The role of the social worker on the case management team
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
The role of the social worker in the acute care setting has been evolving for the last two decades. Once seen as the primary owners of discharge planning, social work roles and functions have changed and grown. During the 1990s, many hospitals eliminated social workers in an effort at cost containment, a strategy that proved to be non-beneficial over time. Today many hospitals are still struggling with determining the demarcation of the roles and responsibilities of the nurse case manager versus the social worker. In this issue we will take a look at how these roles are related and complimentary.
Social workers and nurse case managers have different, yet complimentary skill sets. Each discipline brings different knowledge to the interdisciplinary team. Case management departments have to consider the unique differences between the two disciplines when developing their case management models and when they are determining roles, functions, and caseloads. Some case management departments have combined the social workers and case managers and asked them to perform the same roles and functions. This kind of approach does not optimize the knowledge, education, and experiential differences between the two disciplines. It does not respect the talent and expertise that each contributes toward making the team stronger.
In the beginning of the transition toward acute care case management, most hospitals had what we now think of as the "traditional" model. These models evolved in a fee-for-service environment in which the fiscal incentives included more reimbursement for a longer length of stay. The reimbursement scheme was based on a per diem system in which few questions were asked in terms of medical necessity or appropriate length of stay. Lengths of stay were long, and hospitals were incentivized to keep patients in the inpatient setting.
Social workers in the acute care setting worked on a referral basis. Referrals were based on high-risk criteria that typically focused on social dysfunction and life-altering medical events with the option to also independently case find. The social worker performed mainly discharge planning combined with counseling. Discharge planning was, however, somewhat limited in comparison to today's healthcare environment. Home care services were much more limited in scope, and sub-acute care was not widespread. Social workers participated actively when patients needed to be placed in skilled nursing facilities and actively worked with the patient and family to make these kinds of transitions as smooth as possible.
Prior to prospective payment, utilization review consisted of determining whether the patient needed to be in the hospital. Even when patients appeared to no longer need acute care, little was done to move them out of the hospital in a pro-active manner. The philosophy was geared toward optimizing the length of stay by keeping the patient in the hospital as long as possible.
With the advent of prospective payment in the mid-1980s, the field began to shift. Prospective payment was developed to contain costs by prospectively determining the amount the hospital would be paid for specific patient types. The fiscal incentives changed from longer lengths of stay in a fee-for-service environment, to fixed payments that required tighter lengths of stay and resource management. The tighter fiscal environment that came as a result of prospective payment required some immediate changes in terms of how hospitals did business. In such an environment, the role of the social worker began to change and evolve. Social workers became more involved with discharge planning as it became more and more of a focal point. As discharge planning rose in importance, psychosocial counseling became less of a focus and became something that social workers did "when time permitted." While social work roles were rapidly changing, utilization review was evolving into case management. The role of the social worker was becoming pulled beyond the social worker's scope of knowledge as discharge planning became more clinical and less psychosocial in nature.
Unfortunately, during this time, social workers performing discharge planning and nurses performing utilization review remained segregated. Usually reporting to different administrators, there was minimal emphasis on integration of the roles, although the field was moving in that direction. By the end of the 1980s, many hospitals began to recognize the need to consider the roles and functions of both disciplines in a different way. By the end of the 1980s and beginning of the 1990s, many hospitals had begun to evolve into some form of acute care case management. These new models began to redefine the role of the social worker to address the changing healthcare landscape.
Paradigm shift for social workers
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
During the transition to hospital case management, many hospitals shifted to nurse-driven discharge planning. It was also during this time that some hospitals significantly reduced and/or eliminated social workers from the acute care setting. This approach, which was extremely short-sighted, resulted in hospitals being unable to meet the psychosocial needs of their patients.
This deficiency resulted in the advent of a redefinition of the role of the social worker. In addition to the psychosocial patient needs, managed care required other changes in how the business side of healthcare was viewed. A greater emphasis on authorizations, third-party payer denials, and the changes in home care and sub-acute care required more emphasis on nurses as the drivers of these processes.
The paradigm shift for social workers was a redefinition of their roles and functions. Nurse case managers began to focus on the management of care processes and outcomes as a way of managing shorter and shorter expected lengths of stay. In this accelerated environment, it became more important that all patients be assessed for continuing care needs. In addition, case managers began to manage the clinical components of discharge planning, and social workers then were able to concentrate on the psychosocial components of the discharge planning process.
Acute care social work in today's environment
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
The challenge in any case management model or department is to ensure that the skill sets of the social work and nurse case management staff are optimized. Recognize that each discipline brings different, yet complimentary, skills sets to the case management team. Each hospital must evaluate its specific patient population and needs, and adapt the staffing accordingly.
The case management department should prospectively create a list of referral criteria. The list should be dependent on the patient population the hospital serves and the split of nurse case mangers versus social workers. For example, in some departments the social workers might strictly be doing psychosocial counseling and intervention. In others, they might be doing a combination of psychosocial counseling and discharge planning. To determine the appropriate referral criteria, the roles and functions of the social workers must be clearly defined.
One way to think of this is in the illustration, below. This illustration describes the differences in skill sets that each discipline brings to the team. By aligning the clinical components of discharge planning with the nurse case manager, and the psychosocial components with the social worker, the work associated with discharge planning can be deployed appropriately. In this way, the skill sets of each discipline can be most optimized.
In this model, the social worker works collaboratively with the nurse case manager on high-risk cases. Patients are assigned to the social worker based on the pre-determined criteria list. In most case management departments, and in the integrated model in particular, the social worker and nurse case manager share some of the elements of discharge planning. Because the social workers are focused on the psychosocial elements, they might take primary responsibility for nursing home placements, legal issues related to discharge planning, and difficult family issues or hospice placements, as examples. These are issues with a greater degree of psychosocial need associated with them.
