The future of health social work

The Future of Health Social WorkArticle in Social Work in Health Care · February 2003 DOI: 10.1300/J010v37n03_01 · Source: PubMed CITATIONS 19 READS 1,117 3 authors, including: Some of t

The Future of Health Social Work

Article  in   Social Work in Health Care · February 2003

DOI: 10.1300/J010v37n03_01 · Source: PubMed

CITATIONS

19

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The Future of Health Social Work

Edward V Pecukonis, PhD, MSW Llewellyn Cornelius, PhD, MSW Margarete Parrish, PhD, MSW

ABSTRACT The practice of social work in health care is at a critical

junc-ture, and faces an uncertain future The authors provide an overview of the challenges facing social work practice within the health care setting, as well

as recommendations for enhancing social work practice and education Challenges discussed include economic factors, demographic changes, and technological advances influencing the practice of social work in health care The need for a proactive stance among social work professionals and educators is promoted The proposed changes are intended to stimulate dis-cussion and an exchange of ideas needed to maintain Social Work’s relevance and integrity in the evolving health care delivery system. [Article copies avail-able for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>

© 2003 by The Haworth Press, Inc All rights reserved.]

KEYWORDS Social work, health care, health care delivery systems,

organization, social work education

THE CHALLENGES FACING SOCIAL WORK

IN HEALTH CARE SETTINGS

The practice of social work in health care faces an uncertain future Like other health professions, social work is being compelled to rethink Edward V Pecukonis and Llewellyn Cornelius are Associate Professors, and Margarete Parrish is Assistant Professor, School of Social Work, University of Mary-land, 525 West Redwood Street, Baltimore, MD 21201.

Social Work in Health Care, Vol 37(3) 2003 http://www.haworthpress.com/store/product.asp?sku=J010

 2003 by The Haworth Press, Inc All rights reserved.

its mission and to identify the practice components needing change Many of the challenges, such as managed care, currently influence so-cial work practice, while others, such as genetic engineering, are immi-nent and will revolutionize how health care is delivered in this country

As a profession, we must prepare for these changes while remaining connected to the integrity of our profession

In general, the following four factors will have dramatic influence on the practice of social work within the health care setting: (1) The organi-zation and delivery of health services, (2) The supply of health care pro-viders, (3) The changing demographics of the population and (4) Advances

in genetic engineering This paper will explore and summarize these trends and suggest a course of action to address these challenges

THE ORGANIZATION AND DELIVERY OF HEALTH CARE

Most of the recent changes in health care delivery are the result of cost containment strategies that can be lumped under the rubric of man-aged care The acute care hospital, once the crucible of health care de-livery, has been restricted and reorganized by strategies to reduce the cost of health care in this country As predicted in the early 1980s by Jeff Goldsmith (1981) in “Can Hospitals Survive?” the bulk of health care service is now delivered in ambulatory care centers whose primary function is to control the cost of diagnosing and treating disease In fact approximately 98% of all medical encounters now occur in non-hospi-tal settings (Berkman, 1996)

Traditional Hospital Systems: The Way of the Dinosaur

Related to the shift from hospital to community-centered care is the fact that many large hospital systems have merged with others, dimin-ished in size, or been dismantled Occupancy rates during the past fif-teen years have on the average been below 70% for the majority of hospitals in our health care system (AHA, 2001) In addition, hospital utilization, as measured by admissions, lengths of stay and surgeries performed, has decreased dramatically (AHA, 2001)

In response to the decline in hospital admissions and length of stay, over 650 community hospitals within the United States closed their doors between 1987 and 1999 (DHHS, 1999) During those same years many of these hospitals became dependent on federal subsidies for indi-gent care and graduate medical education Today, these sources of

funding are less reliable For example, since 1965 the Medicare and Medicaid programs supported graduate medical education in teaching hospitals Prior to the passage of the Balanced Budget Act of 1997, Medicare and Medicaid provided over $8 billion per year in support of these teaching hospitals (Committee on Pediatric Workforce, 2001) These funds were principally used to support residency-training pro-grams and provide health care services to indigent populations This trend along with more recent legislation to reduce the oversupply of physicians is expected to have a negative impact on the amount of health care services provided to indigent populations by teaching hospi-tals (Modern Healthcare, 1999; Debas, 1997) Bellandi (2000) suggests that the Medicare and Medicaid spending constraints enacted under the Balanced Budget Amendments of 1997 promoted hospital layoffs, and reductions in service and hospital closures In 1998 alone, 28 urban and

