The Evolving Role of Social Work in Managed Care, Disease Management and End-of-Life Care

by Karen Michaeli, M.S.W.

The need for new roles in social work

Social workers have long participated in health care as medical social workers, addressing the psychosocial dimensions of a patient's hospital stay and discharge.<span> </span>Social worker Ida Cannon (1877-1960) believed that "medical practice could not be effective without examining the link between illness and the social conditions of the patient" (Bartlett, 1975) and in 1915, established the first hospital social work department in the United States at Massachussetts General Hospital. With trends in health care including increased outpatient services and attention to lifestyle factors in disease, social workers must adapt to the new health care environment, defining clinical roles in whole-patient care outside the hospital setting. "Recent research suggests that [existing] social work practice roles are being impeded by a movement toward ambulatory and community care, the dynamics of managed care, the requirement that outcomes of practice be measurable, the growing elderly population, the more frequent occurrence of biomedical ethical issues in health care delivery, and increasing numbers of people from diverse cultural backgrounds who require health care" (Berger et al., 1996; Kadushin & Egan, 1997; Netting & Williams, 1996).

It is also necessary for the discipline of social work to define roles in developing managed care policies and marketplace strategies. "Policy and macro practice challenges concern the processes of state governments, insurance commissions and the regulation of managed care organizations, the creation of more fully integrated systems of service delivery, and analyses of the implications of adoption of market mechanisms in this fragile arena of human services. Cultivation of a future generation of health administrators who must learn 'to speak the language of business no matter how crass the terminology may seem' is a part of these requirements" (Netting & Williams<span class="medium-normal">, 1996</span>).

Disease management's contribution to the need for new social work roles

A development in the field of managed care is disease management. Sometimes referred to as care management or the chronic care model, disease management is defined by the Kaiser Permanente medical care system as "coordinated health care for logical groupings of members…intended to prospectively improve, maintain, or limit the degradation of their functional status. Coordinated means that care is delivered by teams of varying composition. Logical groupings refers to disease-specific groups such as patients with a single chronic disease (for example, diabetes)" (Juhn, Solomon & Pettay, 1998), asthma, congestive heart failure, or even, as proposed here, the condition known as end-of-life.

<span>The field of social work is uniquely positioned to ensure the effective administrative</span> as well as clinical delivery of disease management programs because of the discipline's characteristic person-in-environment theoretical framework, also described as an ecosystems perspective. The environmental, multidisciplinary nature of the disease management model is compatible with social work's view of the individual as a coconstructor of larger, dynamic, intersecting systems. "The hospital…must become part of a primary care network of community-oriented delivery systems focused on chronic disease management. In this model, the social worker treats the patient throughout the continuum of care. Therefore, dynamic training that addresses the changing health care environment will be needed" (Berkman, 1996). With clinical as well as administrative and policy-focused ("integrated") concentrations offered in graduate social work education as well as the dual MSW/MBA, MSW/MPH and MSW/MHA degree programs beginning to appear, masters level social workers posses not only the training to participate clinically in disease management, but also the systems-level expertise to provide administrative leadership in developing and delivering such programs.

Social work and health care management: common skill sets

Health care management skills include motivation, communication, delegation, counseling, strategic planning, personnel management, staff coaching, time and stress management, teamwork, conflict management, interviewing, budgeting and resource management (Sperry, 2003), all of which may be considered skills integral to social work practice. Specific organizational concepts such as change management may also benefit from social work leadership. Organizational change is an area of particular expertise for integrated social work practitioners: Brager and Holloway (1978) describe change management or "change practice" as an actual field of social work practice. Business theorists in recent years have introduced concepts such as systems theory and learning organizations (Senge, 1990), which echo social work's systems perspective and empowerment theory.

Similarly, stewardship is another empowerment-oriented trend in business, which proposes that organizations should replace traditional management tools of control and consistency with partnership and choice. "Individuals who see themselves as stewards will choose responsibility over entitlement and hold themselves accountable to those over whom they exercise power" (Block, 1993). This is a classic social work perspective.