Purely psychosocial skills that social workers have include:
- providing emotional support related to illness, trauma, violence, abuse, or family conflict;
- identifying barriers to effecting a safe and timely discharge plan;
- collaborating with the case manager in the discharge planning process on complex patients;
- ensuring access to continuing case services, particularly for nursing home placements.
With an understanding of the unique skill sets of the social worker, a prospective referral list can be created. Below is a list of potential referral criteria:
- adjustment to illness/difficulty coping;
- major illness causing lifestyle change;
- behavior management problems;
- new or poor prognosis;
- end-stage disease;
- family concerns and/or conflicts;
- cultural and/or language issues;
- inadequate social and/or financial supports;
- issues of non-adherence;
- abuse and/or neglect of elder, adult, or child;
- multi-system trauma patient;
- psychiatric and/or substance abuse or history;
- homelessness;
- patient and/or family considering long-term care placement;
- blood alcohol level > 1.0 on admission.
Collaborating on issues of non-compliance
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
The list in the previous article is intended to represent issues that are purely social work in nature. However, like any two related disciplines, there are patient issues that can overlap and may be shared between the two disciplines. In these cases, there will be issues that can be appropriately shared between the nurse case manager and the social worker.
The RN case manager can address patient education by assessing for knowledge deficits related to medications, follow-up, appointments, etc. The social worker can address patients refusing to accept needed services and leaving against medical advice. The social worker can handle crisis intervention: substance abuse, family dysfunction, and/or problems coping with illness.
Here are additional examples of collaborating in various areas:
• Collaborating on issues of non-payment.
RN case manager: Addresses questions about insurance/benefit coverage.
Social worker: Addresses entitlements (Medicaid, disability, HIV/AIDS services, and food stamps) and community services (housing and Red Cross).
• Collaborating on obtaining medications.
RN case manager: Asks physician to prescribe least costly drug, asks hospital pharmacy to supply drug, and facilitates use of voucher system with local pharmacy.
Social worker: Refers patient for entitlements. Helps patient negotiate payment plan with local pharmacy. Explores other options such as veteran's services. Facilitates use of voucher system with local pharmacy.
• Collaborating on homeless patients.
RN case manager: Handles shelter referrals.
Social worker: Obtains social history related to homelessness, performs financial assessment, and contacts family/friends and community agencies.
Once a referral has been made to the social worker, a social work assessment should be completed. Each social work department should have a standardized assessment tool to use for this purpose. The referrals to social work should take place on the day of admission, if appropriate, or later in the stay if circumstances change. For this reason, ongoing assessments and reassessments are critical to the roles of the case manager and the social worker.
If the social worker picks up the case on admission, that situation does not mean that he or she needs to keep the case until discharge. The intervention might be a one-time event, and they might be able to close the case after that time. Conversely, a particular patient might not need to be seen by social work on admission, but during the course of the hospital stay, the patient's situation and/or needs change. At that point, the social worker might need to get involved and pick up the case. Therefore the caseload of a social worker will change throughout the course of a patient's hospital stay. The same patient might be assigned and then unassigned to the social worker as circumstances change. This situation is in direct contrast to the role of the nurse case manager, who picks up the patients on admission and keeps them until discharge.
For these reasons, it is much more difficult to measure social worker caseloads. The volume of patients should be based on "open" cases, not beds, and should not generally exceed 18 patients.
Social workers and psychosocial counseling
Some social workers might need to have their counseling skills refreshed. It is not uncommon for a social worker to take a job as a discharge planner in a hospital without ever having done psychosocial counseling and support work. When this model transition takes place, a social worker who has not done counseling, or has not done counseling for a long time, might feel nervous about the new function. It is important that case management leaders understand this nervousness and provide refresher educational opportunities to these individuals.
The opportunity for a social worker to transition away from discharge planning and toward more purely social work functions such as counseling will require that the entire organization understand the evolving and emerging roles of social work in contemporary acute care case management. If the physicians in your hospital only know social workers as discharge planners, they might need to be informed of the shift of some discharge planning functions away from social work and to the nurse case managers. A good communication plan will be important, as well as constant reinforcement to the interdisciplinary care team as issues arise. For the perception of social work to change, communication and feedback will be required.
Consider each inappropriate social work referral as a "teachable moment." Explain the new social work role, and explain the rationale for it. The department of nursing will be just as important in this process, as too many might be accustomed to calling social work for issues that might now need to go to the RN case manager. In addition, they will need to understand that the social work staff is available for other issues under the umbrella of psychosocial counseling and support.
Of course the flip side to this is the situation in which a hospital might have social workers doing no discharge planning at all. In these circumstances, if the integrated model is being implemented, then social workers might need to pick up some discharge planning functions that they were not doing in the past. The social workers will need to be educated on everything related to discharge planning and will have to learn how to manage both functions, i.e. discharge planning and psychosocial counseling and support.
The role of social work is transitioning and new case management models are being implemented that optimize the skill sets of the nurses and the social workers. Even so, old perceptions and paradigms are sometimes hard to change. Be patient, but diligent, as these transitions take place.
The role of the social worker has evolved and grown as acute care case management has evolved and grown. Today's social workers have a renewed interest in psychosocial support to their patients and families. In addition, social workers play a vital role in helping to facilitate socially complex discharge planning issues and the transitions of patients from the acute to lower levels of care. Each case management department should take the time to assess their social worker's roles and functions to ensure that they are meeting the needs of the current and future healthcare environments.
The role of the social worker in the acute care setting has been evolving for the last two decades.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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