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Interdisciplinary Medical Social Work: A Working Taxonomy

Interdisciplinary Medical Social Work: A Working Taxonomy PETER MARAMALDI, PhD, MPH, LCSW Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, Boston, Massachusetts, USA ALEXANDRA SOBRAN, MSW, LICSW, LISA SCHECK, MSW, LICSW, NATALIE CUSATO, MSW, MPH, LICSW, and IRENE LEE, MSW, LICSW Social Work Department, Massachusetts General Hospital, Boston, Massachusetts, USA ERINA WHITE, PhD Candidate, LICSW, MPH Simmons School of Social Work, Boston Children’s Hospital, Boston, Massachusetts, USA TAMARA J. CADET, PhD, LICSW, MPH Simmons College School of Social Work, Harvard School of Dental Medicine, Boston, Massachusetts, USA Findings from a year-long exploratory study aimed at describing universal functions of medical social work with interdisciplinary teams in acute care settings are reported here. A universal taxonomy of interdisciplinary social work skills and competencies was empirically identified through a participatory action research framework. Findings support previous conceptual descriptions of medical social work’s overarching and historical role to help interdisciplinary teams in acute care to consider patients’ home environment, knowledge, beliefs, culture, and resources during assessment, treatment, and discharge planning. The empirically determined taxonomy reported is intended to provide social workers a framework with which to articulate and evaluate their core competencies on interdisciplinary medical teams. KEYWORDS medical social work, interdisciplinary teams, participatory research Received March 10, 2014; accepted March 14, 2014. Address correspondence to Peter Maramaldi, Simmons College School of Social Work, Harvard School of Dental Medicine, Harvard School of Public Health, 300 The Fenway, Boston, MA 02115. E-mail: [email protected] 532 Interdisciplinary Medical Social Work 533 THE PROBLEM Although health care in the United States has made tremendous technological gains during the last century, it has also taken on unforeseen dimensions related to distribution and utilization of scarce resources (Berkman, 1996; Rehr & Rosenberg, 2006). Prior to the passage of The Patient Protection and Affordable Care Act (2010), health care was traditionally distributed as a commodity, rather than an inalienable right. Market forces dictated the distribution of resources on both the supply and demand sides of healthcare (Chirba Martin, 2009). Social work has not fared well in resource allocation for a variety of reasons including an erosion of government funding, limited support for social services by insurance companies, and the inadequate demonstration of its potential contribution to health care (Rehr & Rosenberg, 2006). Medical social workers tend to under-articulate their clinical contributions to patients and interdisciplinary teams (Abramson & Mizrahi, 2003; Carrigan, 1978; Globerman, White, Mullings, & Davies, 2003). Descriptors such as “providing support,” “counseling,” and “working with family” do not capture the full extent of the interdisciplinary clinical social work practice. Interdisciplinary curriculum scholars note the importance of standardizing the “objectives, outcomes, and competencies expected for each discipline” (Newhouse & Spring, 2010, p. 315). Thus, our findings offer an empirically determined taxonomy to assist clinical social workers to frame their contributions in operational terms that are easily recognized by other health disciplines and clearly defined for measurement and evaluation. We demonstrate here the potential disciplinary contributions that social work brings to interdisciplinary teams as part of the larger national effort to improve the overall quality of health care. This taxonomy may help clinicians demonstrate their clinical effectiveness and utilize evidence informed interdisciplinary approaches with patients and their families. The recent passage of the Patient Protection and Affordable Care Act (ACA) (2010) indicates that health care quality improvement programs should “assist health care providers in working with other health care providers across the continuum of care” and should work at “engaging patients and their families in improving the care and patient health outcomes” (The Patient Protection and Affordable Care Act, 2010). The law offers a unique opportunity for social workers to participate in teams intended to increase quality while reducing costs. BACKGROUND For more than a century, social workers engaged in interdisciplinary collaboration and practice have worked from a values-based commitment to provide the best available care to vulnerable populations, to develop interventions aimed at health promotion and disease prevention, and to maintain 534 P. Maramaldi et al. a biopsychosocial perspective on health care. The interdisciplinary functions and patient-centered perspectives currently espoused by the ACA are for social work, essentially a return to the roots of the medical social work more than a century ago. At the turn of the previous century, providers treating low-income and immigrant populations in large urban hospitals—in cities such as New York, Baltimore, and Boston—observed the interactive