The interdisciplinary collaboration necessary in health care management is another characteristic of social work practice. According to Bronstein (2003), "Trends in social problems and professional practice make it virtually impossible to serve clients effectively without collaborating with professionals from various disciplines." Disease management expert Patricia Salber, in a commissioned paper on research priorities for chronic illness for the Agency for Healthcare Research and Quality, reports that "teams of experts, ranging from advanced practice nurses to dieticians to behavioral change specialists need to be brought to bear if we are to provide meaningful ongoing support to patients living day after day, year after year with one or more chronic conditions" (Salber, 2001). The clinical participation of social workers in interdisciplinary care teams is well established. "Quality and cost benefits can occur when social workers address such issues as adherence, psychosocial factors, and depression in terms of the patient's global recovery and concurrent enhancement of quality of life" (Claiborne & Vandenburgh, 2001). The changing landscape of health care includes "increasing numbers of immigrants, people in poverty, and patients with limited or no insurance. These changes necessitate the inclusion of social workers in interdisciplinary teams. Schilling and Schilling (1987) argued that this changing population has prompted a move from health care's entrepreneurial emphasis to a focus on clinics and treatment of special populations" (Bronstein, 2003).

End-of-life care and long-term care as "disease management populations", and the social work role

End-of-life care and long-term care serve the "special populations" to which Bronstein refers and already benefit from the practice of clinical social workers, but these arenas of care may benefit as well from the organizational management and strategic leadership of "integrated" social workers. Furthermore, these areas of chronic care would be more effectively managed, in terms of both quality and cost, from the disease management perspective. The approach may be understood as a mass-customized (business concept referring to the customization and personalization of products and services for individual consumers at mass production prices), patient-centered variation of social work models of community assessment, particularly "problem-oriented assessments" which use interdisciplinary teams to "coordinate programs and cases" (Hardcastle, Wenour, & Powers, 1997).

<span>Indeed, case management is a hallmark discipline of social work practice that encompasses not only the development and coordination of services to individuals or communities, but also to organizations, institutions and potentially even industries. "The use of case manager as a concept and a job title is diverse. It ranges from a position title providing a minimal set of services…to providing a comprehensive array of services in which the case manager provides little direct intervention or few services, concentrating instead on system development and management tasks" (Hardcastle et al.).</span>

A social work systems perspective on disease management's place in end-of-life care would emphasize a spectrum of assets and needs from the community to the individual level. Patient-centered team care, as well as the design and management of such service delivery, is well aligned with social work's practice of strengths-based community assessment (Murty, 2004) and client-centered practice, and effectively addresses the constellation of patient needs at the end of life. Cost effectiveness is another benefit of a disease management model for palliative care. There exists some conflicting research addressing the common perception that "most medical expenses are accounted for by terminally ill persons whose lives were prolonged by expensive techniques" (Lubitz & Riley, 1993) though regardless of the accuracy of this claim, the disease management model has cost saving potential for the treatment of any long-term condition including the "condition" of dying. Clinically, social workers act as "'context interpreters' by providing individuals and families with the information they need to understand the natural course of the illness, the likely dying trajectory, and the medical decisions that they are likely to face" (Bern-Klug, Gessert, & Forbes, 2001). Such context interpretation is also crucial to the management of palliative care programs at the executive leadership level.

