11 Social Work and the Health Care System

Introduction

Medical social work can be defined as a specific form of specialized medical and public health care that focuses on the relationship between disease and human maladjustment (NASW, 2012; Gehlert, 2011). Medical social work is viewed as one of the most significant fields in practice. It has been acknowledged as the first subspecialty discipline to practice in hospital, public health, and clinical settings (Allen & Spitzer, 2016).

Medical social workers practice in a variety of healthcare settings such as hospitals, community clinics, preventative public health programs, acute care, hospice, and out-patient medical centers that focus on specialized treatments or populations. These professionals help patients and their families through life-changing and sometimes traumatic medical experiences. They often monitor and evaluate a patient’s mental and emotional health as they transition through a variety of medical treatments. Medical social workers also often find themselves helping the patient and family solve problems be that of financial difficulties or one-to-one counseling to help cope with new stressors (Mizrahi & Davis, 2008; NASW, 2016).

In the 20th century, social service departments in hospitals were developed to address problems associated with the increase of immigration and poverty. The need for medical social work in the United States has intensified due to the substantial inequality of health care resources. Individuals and families that live in poverty or who are a part of certain ethnic communities are additionally at a disadvantage because they are more prone to experience higher rates of acute or chronic illnesses. Therefore, the unequal distribution of healthcare insurance coverage in the United States hinders some people from seeking medical treatments due to their socioeconomic status.  In 2020, 31.6 million people were uninsured in the US, including 3. million children (Cha & Cohen, 2022).

All medical social workers must familiarize themselves with cross-cultural knowledge in order to provide effective health care. They do this by familiarizing themselves with an array of different ethnicities, cultural beliefs, practices, and values that shape their family system. Medical social workers must have the ability to recognize how oppression can affect an individual’s bio-psycho-social-spiritual well-being. As future social workers, being able to understand and identify these issues will enhance your skills as a professional to provide excellent health care (Mizrahi & Davis, 2008; NASW, 2016).

Goals of Medical Social Work Practice

The National Association of Social Workers (NASW) Standard for Social Work Practice in Health Care Setting (2016) describes eight standards of practice for health care social workers to follow. The eight goals were created as a guideline so that medical social workers would deliver excellent care. The Eight Standards of Practice for Health Care Social Workers are:

1. All medical social workers in the healthcare arena must practice in accordance with the social work code of ethics.
2. Advocate for client’s right to self-determination, confidentiality, access to supportive services and resources, and appropriate inclusion in decision making that affects their overall health and well-being.
3. Encourage social work participation in the development, refinement, and integration of best practices in health care.
4. Enhance the quality of social work services provided to clients and families in health care settings.
5. Promote social work participation in system wide quality improvement and research efforts within health care settings.
6. Provide a basis for the development of continuing education materials and programs related to social work in health care settings.
7. Promote social work participation in the development and refinement of public policy at the local, state, federal, and tribal levels to support the well-being of clients, families, and communities served by the rapidly evolving U.S. health care system.
8. Inform policymakers, employers, and the public about the essential role of social workers across the health care continuum.

The first and second standards of practice are extremely important to remember as you become professional social workers. Social work’s primary goal is to provide excellent service and to promote social justice for all patients, thereby ensuring that all medical and psychological services are met. Therefore, all medical social workers must practice in accordance with the social work code of ethics and core values.

Medical social workers must also embrace the importance of human relationships by building a positive and lasting rapport with clients. Medical social workers advocate for the patient’s right to self-determination. Every patient is entitled to make their own decision based on treatment recommendations. The treatment team may desire and advocate for the best medical care for their patient; however, it is the patient’s decision to follow through with treatment. There are times when a patient may not be able to speak for themselves. You could encounter these situations when the patient is a child or if an adult has a cognitive impairment that enables them to make decisions for themselves. In these cases, the family has the authority to make the decision based on what they feel is the best course of action (NASW, 2016). Finally, social workers should always strive for professional competence by increasing the use of education and research and applying them to practice (NASW, 2016).

Teamwork in Healthcare

The use of multidisciplinary teams is an effective part of healthcare treatment. A multidisciplinary team is defined as a group of professionals that specialize in different disciplines that come together to deliver quality health care that addresses the patient’s well-being (Mitchell, Tieman & Shelby-James, 2008; Nancarrow et al., 2013; Allen & Spitzer, 2015). Medical social workers, physicians, nurses, and activity therapists experience several types of interactions with patients in which different behaviors are assessed, and the team then collaborates to resolve a variety of issues (Allen & Spitzer, 2015). Using this approach allows the team to provide better-quality outcomes and to enhance client satisfaction. Of course, a team may be comprised of members from the same disciplinary background. An example would be a team of medical social workers who discuss treatment plans according to the results of a patient’s assessment. Working in a team allows for individual ideas to be heard and as a group develop a specific treatment plan.

