5% of the more than 35,000 active certified case managers are social workers.)

Regardless of their backgrounds, professional case managers, especially those who are board certified, often fulfill the vital care coordination role. As recent trends in health care have demonstrated, care coordination has been identified as a highly effective means to increase efficiency in health care, reduce costs, and support improved clinical, financial, and satisfaction outcomes. More and more, health systems, accountable care organizations, and patient-centered medical homes are using care coordinators (Evans & Meyer, 2015).

By focusing on psychosocial issues as well as facilitating communication and understanding among all parties, social workers can support care coordination while also exerting a strong positive influence on the ability of the transdisciplinary team in multiple care settings across the health spectrum.

The Changing Health Care Environment
The professionally diverse health care team functions within a system that is increasingly complex and potentially confusing for the average consumer. That challenge is heightened further with an increase in the number of people entering the system. According to reports, approximately 16.4 million people have gained health care coverage since the Affordable Care Act was passed. This number includes 14.1 million adults who gained health coverage since the beginning of open enrollment in October 2013. Also included in the total are people who signed up for Medicaid under a health law provision that let states change eligibility requirements so that more people above the poverty level would qualify (Armour, 2015).

As more people enter the system, some may be accessing care in new or different ways. For example, instead of going to the hospital emergency department (ED) when they become sick, more people will be treated by primary care doctors and/or in accountable care organizations. At the same time, there may be confusion on the part of some newly insured people about the difference between coverage and access. This underscores the need to educate patients as consumers.

With bigger caseloads, physicians and nurses don't have the time to fully help individuals understand the extent and limits of their health coverage and/or how to make the best choices for themselves. In addition, patients are sometimes reticent to ask doctors and nurses questions. Often people are so overwhelmed, they can't even think of the right questions to ask a doctor or nurse. Drawing on their communication skills and counseling expertise, social workers—often working with a professional case manager or in the case manager role themselves—can help empower and educate people about asking questions of the doctor, nurses, or other caregivers. It may be as simple as asking the individual, "Did you understand the doctor's instructions? Can you repeat back to me what you heard? Is there anything that's unclear to you?" The social worker may be able to facilitate a conversation between the patient and the doctor or nurse that otherwise wouldn't have occurred.

The social worker can also model cultural awareness and sensitivity within the transdisciplinary team. This can prevent misunderstandings that undermine the effectiveness of care. For example, in some Asian cultures it's typical for listeners to nod and say "yes" to indicate that they are hearing what the speaker is saying; however, this shouldn't be interpreted as agreement or full understanding. Greater cultural awareness among all parties decreases the potential for misunderstandings and miscommunication.

Among all patients, improved understanding of diagnoses, treatment, and physician orders can support compliance with medication, self-care, and follow-up. The more compliant the individual is, the greater the likelihood of achieving improved health outcomes with decreased incidences of relapses, ED visits, and readmissions to the hospital.

By collaborating with discharge planners at acute and subacute care facilities, social workers can help identify community resources that individuals need postdischarge. This skill will become even more important as more people, including those newly insured, receive care within the community. Helping individuals and their families/support systems access community resources is essential during transitions of care. Unsuccessful transitions typically lead to unnecessary ED visits and hospital readmissions.

In today's complex and increasingly confusing health care system, the role of the social worker will become even more impactful for a wide variety of individuals. Within transdisciplinary teams that are truly patient-centric and guided by the patient's goals and objectives, the social worker contributes highly valued skills, especially in-depth knowledge of psychosocial issues and communication. For this expertise to be used appropriately and for a variety of patients, social workers may need to educate their transdisciplinary teammates so that they are all working together to provide holistic, patient-centric care. 

— Jane Harkey, RN-BC, MSW, CCM, is a commissioner and secretary of the Commission for Case Manager Certification (CCMC).

— Michael Demoratz, PhD, LCSW, CCM, is a CCMC commissioner and national director of clinical services for AMADA Senior Care.

Armour, S. (2015). Uninsured rate down sharply since health law was enacted. Wall Street Journal. Retrieved June 28, 2015, from http://www.wsj.com/articles/uninsured-rate-down-35-since-health-law-was-enacted-1426528905.