nature of psychosocial and biological conditions, and attempted to address those issues in part through what we now call social work (Berkman & Maramaldi, 2001). HISTORICAL CONTEXT: WHAT IS OLD IS NEW In her seminal 1915 book on social work in hospitals, Ida Cannon, generally known to be the founder of medical social work (Rehr & Rosenberg, 2006), reflected on her early years when she was invited to Boston by Richard Cabot, who was a Professor of Medicine at Harvard. Her writings related her cross-disciplinary experiences at the Massachusetts General Hospital (MGH) and her training at the Simmons School of Social Work, which were both affiliated with the Harvard Medical School. She posited that the charge of the hospital social worker was to assume the role of “interpreter,” and to bridge the communication gap between patients, families, and other providers. Almost a century later, the Institute of Medicine (IOM) report (2008) on meeting psychosocial health needs for the whole patient underscores the importance of fostering communication. The IOM report states that the entire medical team should work to enhance communication with the patient and family. Patient–provider communication—meaning team members’ listening and speaking with patients—is a critical element of diagnosis, treatment, and discharge. More recently, the ACA (2010) calls for providers to work efficaciously across disciplines to meet patient-centered objectives. The Act has led to the emergence of accountable care organizations (ACOs) aimed at improving quality while containing costs (Fisher & Shortell, 2010; Walker & McKethan, 2012). Given the current demands to shorten hospital stays, the extension of treatment across the continuum of community care, and ubiquitous barriers to patient–provider communication, social work—with its focus on person-in-environment—is ideally suited to facilitate meaningful interactions between patients, families, and interdisciplinary teams. The communication that Cannon described in 1915 was intended to increase what now falls under the rubric of health literacy. For the purposes of this article, health literacy refers to “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (The Patient Protection and Affordable Care Act, 2010, p. 473). The American Medical Association (AMA) Foundation (2008) has estimated Interdisciplinary Medical Social Work 535 that as many as 38% of Americans have limited functional health literacy. Communication strategies, such as encouraging patients to ask questions and verifying their comprehension, have been recommended first steps to enhance health literacy (The Joint Commission, 2007). Social workers on interdisciplinary teams can serve a critical role in addressing the growing national health literacy concerns. Moreover, interdisciplinary teams are ideally positioned to implement effective communication strategies (Kripalani, Jackson, Schnipper, & Coleman, 2007; Oates & Paasche-Orlow 2009). The IOM (2004) suggests that the patient’s diagnosis, treatment, and discharge will be favorably enhanced when interdisciplinary teams facilitate clear consistent communication in a way that is culturally and linguistically relevant for the patient. The spirit of the 2004 report is remarkably similar to Cannon’s 1915 call for social work’s role in promoting communication between patients, families, and providers during hospitalization. From the earliest days of the profession, social work has been uniquely positioned to bring psychosocial considerations into interdisciplinary discourse in acute-care treatment (Berkman, 1996). A century ago, Cannon argued for interdisciplinary collaboration before the term was widely recognized. She stated that the social worker must “have the technical skill of the social expert, and the ability to adapt that skill to the medical institution … she should also have the power to insist that the social point of view, as well as the medical, receives its due recognition” (Cannon, 1915, pp. 181–182). Starting with diagnosis and the subsequent development of an evidenceinformed treatment plan (Cowles, 2003; Dziegielewski, 2004), expedient optimization of physical well-being of the identified patient through medical intervention is the primary focus of hospitalization (Small et al., 2007). Once patients are medically stable, understanding their home environment and resources is a key element of effective interdisciplinary care, especially when discharge plans are intended to extend treatment into the patients’ community (Bronstein, 2003; Clark et al., 2005; Zimmerman & Dabenko, 2007). Planning for the whole patient, in the context of his/her environment increases well-being, diminishes the likelihood of medical complications, and decreases relapse (Berkman, 1996; IOM, 2008). Family-centered care (American Academy of Pediatrics, 2003; IOM, 2001; Johnson et al., 2008) requires a diagnosis and subsequent treatment to include psychosocial factors such as the patient’s and family’s perceptions of health and illness, cultural beliefs, environmental, and social support factors that may impede compliance with medical regimen (Bronstein, 2003; Zimmerman & Dabenko, 2007). The IOM (2008) report on meeting psychosocial health needs