Biopsychosocial-Spiritual Assessments

The recommended health care approach to psychological evaluations is through the use of a biopsychosocial-spiritual assessment (NASW, 2016; Social Work Licensure Exam, 2008). This approach focuses on the individual as a whole and takes into account their biological, psychological, social, and spiritual sense of self. Together the interdisciplinary team can focus on the individual’s treatment from all professional perspectives. Using this approach allows for each discipline to provide optimal health care (Gehlert & Browne, 2011).

The term biopsychosocial assessment or biopsychosocial-spiritual assessment is an approach you will hear throughout school. This model examines not just the medical aspect of care whose primary focus is on the biological causes of a disease. Rather, the biopsychosocial-spiritual model examines a patient’s well-being through a holistic approach (Gehlert & Browne, 2011; McDaniel, Hepworth & Doherty, 2014. Allen & Spitzer, 2015). The Biopsychosocial Spiritual (BPSS) Assessment offers a historical context for what the client presents with and assesses the client’s history, strengths, and resources. How do the following four areas contribute to the client’s current functioning?

1. Biology: basic needs – the client’s access to food, shelter, etc.
2. Psychological: history, personality, self-concept, medication, diagnosis, and treatment history
3. Social: support system (friends, family, social environment). Knowledge of life stages and development are essential
4. Spiritual: sense of self, sense of meaning and purpose in life, religion, and its context in client’s life

The Biopsychosocial assessment may use the ROPES method of identifying strengths: Resources, Options, Possibilities, Exceptions, and Solutions (Social Work Licensure Exam, 2009).

Medical Social Work Job Descriptions

General Functions

According to The Social Workers in Hospitals and Medical Centers Occupation Profile (2017), medical social workers employ a myriad of skills and approaches to ensure quality health care. The following list provides examples of tasks that most medical social workers use when providing services.

• Conducting initial psychosocial-spiritual assessments and screenings for patients and making referrals for individual, family and or group therapy if needed.
• Educating the patient and family members of the individual’s illness and treatment options, as well as consequences of various treatments or refusal of treatment.
• Helping patients and their families adjust to the hospital dynamics and exploring emotional and social responses to illness and treatment.
• Educating the patient and family on the roles of the healthcare team. Assisting patients and their families in communicating with one another and with the members of the multidisciplinary team.
• Facilitating decision making on behalf of patients and families.
• Educating hospital staff on patients’ psychosocial issues.
• Coordinating patient discharge with a safety plan and continued care planning by providing patient navigation services.
• Arranging resources/funds for finances, medications, medical equipment, and other special needs services (National Association of Social Workers, 2016).

Emergency Room Social Work

Emergency room social workers provide services to triage patients. Depending on the location and clientele of the specific hospital, one of their main functions may be to diagnose and assess patients who show signs of mental illness. The medical social worker also performs discharge planning as a means of assurance that every patient will have a safety plan when discharged from the hospital (Fusenig, 2012). The following is a list of tasks that emergency room social workers may perform:

• Performs mental health assessments and suicide evaluations.
• Conduct stress evaluations.
• Death notifications to family members.
• Counsel’s victims of violent crimes, domestic violence, substance abusers and families of deceased or terminally ill patients.
• Refers patients to community resources.
• Provides financial assistance.
• Conducts child and adult protective service reporting.
• Conducts domestic violence and sex trafficking screenings.
• Diagnoses and conducts mental health intake evaluations to establish proper psychiatric care.
• Conducts discharge planning; knowledge of community resources and services (Fusenig, 2012).

Hospice or Palliative Care Social Work

Hospice social workers work in a variety of different medical settings. At times, there are hospice organizations that come into a hospital to provide assistance to those who are nearing the end of their life. The following is a list of tasks that hospice and palliative care social workers perform:

• Ensuring that patients and family members have access to resources that will provide physical comfort.
• Providing emotional and spiritual support to patients and their family members.
• Lead support groups for family members and in-service training to nurses, physicians, and other social workers who are involved in the treatment process.
• Ensure proper medical transitions from palliative care to hospice care if needed.
• Act as care coordinators; providing treatment planning with other members of the patient’s treatment team (SocialWorkLicensure.Org, 2017).

Advocacy and Policy In Healthcare-Related Social Work

One of the most important roles of all social workers is to advocate for their clients. In the healthcare system, social workers do this by representing, promoting change, speaking on behalf of the client, assessing rights and benefits, and securing social justice. It is pertinent that all receive fair and equitable access to all medical services and benefits (NASW, 2012).