15 rural hospitals were closed (Bellandi, 2000) Still others speculate that the survival of the teaching hospital will be determined by the movement of outpatient care to managed care organizations (Rovner, 1999; Debas, 1997) Regardless of the cause, it is clear that hospitals across this nation are closing their doors

In an effort to survive, many hospitals have developed creative mar-keting strategies For example, some community hospitals faced with occupancy problems have merged with larger medical systems or aca-demic institutions Such steps have been taken with the hope of monop-olizing market share within a specific geographic region Another

strategy, to fill the empty beds, has been to develop “centers of

excel-lence” that promise specialized service at a good price, (i.e.,

car-diac-care centers, women’s health programs, etc.) These strategies, although promising in the short run, will confront the same long term difficulty of, “How do we fill the beds” when more and more health care

is being delivered on an outpatient basis?

Managed Care

The past 15 years has witnessed the industrialization of health care with annual costs approaching $1.2 trillion or approximately 14% of the United States Gross National Product (HCFA, 1999) Currently, an esti-mated 90% of these medical expenses are handled by MCO’s or man-aged care organizations (U.S Census Bureau, 2000) Despite consumer backlash and demands for more provider accountability, managed health care is here to stay as this system is now encased within a business infra-structure that will be difficult to dismantle

Health Care Models of Practice

Concurrent with the changes in the organization of health care, the model of health care delivery has changed during the past decade His-torically, an acute care model was utilized, where the inpatient health care system was discretely focused on the physical factors contributing

to the acute medical condition This model depicts illness as an isolated event, with the patient being hospitalized, treated and discharged “The role of the Social Worker in this framework was focused on dis-charge planning, reducing lengths of stay and (eliminating) rehospitalization” (Berkman, 1996, p 3) Within our present environ-ment, the practice of discharge planning (historically implemented by social work), has been narrowly redefined and now often completed by other health professions such as nursing Without social work input, discharge planning has become more of an event rather than a compre-hensive process Thus, we have moved away from the psychosocial as-sessment model, unique to social work practice, to a brief discussion of medication management and follow-up appointments Although the so-cial worker has attempted to protest and resist this loss of role in dis-charge planning, perhaps we need to ask ourselves if this is a battle we want to wage given the present trend towards community-oriented care The current health care delivery model reflects a complex system of pa-tient care that addresses papa-tient needs along a comprehensive health continuum–ranging from primary prevention to chronic disease man-agement This “health continuum model” assumes that a patient’s hos-pitalization and discharge is only one brief aspect along a continuum of care Today, the majority of health care service is delivered and man-aged in ambulatory settings Perhaps this is where we should direct our energies when rethinking our roles in the evolving health care setting

THE SUPPLY OF HEALTH CARE PROVIDERS

The practice of health social work is influenced not only by changes

in the organization and delivery of health services, but also by the avail-ability of health providers For example, there are approximately 670,000 physicians in the United States (AMA, 2001) An additional 67,000 stu-dents are in medical school (Barzansky et al., 2001) with an additional 97,000 residents completing their specialty training each year (Brotheton, 2001) These numbers suggest an ever-increasing supply of physicians, who typically prefer specialty focus to primary care practice Debas

(1997) indicates that specialty physicians have represented the largest increase in practicing physicians since 1965 For example, the number

of specialists rose from 56 per 100,000 population in 1965, to just over

123 per 100,000 population in 1992

The supply of physicians has been relevant to health social work for two reasons: (1) The potential for improving access to care for the indi-gent and (2) the impact of social work on medicine’s monopoly in pro-viding mental health services In regards to the supply of physicians and access to care, the challenge has been not so much the supply of physi-cians but their distribution Both the federal government and American Medical Association have been trying to find ways to encourage physi-cians to practice in underserved areas i.e., inner city and rural areas In terms of mental health services, it is clear that other health care providers (e.g., nurses and primary care physicians) have incorporated psychosocial interventions into their practice reducing the monopoly over these ser-vices that psychiatrists once enjoyed In addition, social workers have been seen as a cost effective substitute for psychiatrists in the provision

of selected mental health services

Psychiatry

Although psychiatry has attempted to re-affiliate itself with the medi-cal community since the early ’80s (through attempts at re-medimedi-calizing psychiatry) this specialty faces a major crisis With much of first-line psychiatric assessment and care now being handled within the primary care setting (by family physicians and pediatricians, or by non-medical providers such as social workers and psychologists) the psychiatrist of-ten assumes a consultive role by only seeing patients that cannot be ade-quately treated or managed in other settings