for the whole patient supports communication in family-centered care. It posits that the partnership between the interdisciplinary provider team and the patient/family is the key to identifying, or assessing the psychosocial needs in any given case. Although the focus of 536 P. Maramaldi et al. the report is cancer care, it underscores the importance of medical teams engaging patients, family caregivers, and community-based providers in the development of viable treatment and discharge plans that will sustain health and well-being. This is also consistent with the principles of ACOs to create optimal care plans that are evidence-based and include the patients’ circumstances (Walker & McKethan, 2012). Previous empirical research indicates that the overlap of professional competencies (D’Amour, Ferrada-Videla, Rodriguez, & Beaulieu, 2005; Pike & Wandel, 1991; Satin, 2008) is a key component to interdisciplinary synergy (Newhouse & Spring, 2010). As a result, provider awareness of their function within the array of disciplinary competencies is critical to the creation of a cohesive interdisciplinary team (Baker, Day & Salas, 2006). Interdisciplinary research indicates that team success hinges on the identification of roles, competencies within these roles, and the overlap between roles (Baker et al., 2006; Newhouse & Spring, 2010). CONCEPTUAL FRAMEWORK: INTERDISCIPLINARY COLLABORATION Interdisciplinary collaboration in hospitals occurs among professionally trained specialists representing medicine, nursing, clinical social work, psychiatry (including psychology), nutrition, chaplaincy, and other ancillary disciplines. Interdisciplinary teams assign roles based on disciplinary competence. The hallmark of effective interdisciplinary collaboration is members’ ongoing learning about other disciplines, flexibility and overlapping of roles when competencies permit (Cowles, 2003; Dziegielewski, 2004). By contrast, multidisciplinary teams know other disciplines, plan together, and avoid intrusion on the practice domain of other professions. While competence and identity are developed within one’s discipline on multidisciplinary teams, there tends to be little or no functional overlap between disciplines (Satin, 2008; Schofield & Amodeo, 1999). Satin (2008) frames overlap in interdisciplinary approaches based on spheres of professional competence. Primary competence refers to unique or superior expertise associated with a specific discipline. Secondary competence refers to spheres where one’s discipline provides the expertise, training, and licensure to perform functions that overlap with another discipline’s area of primary competence. Tertiary competence refers to spheres where one has little or no specialized competence; anyone on the team can perform that function. While each discipline may have its own designated primary, secondary, and tertiary competencies, professional competencies overlap, particularly in today’s climate of increased trainings and specializations. Research findings indicating strain between physicians, nurses, and Interdisciplinary Medical Social Work 537 social workers (Cowles & Lefcowitz, 1995; Reese & Sontag, 2001) suggests a need for greater role definition and competency measures. During the current investigation, we observed that even teams with high levels of cohesion and familiarity experienced tension regarding task-allocation and role definitions, often between nurses and social workers in regard to psychosocial issues. Empirical investigations (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000; Netting & Williams, 1996) indicate that psychosocial assessment and intervention are no longer an exclusive domain of social work. There is, however, some agreement that clinical social work’s primary competence is to address psychosocial concerns in the biopsychosocial context (Beder, 2006; Berkman, 1996; Cowles, 2003; Dziegielewski, 2004). To varying degrees, physicians and nurses increasingly recognize that social workers’ primary competence in psychosocial and environmental aspects of cases enhance treatment and improve outcomes (Keefe, Geron, & Enguidanos, 2009; Rock & Cooper, 2000). Existing literature on interdisciplinary medical teams has tended to focus on social workers and physicians views about collaboration (Cowles & Lefcowitz, 1992; Mizrahi & Abramson, 2000), efficacy of differing collaborative styles of physicians and social workers (Abramson & Mizrahi, 2003; Globerman et al., 2003), and social workers’ perspectives regarding their roles in the medical setting (Abramson & Mizrahi, 1996; Cowles, 2003; Kitchen & Brook, 2005; Mizrahi & Abramson, 2000). Few empirical studies have investigated collaborative roles and relationships in the same setting or services (Mizrahi & Abramson, 2000). Published studies that have examined team members’ roles and relationships in the same setting or service focused on hospice, palliative, and geriatric care (Colón & Otis-Green, 2008; Oliver & Peck, 2006; Waldrop, 2006). The study reported here identifies social workers’ perceptions of their primary psychosocial competencies within interdisciplinary medical teams, which—to our knowledge—has not been empirically investigated and published. PURPOSE OF THIS