Long-term care, too, is an arena with the potential for quality improvement with the application of the disease management model as well as leadership from the social work discipline. Because of lower infant mortality rates and improvements in the care of those with chronic illness, most people "die of chronic, progressive illnesses (such as end-stage heart and lung disease, cancer, stroke, and dementia) with unpredictable clinical courses and prognoses; current reimbursement systems are unresponsive to this patient population and their families, failing to provide primary care with continuity, support for family caregivers, and homecare services, and instead promoting fragmented specialized care tied to procedures and hospitals, for lack of any other coherent alternative financing mechanism" (Meier & Morrison, 1999). A Kaiser Family Foundation health poll report released in June 2005 indicates that consumer perceptions of long-term care are poor. "<span>Compared with other players in the health care industry, nursing homes rank below drug companies in the share of adults who say they are doing a 'good job' serving health care consumers. While majorities say nurses (84%), doctors (69%) and hospitals (64%) do a 'good job' serving consumers, nursing homes (35%) rank below pharmaceutical companies (43%) and just above health insurance companies (34%), and HMOs (30%)" (Kaiser Family Foundation, 2005). The current disjuncture between the long-term care system and the needs of its consumers is unacceptable to patients and families. A streamlined, team-based management approach including social workers at both clinical and executive levels would improve quality by transforming functional relationships between professionals and patients and among professionals themselves; would create improved, multifactorial means of defining and measuring outcomes; and would reduce the costs of long-term care as well as palliative care.</span>

<span>
</span> 

References

Bartlett, H.M. (1975). Ida M. Cannon: Pioneer in medical social work. Social Service Review, 49(2).

Berger, C., Cayner, J., Jensen, G., Mizrahi, T., Scesny, A., & Trachtenberg, J. (1996). The changing scene of social work in hospitals. Health & Social Work, 21, 167-177.

Berkman, B. (1996). The emerging health care world: Implications for social work practice and education. Social Work, 41, 541-551.

Bern-Klug, M., Gessert, C., & Forbes, S. (2001). The need to revise assumptions about the end of life: Implications for social work practice. Health & Social Work, 26(1), 38-48.

Block, P. (1993). Stewardship: Choosing service over self-interest. San Francisco: Berrett-Koehler.

Brager, G., & Holloway, S. (1978). Preparing the organization for change. Changing Human Service Organizations. New York, NY: Free Press.

Bronstein, L. (2003). A model for interdisciplinary collaboration. Social Work, 48(3), 297-306.

Claiborne, N., & Vandenburgh, H. (2001). Social workers' role in disease management. Health & Social Work, 26(4), 217-225.

Hardcastle, D.A., Wenour, S., & Powers, P.R. (1997). Community practice: Theories and skills for social workers. NY: Oxford University Press.

Juhn, P., Solomon, N., & Pettay, H. (1998). Care management: The next level of innovation for Kaiser Permanente. Permanente Journal, 2(2), 38-43.

Kadushin, G., & Egan, M. (1997). Educating students for a changing health care environment: An examination of health care practice course outlines. Paper presented at the Annual Program Meeting of the Council on Social Work Education, Chicago.

Kaiser Family Foundation. (2005). Kaiser health poll report: The public's views on long-term care. Retrieved July 15, 2005 from http://www.kff.org/healthpollreport/june_2005

Keigher, S.M. (1997). <span>What role for social work in the new health care practice paradigm?</span> Health & Social Work, 22<span>(2),</span> 0360-7283.

Lubitz, J.D., & Riley, G.F. (1993). Trends in Medicare payments in the last year of life. The New England Journal of Medicine, 328(15), 1092-1096.

Meier, D.E., & Morrison, R.S. (1999). Old age and care near the end of life. Generations, 23(1), 6-11.

<span>Murty, S. (2004). Mapping community assets: The key to effective rural social work. In T. L. Scales and C. L. Streeter (Eds.), Asset-Building to Sustain Rural Communities. Pacific Grove, CA: Brooks/Cole.</span>

Netting, F. E., & Williams, E G. (1996). Case management-physician collaboration: Implications for professional identification, roles, and relationships. Health & Social Work, 21, 216-224.

Salber, P.R. (2001). Outcomes research priorities in chronic care: A purchaser perspective. Rockville, MD: Agency for Healthcare Research and Quality.

Schilling, R.F., & Schilling, R.F. (1987). Social work and medicine: Shared interests. Social Work, 32, 231-234.

Senge, P.M. (1990). The Fifth Discipline: The art and practice of the learning organization. London: Random House.

Sperry, L. (2003). Becoming an effective health care manager: The essential skills of leadership. Baltimore: Health Professions Press.