The healthcare system is driven by policies that outline the rules and regulations of the organization. Policies are developed based off the organization’s ideas of acceptable and well-defined standards of healthcare practices. These policies are also implemented to reduce chaos, confusion, and legal issues that may arise due to unethical practice. Some of these policies include:

• Patient care recipient rights.
• Abuse and neglect investigation policies.
• Administrative policies
• Information management policies – HIPAA (Health Insurance Portability and Accountably Act)
• Accreditation Standards
• Medication Procedures

All physicians, nurses, social workers, administrative staff, and patient care workers must abide by all policies to produce effective outcomes for the organization.

Job Description Summary

Medical social workers play a very important role in the care and needs of all patients in the health care system. Above was a brief introduction to several types of medical social work job descriptions.

Always keep in mind, as you pursue your education in social work, and later in the health care field, the profession and practice will always be founded on the code of ethics.

Intimate Partner Violence

As mentioned in Emergency Room Social Work, it may be common to identify and serve the needs of people experiencing intimate partner violence (IPV) and human trafficking, especially sex trafficking. Therefore, the following sections will introduce you to these critical areas of need.

IPV Defined

“Violence sprouts in intimacy. Except for the police and army, family is the most violent social group, and a home is the most violent social space of our society. A person is most likely to be hit or killed in his/her own home by another member of the family than anywhere else or by anyone else” (Stark & Flitcraft, 1996)

Intimate partner violence has been recognized in the United States and other countries as a significant public health issue. This type of violence is universally condemned due to its heinous nature. The term,

intimate partner violence (IPV) is defined as any incident or pattern of behaviors (physical, psychological, sexual, or verbal) used by one partner to maintain power and control over the relationship. IPV is also considered to be an act of violence that takes place between intimate partners – heterosexual, cohabitating, married, same sex or dating (McGarry, Ali, & Hinchliff, 2016; Stark & Filtcraft, 1998).

Historically, in the United States, IPV has been considered an act of violence committed by men towards women. Although, this is still a societal belief, according to the National Intimate Partner and Sexual Violence Survey of 2010 – 2012, more than “1 in 4 men (28.5%) in the United States have experienced rape, physical violence and or stalking by an intimate partner in their lifetime, and 1 in 7 men (13.8%) have experienced severe physical violence by an intimate partner (e.g., hit with a fist or something hard, beaten, slammed against something at some point in their lifetime” (Achieng, 2017, p.2).

Types of Violence

Intimate partner violence (IPV) refers to violence and abuse by a current or former romantic partner and includes the following types of violence (Breiding et al., 2015):

• Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.
• Sexual violence is forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical
  sexual event (e.g., sexting) when the partner does not or cannot consent.
• Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own
  safety or the safety of someone close to the victim.
• Psychological aggression is the use of verbal and non-verbal communication with the intent to harm a partner mentally
  or emotionally and/or to exert control over a partner.

Mandatory Reporting

In many intimate partner violence cases, victims have the tendency to not disclose to medical professionals or law enforcement due to repercussions from the offender. Many victims fear retaliation, family separations, violation of confidentiality and security. In these instances, a social worker could do more harm than help the situation. As of 2002 only seven states have laws that make it mandatory to report actual or suspected victims of IPV (Hamberger, 2004). Most states have laws where reporting is an option. However, conditions apply for protecting an individual’s identity. Social workers can be put into these challenging positions because of confidentiality and following an ethical obligation. Potential positive outcomes and limitations from mandatory reporting by medical social workers include:

• Increase victim’s safety due to early detections and interventions.
• Improvement of patient care due to early identifications, which would allow for physicians and social workers to preform rape kits, treatment of any diseases or injuries due to the assault.
• Allow social workers to immediately assess trauma and to advocate for resources as soon as the incident occurred.
• Improve hospitals resources and outcomes by better documentation of IPV into medical records which will increase the availability of data to facilitate future research.

However, mandatory reporting could undermine a key component of IPV interventions of empowering the individual’s rights to self-disclosure (Hamberger, 2004).

Prevention of IPV In Healthcare

Health/medical social workers focus primarily on the individual, family, and community to help reduce violence and its consequences. To reduce the occurrences of violence, social workers and community action agencies develop interventions to educate communities through public awareness using television commercials, billboards, radio broadcasts, IPV trainings, self-defense classes, and IPV screenings in hospitals (Haegerich & Dahlberg, 2011). There are four primary steps that health social workers take to insure a prevention plan.