STUDY The purpose of this exploratory study was to document the historically grounded disciplinary competencies of clinical social work within the context of interdisciplinary teams in medical settings. The stakeholder-driven aims of this participatory action research study were to: (1) identify social workers’ perceptions of universal elements of clinical practice on interdisciplinary teams and (2) develop an evidence-based taxonomy of interdisciplinary practice skills and competencies based on the experiences and observations of clinical social workers. Due to limited resources, the inclusion of other disciplines was beyond the scope of this study. The intent of the second 538 P. Maramaldi et al. aim is to help social work clinicians frame their contributions to teams with the accuracy and rigor required in medical settings. The study answered the research question: What are perceptions of social workers about the disciplinary functions, skills and competencies of clinical social work on interdisciplinary teams in acute care treatment settings? METHODS Participatory action research (PAR), is a collaborative research approach designed to understand and improve on a community’s practices while empowering the population of interest (Glasson, Chang, & Bidewell, 2008). A research partnership is created between a community and researchers to increase knowledge and understanding of a given phenomenon and integrate the knowledge gained to improve outcomes (Israel, Eng, Schulz, & Parker, 2005). The phenomenon of interest in the current study was the perception of socials workers about their disciplinary functions, skills, and competencies on interdisciplinary teams in hospital settings. Our approach was adapted from a nursing study that used elements of PAR, to collect empirical evidence to improve clinical practice (Glasson et al., 2008). We utilized PAR to empower social workers in their community, the hospital setting, to utilize their clinical knowledge to improve their clinical processes and outcomes. Table 1 summarizes the steps that we took in the PAR approach to improve clinical practice. TABLE 1 Summary of Actions Taken in the Participatory Action Research Process Research action Action taken in current study Reflecting Research scientist presented ideas for participatory action research aimed at improving practice. Specific research topics were discussed. Planning Clinical staff overrode researcher and set aims and questions to better reflect stakeholder interests Implementing Extensive review of archival and current literature resulted in decision to develop taxonomy of social work clinical practice in interdisciplinary settings Observing outcomes Social work clinicians, clinical director, and scientist used deductive findings to develop a conceptual model, which was used to frame inductive observations of interdisciplinary practice Feedback During weekly meetings, the research team reviewed individual cases with the aim of identifying universal rather than case specific functions Replanning Clinicians, clinical supervisor, and scientist took findings identified as universal functions back into practice, supervision, and observations seeking to identify new functions until saturation was attained Adapted from Glasson et al. (2008). Interdisciplinary Medical Social Work 539 While the steps in Table 1 are presented in a linear manner, this process was dynamic and interactive. During the planning phase of the PAR process, the clinicians disagreed with the research scientist’s suggestions and provided goals and aims that better reflected their interests. Thus, the goals, aims, and research questions were not dictated by one individual, the research scientist, but by the group most affected by the issue similar to the overall goals of PAR. As a result, the social worker participants and the research scientist reviewed archival and current research on the role of the hospital-based social worker. In reviewing their current practice, the social worker participants concluded that, in general, medical social workers tend not to fully articulate the exact functions that they perform on interdisciplinary teams. Descriptors like “providing support,” “counseling,” and “working with the family” did not capture the full extent of their interdisciplinary clinical practice. The research team decided to develop an empirically driven taxonomy of the universal functions skills and competencies of clinical social work on interdisciplinary teams. Subjects Five members of the core participatory panel investigated the work performed by a total of 37 expert clinical social workers in a large New England teaching hospital for a period of twelve months. The core research panel consisted of three clinical social workers assigned to interdisciplinary teams in Pediatric Services, a senior clinical director, and the social work research scientist. Social work was the only discipline included in the core research panel, which will be discussed as a limitation below. DESIGN Using participatory research methods (Coghlan & Brannick, 2005; James, Milenkiewicz & Bucknam, 2007), the panel participated in every phase of the research study from the development of research questions through the analysis, and