The Western health care system is broken. The ways in which it is broken and the degree to which it is broken vary from country to country (and within countries), but the reality remains that costs continue to rise and people continue to receive care that is fragmented, incomplete, and sometimes inappropriate. And in some places there are large groups of people who do not have access to non-emergency care (the U.S is one of those places).
Among other things, the problem with most Western health systems is that they were created on a Western paradigm of illness, that is, one that assumes an agent that causes an acute condition and that this condition can be eradicated with the correct drug or surgical procedure. This model also generally echoes mind/body dualism. The reality is that there are many long-term, chronic health care conditions that are now being treated within our systems. These health conditions don’t respond well to this Western medical paradigm.
The current transformation that is underway focuses on integrating health and social care across all health and behavioral health conditions. This is an admirable goal. It recognizes that social conditions play an important role in the prevention and management of health conditions, especially chronic conditions. The system change is being driven by two major forces: 1) a growing body of research supporting the interrelatedness of psychosocial factors and chronic health conditions (see, for example the ACE study which documents the relationship between childhood trauma and adverse adult health outcomes), the interconnection between mind and body, and the impact of physical and behavioral health on each other; and 2) a desire for fiscal savings and better financial sustainability. It should be noted that a recent review of the international literature on integrated financing of health and social care found that the research had mostly failed to focus on the key outcomes: improved health status and cost-effectiveness[i] leaving us uncertain if these efforts will even address these two broad concerns.
There are many models of integrated care that are being developed and explored. Almost all rely on care teams of some sort. And within most teams there is someone with a role of care/case management. What’s noteworthy, at least in the U.S., is that these models don’t mention social work explicitly–there are many other professions that will be doing these roles too. However, I think that by virtue of our training, social work is uniquely positioned to do these roles well, and I don’t think this is just my professional bias talking. Our school (University at Buffalo School of Social Work) has been working with a regional health system partner who sought us out because of this same belief. Social workers have experience working across system and professional boundaries, we are used to working in teams, and we assess the whole person within the context of the environment. In addition, we understand policy and practice. For all of the reasons, we have a lot to offer to this system transformation. It’s a time of great opportunity.
However, this system change presents us–the social work profession–with substantial challenges, as well. I’ll list these as bullet points, although each is worthy of a blog post in its own right. It’s by no means a comprehensive list, just the ones that come to my mind immediately (the order is numbered to assist in referencing specific points and does not reflect prioritization):
- We need to better promote what social workers do and why social work is important in this effort to integrate health and social care. Most policy makers don’t think of social workers when these changes are constructed. This topic (the lack of overall knowledge of social work) comes up a lot in our Twitter debates, so I’ll assume that readers generally know what I mean about this.
- We need to stay conversant with the practice literature related to the interconnectedness of mind and body. For many of us, that will mean become more knowledgeable and comfortable with the language of neuroscience and human biology, if only so we are better able to communicate with colleagues in the health professions and keep them informed about the impact of psychosocial interventions on the mind/body. In addition, I think knowledge about Eastern perspectives on health will prove invaluable. The acceptability of “alternative” approaches to health care is growing; acupuncture, yoga, meditation and massage are being increasingly accepted. These approaches have their roots in paradigms that are very different that Western approaches to wellness; understanding how to use them effectively will require understanding how these approaches view wellness and disease.
- It’s not enough for us to be doing the work on the front lines if we truly want to shape this transformation. We need to be part of the process of designing and evaluating the models for integration.This requires more comfort with applied research/evaluation than many social workers currently have. I think the discomfort with research/evaluation comes from not having enough experience with it. While it’s taught in our professional programs, most graduate programs in the U.S put their advanced research course in the last year of the MSW program. I think students need more opportunities to practice these skills prior to graduation than just this advanced course, and they aren’t likely to get that experience in their field placements unless they can implement their skills more independently. Our faculty tried to address this problem by placing both research courses (introduction to research and applied research) in the foundation year of the MSW and like most schools students complete a research project in the course. This allows advanced year students to do additional research under faculty supervision, either within their field placements or on separate projects. We’ve seen more students choose this option since we’ve made this change, although it’s still too soon to see what kind of a difference it will make in the long run.
- We need to become more fluent in using technology. This means doing more than being users of electronic records (which will be a key component in integrating health and social care). It means we need to become comfortable with using technology to create solutions to the problems we confront in our policy and practice. I think that we have a long way to go on this topic, at least in the U.S. (see my blog posts on the 2010 U.S. social work congress imperatives and fears about technology).
- While we must stay true to our values and focus on quality and positive outcomes for clients, we also must strengthen our skills in speaking the language of policy makers, that is, the language of cost-benefits. Many of us are still not able to communicate in this language. We need to become conversant in the language of key stakeholders and translate what we are doing into that language. This is one reason that the World Health Organization has adopted the concept of the global burden of disease–it provides a standard way to communicate the impact of disease that can be more easily translated into a cost-benefit analysis.
- At least within the U.S., I think the emphasis on integration of health and social care will spark the growth of Doctorate in Social Work (DSW) programs, that is, a practice doctorate (as opposed to the PhD, which is really designed for academic and research settings). This transformation is already well underway within nursing, physical therapy, pharmacy, and other allied health professions. Therefore, unless our profession makes this change, within health care systems social workers will be the only professionals without the title of doctor, a differential that will adversely affect our power and credibility. How we will incorporate this degree into our profession and what the impact will be on our other professional degrees, will be a key challenge ahead. [see Edwards, R.L. The Doctorate in Social Work (DSW) Degree: Emergence of a New Practice Doctorate[ii]].
The current reality is that there is no one approach to integration of health and social care. People understand it needs to happen, and there are various models being explored for how to do it. At the same time, if the dominant paradigm for health, illness, and wellness doesn’t become less dualistic and more holistic, then I am not optimistic about the success of this transformation. I think social workers can play a key role in this important policy effort. But to do so, we will need to use the challenges as opportunities to grow, both individually and as a profession.
 My experience as a social worker has been exclusively within the United States. While I’ve had the benefits of glimpsing what health care looks like in several other countries, my perspective will reflect a U.S. bias. While there are, no doubt, shared experiences and issues that cross international borders, there are also unique issues within each nation and jurisdiction. Effective policy solutions must be designed to fit within the culture and structure of its target country.
 Health Evidence Network (HEN) Financial Integration across Health and Social Care: Evidence Review. http://www.euro.who.int/en/what-we-do/data-and-evidence/health-evidence-network-hen/publications/hen-summaries-of-network-members-reports/financial-integration-across-health-and-social-care-evidence-review Accessed January 16, 2012, 2:10pm EST
 Edwards, R.L. The Doctorate in Social Work (DSW) Degree: Emergence of a New Practice Doctorate Report of the Task Force on the DSW Degree Convened by the Social Work Leadership Forum, April 16, 2011. http://www.naddssw.org/pages/wp-content/uploads/2009/09/DSW-Degree-Task-Force-Report-April-16-2011.pdf, accessed January 16, 2012, 3:30pm EST
Dr. Nancy Smyth (@njsmyth) is Professor and Dean of School of Social Work at University at Buffalo and Associate Research Scientist at Research Institute on Addictions. She is also a member of @SWSCmedia Expert Panel.
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