It is not surprising that most psychiatric residencies continue to have great difficulty filling training slots For example, between 1988-1998 residency programs in psychiatry showed a 42.5% decrease in filling available training spots (NRMP, 1999) Medical students appear less and less interested in pursuing careers in psychiatry, where income po-tential continues to be challenged by managed care Medical students leaving school with significant loan indebtedness are opting for higher paying specialties In fact, reimbursement for psychiatric services is far less than any other branch of medicine (Blackmon, 1993) Limited re-imbursement for psychiatric care may not only be reflected in the differ-ences in compensation relative to other medical specialties, but may also be influenced by the population’s growing preference for social

work services For example, Fall, Jennings and Eberts (1999) report that

33 percent of mental health consumers surveyed were seen by social worker’s compared to 20 percent for psychiatrists, 18 percent for psy-chologists, 12 percent for master level professional counselors and 7 percent for doctoral level licensed professional counselors

CHANGING DEMOGRAPHICS IN THE UNITED STATES

A third tier of factors influencing the delivery of health social work considers the changing composition of the U.S population The chang-ing demographics of the American population have significant practice implications for social workers During the next 15 years the overall population in the United States will continue to age and increase in eth-nic and cultural diversity

First, Americans are living longer By 2025 the average life expec-tancy will be 82 years for women and 76 years for men, with more than 150,000 people surviving past the age of 100 (U.S Census 1999) Baby boomers make up 47% of today’s work force, with the majority of these individuals eligible for retirement around the year 2020 (U.S Census, 2000)

America is also becoming ethnically diverse Today, approximately 82% of the population is white However, this percentage is decreasing and will level off to about 79% in the year 2015 At that time, it is antici-pated that Asians will make up 5%; African Americans 13% and Lati-nos will compromise approximately 15% of the U.S population By

2050 the U.S population will double with minority groups comprising nearly 40% of U.S citizens (U.S Census, 2000) The aging and diversi-fication of our country have implications for social work practice that will demand the development of practice methods directed at empower-ing the elderly and integratempower-ing culturally diverse populations In addi-tion, the social work profession will be in a position both to advocate for and monitor whether clients are receiving culturally competent ser-vices

Health Promotion and Disease Prevention

Along with changing demographics will come changing health care needs With increased numbers of older adults in the population there will also be increases in the proportion of Americans with chronic ill-ness This type of chronic illness will be determined by a host of factors

including a persons social and physical environment, their psychologi-cal make-up, genetic predisposition, access to health care and most im-portantly lifestyle choices Health promotion and disease prevention will become key interventions for improving health and limiting the economic burden of chronic disease Interestingly, the number of peo-ple suffering from chronic disease (such as hypertension or diabetes) is changing, and is expected to increase almost 14% by 2010 Conse-quently, the number of Americans suffering from an ongoing and chronic health problem will approach 100 million or 35% of the entire population within the next decade

Health and Behavior

Some may find it surprising that the leading cause of death in the United States remains cardio-vascular disease (Hoyert et al., 2001) It has been widely reported that the five leading risk factors for develop-ing cardio-vascular disease are: diet, obesity, sedentary life style, smok-ing, and hypertension (NHIS, 2001) Interestingly, all of these risk factors reflect behaviors or life style choices Thus, the leading cause of death in this country is not some exotic disease of unknown origin, but rather common everyday behavior We do not need a degree in chemis-try, pharmacology or medicine to recognize or treat these risk factors Changing behavior represents an area of social work expertise