finally to the article preparation. The research collaboration was driven by the principles of participatory research (Israel et al., 2005; Glasson et al., 2008). We used deductive approaches by reviewing archival and current published peer-reviewed literature, and inductive approaches by reflecting on practice using a retrospective qualitative case review methodology (Anthony & Jack, 2009; Yin, 2008). For the first phase of the study, five members of the core participatory panel met weekly, reported deductive findings from archival sources and current literature about the role 540 P. Maramaldi et al. of social work in multidisciplinary medical settings. This led to the identification of a conceptual model—interdisciplinary collaboration—and the development of the research questions and methodology. During the second phase, the panel met weekly and engaged in a retrospective, focused debriefing about cases and developed and refined the taxonomy of clinical practice and competencies on interdisciplinary teams. Our deductive findings from archival material and current scientific literature informed our inductive observations. We continued the process of reviewing case exemplars to identify competencies until we reached a point of saturation where no new competencies were identified (Glaser & Strauss, 1967). The PAR process enabled the community of social workers to determine their own competencies and to develop an operational taxonomy that defined their role and functions. Deductive Data Collection We conducted archival research in the Massachusetts General Hospital and the Simmons School of Social Work historical archives with expert librarian assistance. Each of these institutions has extensive medical social work archives dating to the earliest days of Ida Cannon’s work in each setting. Deductive findings from the archival material were remarkably relevant in the context of current clinical practice. The interdisciplinary nature of early medical social work emphasized the enhancement of communication among patients, families, and providers, which informed our inductive inquiry. Inductive Data Collection Using a retrospective clinical case review methodology demonstrated in the nursing literature (Glasson et al., 2008), we reflected on a sample of cases and documented the panel’s perceptions of specific social work functions on interdisciplinary teams. The panel used reflections and observations of their own interdisciplinary clinical work in the form of the clinician stakeholders’ personal case notes, not the formal medical record notations. Case notes were used because they tended to evoke more detailed information about social work functions than the more “sanitized” medical records. More specifically, the actual notes written in the medical record were not used because they tended to be abridged and also devoid of the current study’s focus on interactions with other disciplines. In addition, the notes used for this study were deidentified by each clinician stakeholder prior to the retrospective case review sessions in order to protect the confidentiality of patients as well as medical team members. A total of 43 cases were included in the final analysis. Interdisciplinary Medical Social Work 541 ANALYSIS During weekly research meetings, the core panel engaged in a process of identifying common themes (from the 43 cases studies and archival material) until we reached a point of saturation (Padgett, 1988; Glaser & Strauss, 1967). Case data were presented and discussed by the entire research panel, and then re-documented by the research scientist in summary format. The summary was then cross-checked by the entire panel for accuracy. It is important to note that social work was the only discipline participating in the case reviews due to the pilot nature of this study. Findings Universal elements of social work’s function on interdisciplinary teams were extrapolated from 43 cases reviewed for this exploratory study: rapid 360 degree screening (collection of case information from all available sources), assessment, psychosocial intervention, and referral. These functions may seem obvious and are recognized activities of medical social workers (Berkman, 1996; Cowles & Lefcowitz, 1992; Cowles, 2003; National Association of Social Workers, 1990). However, although limited by a single discipline’s (social work) perception, the findings reported here are empirical and frame social work’s disciplinary utility, skills, competencies, and expected outcomes in an interdisciplinary context. During the process of reviewing cases for common universal themes, we also discovered the importance of including the overt articulation of social work’s disciplinary contributions to the case, and stated expected outcomes to the interdisciplinary team. Adding interrelated expected contributions and outcomes to the taxonomy of social work’s disciplinary function brings social work in line with medicine and nursing on interdisciplinary teams. Much like a physician or nurse routinely state and record a planned procedure and its outcome, social workers can do likewise. Although limited by the pilot nature of this study, we found a level of parity among disciplines to occur in some teams