• Measure the incidence and burden over time through public health surveillance.
• Identify factors that place people at risk for, or protect people from, experiencing violence as the victim or perpetrator.
• Developing and using testing strategies through rigorous evaluation that modify risk and protective factors to prevent violence from occurring.
• Facilitating the adoption and dissemination of effective strategies in communities to affect change (Dahlberg & Haegerich, 2011).

Human Trafficking

Human trafficking is defined as the recruitment, transportation, and or harboring of a person by means of threat, force or another form of coercion, abduction, fraud, and deception. It is through the abuse of power over vulnerable individuals that perpetrators can exploit them. It is often combined with extreme violence, torture and degrading treatment that leave psychological wounds for the rest of their lives. Human and sex trafficking is a violation of human rights. It is estimated to effect more than two million victims worldwide (Ahn, Albert & et.al, 2013; Gajic-Veljanoski & Stewart, 2007).

Trafficking Statistics

In 2021 the National Human Trafficking Hotline identified over 16,000 likely vicitms of uman trafficking. “Human Trafficking”, “modern slavery” and “trafficking in persons” are all common terms to refer to when a trafficker exploits another by making them perform labor or sex acts.

• The top types of trafficking are Escort Services, Pornography, Illicit Massage, Health & Beauty, Residential Based Commerical Sex, and Personal Sexual Servitude. During recruitment processes, some are promised substantial earnings and jobs as nannies, waitresses, and modeling. The top recruiter types for human trafficking are Family Members/ Caregivers (33%), Intimate Partners (28%), and Employers (22%).
• The top risk factors for being human trafficked include recent migration/relocation (54%), mental or physical health concerns (10%), substance use concerns (9%), unstable housing (8%), and runaway/homeless youth (7%).
• In 2021, there were 16,610 identified likely victims of human trafficking. With 65% being females.
• In 2016, the National Center for Missing & Exploited Children estimated that 1 in 6 endangered runaways reported to them were likely sex trafficking victims.
• In a 2014 report, the Urban Institute estimated that the underground sex economy ranged from $39.9 million in Denver, Colorado, to $290 million in Atlanta, Georgia.

There are two different forms of human tracking: (1) forced labor and (2) sex trafficking. The following section will focus on sex trafficking due to the increased prevalence in the United States. Additionally, this section will also focus on the roles that health social workers take to identify victims and to provide proper medical care (Gajic-Veljanoski & Stewart, 2007).

Sex Trafficking

Sex trafficking is defined as a commercial sex act which is conducted by force, fraud, coercion, or in which the child or adult is made to perform sexual acts for money. A majority of victims in the United States come from countries such as east and south Asia, Latin America, Russia, and Eastern European countries (Salett, 2006). Health social workers play a vital role in the identification of victims. Below is a list of clues that social workers and other medical professionals look for when assisting patients in hospitals.

• Multiple people in a cramped space
• People living with their employer
• Inability to speak to individuals alone
• Employers holding identity documentation
• Inability to move or leave my current job
• Bruises or other signs of battery
• Submissive, fearful, or depressed demeanor
• Little or no pay

Victims tend to not disclose their issues due to fear of law enforcement, repercussions to family members and most are not aware of agencies that offer services specifically to the population.

Health social workers can also help eliminate the potential of sex trafficking by:

• Identifying victims and assisting them with the proper resources for medical, psychological and shelter needs.
• Serve on organizational committees or as board members who specifically focus on assisting sex trafficking victims and help to improve rehabilitation and reintegration into society.
• Educate vulnerable populations such as children in schools or prostitutes that come through the emergency room on possible preventative measures and signs to look for when being encountered by certain populations (Salett, 2006; Ahn, Albert & et.al, 2013).

Summary of IPV and Sex Trafficking

In health care settings, health social workers will encounter victims and survivors of domestic violence and sex trafficking. Having the knowledge of the increased prevalence of these two societal epidemics will allow social workers to identify victims, promote educational resources and to prevent the increase of violence.

Healthcare Chapter Summary

This chapter examined the roles of medical social workers. Medical social work is a sophisticated and challenging practice that is conducted in multidisciplinary and fast-paced environments. Therefore, professional social workers in this field need to have a clear and concise understanding of the NASW code of ethics and how it relates to patient care. Medical social workers are in charge of advocating for diverse, sometimes vulnerable individuals and communities. Hospitals and insurance companies have become engrossed with enhancing the intake of profits. Because of that, it seems they lack the desire to enhance and develop a promising health care system that will support all populations. Medical social work is so important because it embraces the importance of teamwork, advocacy, and a true commitment to the individual’s medical and personal health care. Finally, please remember that just because you may not hear about or have knowingly been exposed to a societal epidemic (sex trafficking and intimate partner violence) does not mean it is not around you. Be a change agent who holistically supports the needs of each individual to enhance the quality of health care to the world.

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