A social worker’s expertise in changing risk behavior is also relevant when we consider other nation-wide health problems, such as teen preg-nancy, AIDS, drug dependence, domestic/community violence, and obesity Given that behavior choice is the primary reason for these health conditions, effective interventions must be crafted from behav-ioral change strategies The prevention and treatment of these health problems involves changing behavior, representing an important op-portunity for social work

THE GENETICS REVOLUTION

One of the factors that can become both a burden and opportunity for health care delivery in this country is the evolving genetics revolution

On one hand genetic engineering will lead to an increase in new treat-ment that may buffer the effects of acute or chronic illness Conversely, expensive genetically engineered medicines or procedures may not be available to all segments of our society The ethical and scientific issues

are profound Recently, Richard Hayes, (in Williams, 2000) the coordi-nator of the New Human Genetic Technologies, wrote: “We are fast ap-proaching what is arguably the most consequential technological threshold in all of human history: the ability to directly manipulate the genes we pass on to our children” (p.11) Development of these technol-ogies will change life on this planet, as we know it

In 2001 the Human Genome Project was completed and now pro-vides us with a map of our genetic structure These findings will lay the groundwork for advances in biotechnology that will revolutionize health care practice Claims for cures professed by these researchers re-semble science fiction and predict everything from genetically engi-neered medications to children whose genes are selected by parents from on-line catalogues Some even predict the evolution of a geneti-cally enhanced elite that will polarize common humanity, as we know it (Hayes, 2000) Needless to say, the ethical concerns will be profound and require careful thought and discussion As a profession we will need to infuse ourselves into these discussions of how advances in bio-technology will be used by the corporate sector

In general, two types of genetic engineering are being developed: So-matic and Germ line enhancement It is important to understand the dif-ferences between these types of genetic engineering since they have implications for social work practice For example, in Somatic en-hancement, defective genes in the body are repaired and cure disease or enhance physical attributes such as body weight, improving memory or growing hair for a balding man Here the goal is to cheat the aging process and perhaps extend human life by repairing damaged or aging organs/sys-tems within the body Most importantly, these genetic modifications are not passed on to future generations Conversely, in Germ-line enhance-ment the genes associated with reproduction (egg and sperm or embryo) are systematically changed Unlike somatic treatments, Germ line ge-netic enhancements are passed on to future generations Clearly, this type of genetic engineering has profound ethical and moral consider-ations for both society and the health care professions In general, with these advances comes the unsettling questions of who decides what will

be engineered and who will receive these enhancements

Although still experimental, considerable research is focused on de-veloping genetically engineered medications For example, in the past the only way to obtain insulin for human consumption was from ani-mals Today, cloning the human gene that carries the instructions for creating insulin can actually produce insulin Likewise, the human growth hormone can now be produced in significant quantities via

ge-netic engineering The day will come when precision drugs for specific disease states will be custom made, based on the individual’s unique ge-netic structure and history These drugs will be specific in their actions and have little or no side effects

IMPLICATIONS FOR SOCIAL WORK

Given the influence of these variables on health care, what are the im-plications for social work? How should we plan? What opportunities should we pursue? Whatever path our profession chooses, it is

impera-tive that we define the nature of our expertise and clearly articulate

these roles both to the public and other health professions We must be precise about how we can contribute to this new and evolving health care arena It is important to define these roles, own them, promote them, advocate for them, and above all protect them Our traditional roles within the health care setting may become obsolete as we evolve and adapt to our changing health care setting This means rethinking what we do, how we do it and why we do it Above all, we must be proactive in these efforts, becoming advocates shaping practice, educa-tion, training, legislation and policy that will serve to solidify and rein-force these evolving roles

Social Work Education

First, let us consider social work education There are several things that social work education must accomplish during the next 3-5 years:

Introduction of the Brain and the Central Nervous System

to Curriculum

Given the changes that lie ahead, it is imperative that schools of So-cial Work introduce the importance of the central nervous system and its influence on behavior within their curricula and continuing educa-tion programs Historically, Social Work has been steeped in sociologi-cal and personality theory Although it is important that these traditions

be maintained we must also make room for advances in health science Although we must not abandon our belief in the role of social and psy-chological factors shaping human behavior, we need to utilize a true bio psychosocial model of social work intervention Thus, we must include the brain and its influence over behavior and emotion within our