Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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3 A Workforce to Integrate Social Care into Health Care Delivery
3 A Workforce to Integrate Social Care into Health Care Delivery
Pages 59-84
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From page 59... ...
Department of Health and Human Services, such as Addressing the Social Determinants of Health: The Role of Health Professions Education (Committee on Training in Primary Care Medicine and Dentistry, 2016) , shed light on the critical issues of the role of the workforce in addressing social determinants and provide recommendations for improvement.
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From page 60... ...
For example, lawyers have become critical team members for addressing legal matters related to housing and other social factors among patients in community 1 As detailed below, types of workers who provide social care can include nurses; physi cians; social workers; community health workers; social service navigators, aides, assistants, and trained volunteers; home health aides; personal care aides; family caregivers; case managers; gerontologists; lawyers; and others.
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From page 61... ...
. Other factors aiding in the effective functioning of interprofessional teams include allowing team members to maintain their professional identities, particularly in the case of social care workers who work within health care (Garfield and Kangovi, 2019)
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From page 62... ...
. For example, physicians accompanying a social worker on home visits typically come away with a new appreciation for how the social needs that were identified could compromise the care plan they had in mind (Fulmer et al., 2004)
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From page 63... ...
. THE TRADITIONAL HEALTH CARE WORKFORCE As noted above, effectively addressing people's complex social needs requires that workers within the traditional health care system collaborate with workers from outside of it, such as the staff of social service and public health agencies and community-based organizations.
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From page 64... ...
Some nurses are care managers and have great involvement in addressing social needs within health care delivery. Home care nurses assess patients' and families' social needs and may refer patients who have complex social needs to social workers.
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From page 65... ...
Some of the competencies are related to awareness activities, such as being able to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds. Others of the competencies are related to assistance activities, such as the ability to work in interprofessional teams to enhance patient safety and improve patient care quality; having sensitivity and responsiveness to a diverse patient population, including patients diverse in gender, age, culture, race, religion, disabilities, and sexual orientation; and being able to work effectively as members or leaders of a health care team or other professional group (ACGME/ABFM, 2015; Cate, 2013; Leipzig et al., 2014; Parks et al., 2014)
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From page 66... ...
. Medical social workers are directly involved with the health of individuals and work in a variety of settings, typically hospitals, outpatient clinics, community health agencies, social service agencies, skilled nursing facilities, long-term care facilities, hospices, and health insurers' offices.
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From page 67... ...
29) In the area of practice in interprofessional teams, the standards for s ocial workers in health care settings include, for instance, "Social workers practicing in health care settings shall promote collaboration among health care team members, other colleagues, and organizations to support, enhance, and deliver effective services to clients and client support systems" (NASW, 2016, p.
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From page 68... ...
. The North Carolina Community Health Worker Initiative provides technical assistance from CHW experts through the Association of State and Territorial Health Officials with the aims of confirming the roles and competencies of CHWs, standardizing their training and certification, and identifying the infrastructure and policy supports necessary for the effective use of CHWs (NC DHHS, 2019)
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From page 69... ...
Home Health Aides and Personal Care Aides Within the health care sector, home health aides and personal care aides provide extensive social support services to assist older adults and disabled and post-acute care patients in their homes. These direct care workers have close contact with the country's most disadvantaged patients.
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From page 70... ...
According to the National Association for Professional Gerontologists, certified gerontologists report holding such positions as direct service providers (health and community support services) , administrators, chief executive officers, entrepreneurs and business owners, therapists and counselors, resource navigators and information specialists, program directors, professors, researchers, pastors, and geriatricians and other medical doctors.5 In certain states, organizations employing gerontologists with at least a bachelor's degree can be reimbursed for services specified in the waiver agreement with the Centers for Medicare & Medicaid Services' Home and Community-Based Services Program (California Department of Health Care Services, 2019)
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From page 71... ...
Medical–legal partnerships integrate the unique expertise of lawyers into health care settings in order to help clinicians, social workers, and care managers address the social needs of patients in ways that can reduce many health inequities (Regenstein et al., 2018)
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From page 72... ...
. However, this definition of clinical social work is limiting in that it does not reflect the broad array of services that clinical social workers provide, which creates confusion about social work's scope of practice despite curricula and core competencies that reach beyond behavioral health diagnosis and treatment.
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From page 73... ...
As such, the current policies governing the scope of practice for health professionals may not reflect the emerging interest in integrating social care into health care delivery, in the effective use of interprofessional teams, and in having all health care workers practicing to the top of their education and training (IOM, 2011)
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From page 74... ...
• Care Neighborhood is a program in Northern California in which CHWs reach out to those most at risk to address their social, med ical, and behavioral health care needs in order to reduce costs and decrease the use of hospitals and emergency departments (EDs) .7 Care is delivered by one to two CHWs, who are staff members based at each health center organization and integrated into the medical home team (senior leader champion, social worker, and 6 For more information, see http://www.healthreform.ct.gov/ohri/lib/ohri/1._hennepin county-medical-center.pdf (accessed on July 15, 2019)
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From page 75... ...
. Following a hospitalization or re habilitation stay, Bridge social workers engage with the atient, p family members, and inpatient and outpatient providers to en sure smooth discharges that are attentive to social needs and that reinforce primary care engagement.
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From page 76... ...
These health assistants report to a case manage ment team that includes social workers as well as physicians, nurses, and pharmacists. The community health assistants take referrals from primary care physicians and case managers and also directly from community organizations, which can refer someone believed to have a social or health-related need that could benefit from outreach and assistance.
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From page 77... ...
Social workers are specialists in providing social care who have a long history of working within health care delivery. odels that M include community health workers show promise.
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From page 78... ...
2016. Challenges faced by social workers as members of interprofessional collaborative health care teams.
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2016. Interprofessional collaboration and integration as experienced by social workers in health care.
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2018. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: A randomized clinical trial.
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2017. Toward a better understanding of social workers on integrated care teams.
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2018. Integrating social determinants of health into graduate medical education: A call for action.
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From page 83... ...
2005. Resource manual: Social workers & social work services as defined in Medicare law & regulations.
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