but not others, which further supports inclusion of expected contributions and outcomes to the taxonomy. Social work participants on the panel also reported that the quality of their assessments and the related interventions appeared to be enhanced when they overtly stated the expected outcomes to other team members. As a result, we decided to include both social work contributions and outcomes—as interrelated skills and functions—in the taxonomy, presented in Table 2. Awareness and utilization of these interrelated functions appeared to empower social workers to overtly communicate their role and value to the interdisciplinary team. As discussed earlier, understanding competencies within disciplines is an important aspect of functioning interdisciplinary teams. During the retrospective case reviews, the research 542 P. Maramaldi et al. TABLE 2 Taxonomy of Social Work Functions on Interdisciplinary Teams Social work functions Brief description 360 Degree Screening Rapid assessment to identify risk Assessment Explanation of case across interdisciplinary perspectives as the bridge between the patient/family and the team Intervention Actions taken to enhance health and well being Referral Best attempt to connect case with community resources needed to carry interventions across continuum, beyond the hospital Expected Outcome Ensures patient focus, enhances accountability and quality, and contributes to evidence informed practice Contributions to Interdisciplinary Team Reiteration of social work’s unique contributions across professional competencies Competencies Needed Clinical skills and knowledge needed to perform functions team discovered the importance of identifying the competencies needed to contribute and plan outcomes in specific case exemplars. Including the category of competencies needed to perform the interrelated functions was also important to differentiate between core clinical social work competencies and advanced specialty training. The inclusion of competencies brings social work into greater parity with other disciplines that require advanced certifications and advanced training in specific areas of medical service. As a result, we found it important to include competencies as part of the taxonomy. The final taxonomy, therefore, included expected outcome, contributions to the interdisciplinary team, and clinical competencies needed. A case exemplar demonstrates the utility of the taxonomy. Case Exemplar In preparing this article, we discovered a lack of consistent and established protocol for publishing clients’ narratives and stories in psychological, psychiatric, and psychoanalytical journals. In the face of ongoing debates about protecting human subjects in articles such as this, we decided to follow the lead taken in psychiatric literature, to …

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Seizing Interdisciplinary Opportunities in the Changing Landscape of Health and Aging: A Social Work Perspective.

Purpose of the Study: This paper is a revision of the Kent Award Lecture given at the Annual Meeting of the Gerontological Society of America held in New Orleans, Louisiana, in November, 2010. Design and Methods: This paper looks at the evolution in geriatric social work assessment and outcomes research and concludes with observations of the changing landscape in health and aging. Results: Since the 1960s, the policies and the context of health care delivery have changed many times as have geriatric health screening and assessment of patients in need of social health care services. Research on social–behavioral and environmental factors critical in measurement of outcomes of health care has progressed significantly as theories of care and the research technologies that allow us to study these factors have become more sophisticated. Implications: Researchers from multiple disciplines need to study the questions which can build the evidence necessary for empirically supported social policy direction. Opportunities in interdisciplinary geriatric assessment and measurement Seizing Interdisciplinary Opportunities in the Changing Landscape of Health and Aging: A Social Work Perspective Barbara J. Berkman, DSW/PhD* Columbia University School of Social Work, New York, New York. *Address correspondence to Barbara J. Berkman, DSW/PhD, Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027. E-mail: [email protected] Received March 11, 2011; Accepted May 06, 2011 Decision Editor: Rachel Pruchno, PhD An earlier version of this article (“Changing landscape in health and aging: Seizing the opportunity”) was presented as the 2009 Donald P. Kent Lecture on November 21, 2010, at the 63rd Annual Scientific Meeting of the Gerontological Society of America, New Orleans, LA. of outcomes, which are presented to researchers today, are highlighted. Key Words: Assessment, Multidisciplinary, Outcomes, Social-Behavioral Donald Kent believed, and practiced his beliefs, in the importance of linking research on aging to practice and policy. He wrote eloquently on policy issues and the need for researchers from multiple disciplines to study the questions that can build the evidence necessary for empirically supported social policy direction (Kastenbaum & Sherwood, 1972; Ken