The Evolving Role of Social Work in Healthcare

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The Role of Social Work
in Integrated Health
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Judith Anne DeBonis PhD
Department of Social Work
California State University Northridge
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By the end of this module students will:
Understand the changing role of social work in healthcare
Recognize the importance of clearly communicating the social
work role as it relates to IH
Practice skills necessary to work as an effective team member
Realize the value of their personal leadership qualities in IH
Be aware of the positive impact of practice and policy
advocacy actions on IH
Learn how emotional intelligence and relational leadership can
support the need for collaboration in IH
Identify special issues related to ethical standards apply to IH
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Significant Shifts and Changes in Healthcare
Changes in healthcare have impacted the role and
responsibilities of both providers and patients.  These changes
have also resulted in a call for “new roles,” “new models of
treatment,” and “new professional competencies and training”
1
For example—increases in the number of patients who have
chronic health conditions requires a different model of
treatment and more collaboration between patients and
providers.
2
Social Work has been interested in
chronic care for close to 100 years 
3
Historical Role of Social Work in Healthcare
As early as 1915, medical social work was defined as a specific
form of social case work focused on the relationship between
disease and social maladjustment.
3
With an emphasis on the social impediments to health, social
workers were charged with “providing some occupation or
experience for the person jolted out of his regular plan of life by
chronic disease, to offset what he has lost and to make him feel
that he has still a useful place in the world.”
3
Do these concepts
apply to social work
and healthcare today?
“It is an important part of the social worker’s
function to concern herself with the social
problems arising directly out of the nature of
the medical treatment.”
Harriet Bartlett 
3
Current Role of Social Work in Healthcare
Little consensus in the literature as to the role of social work in
healthcare
A wide variety of descriptions reflecting a range of
responsibilities and functions. Including broad conceptual roles
such as the promotion of equality of opportunity, the
advancement of social change, and the task of challenging
injustice
4
Responding to the call for increasing accountability, application of evidence-
based practices, and cost effectiveness, there is movement in Social Work:
1.
Shift to adapt and integrate as behavioral health specialists in primary care settings
2.
Shift to community-based treatment models implementing evidence-based practices
which serve consumers in a cost effective manner, while providing more
comprehensive and integrative quality of care. 
5
3.
Shift to expand Social Work to include research as an important aspect of the social
work role. 
5,6
Then:
Social Work Looked to Medicine as the Model Profession
Medical Social Work did not meet the criteria for a
profession:
Social Work had a “professional spirit” but members did not
have sufficient individual responsibility, lacked a written body of
knowledge and educationally communicable techniques” 
3
Initially social work viewed medicine as a model profession and
an intrapersonal approach as more professional than one
focused on social and environmental factors
3
Now:
Medical Professionals Look to Social Work to Guide Training
Tenets and principles of social work are being incorporated into the
competencies and training of other healthcare providers—physicians,
residents, nurses.  Several examples: 
7
Well-trained residents/physicians are those who further the quality of care and
the humanistic mission of the medical profession.  Residents are required to be:
Ethical, compassionate, effective at creating therapeutic relationships with patients
Able to educate and empower, providing useful information to patients and families 
8
Skilled at working collaboratively with interdisciplinary healthcare teams
A shift  in attitude toward the relationship between physician and patient-
stressing collaboration, the importance of positive interactions, and the role that
all contributing parties serve in meeting the patient’s goals. 
1
Interpersonal Communication
Process Vs. Outcomes
Systems Based Practice 
7
What Social Work Tenets and Principles
Contribute to Integrated Health
Includes a wide range of settings, organizations, populations where social
workers practice.
Focuses on a broad range of health, mental health, as well as the social and
economic aspects of the lives of individuals, groups and communities 
9
Has lead to a health paradigm that more readily acknowledges a range of
psychosocial contributions to the etiology, course and outcome of illness.
10
Importance of a therapeutic relationship
Collaboration
Communication skills
Resilience
Advocacy
Justice 
7
Client Empowerment
Self-Determination
Social work’s value to healthcare delivery remains
its comprehensive view of social and psychological
circumstances as they interact with health and
illness, and its flexible range of helping
interventions to deal with the personal,
interpersonal, and environmental barriers. 
10
Role of Social Work in Primary Care
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addressing a large majority of
personal healthcare needs
developing a sustained
partnership with patients
practicing from a
biopsychosocial systems
perspective in the content of
family and community 
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Refers to Family Medicine,
pediatrics, geriatrics, internal
medicine…not specialty care
Often the first line of entry to the
healthcare system for patients—
their medical home
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Prevention
Health Promotion
Service Delivery Design
Acute and Chronic Care
Treatment
Rehabilitation
Long-Term Care 
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Specific Functions:
A day in the life of social workers in…
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Behavioral health practices must be adapted to
adhere to the fast pace of a primary care setting
See patients for 15-30 minutes to conduct a
focused assessment and to develop a treatment
plan. This information is then discussed with the
Primary Health Provider (PHP) and details a
behavioral health change plan.
Implement, monitor, or change the intervention,
using one to four 15-30 minute appointments.
Use the 5 A’s
Assess- Gather information on symptoms,
emotions, thoughts, and behaviors
Advise – Describe treatment options to patients
Agree- Patients decide on their course of action
Assist- Help patients learn new information,
develop new skills, solve problems, and
overcome barriers
Arrange- Specify when the patient will follow-up
with the provider.
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Discuss medication side effects with
patients, remind patients of skills used to
reduce anxiety
Arrangement for patients for AA Groups,
Anger Management Groups, etc.
Meet with patients during crisis situations,
determining suicidality  (and need for
referral to community services for those
patients who are already reintegrated back
into their communities.
Referrals, where applicable, for patients
needing psychiatric services
One on one and group therapy sessions
Charting
Sit in with presentations on issues relating
to patient care (medications, nutrition)
Attention to self-care 
14
Group Activity
Using the 5A and 5R Brief Intervention Models
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Use the 5 A’s (Assess, Advise,
Agree, Assist, and Arrange)
when the person is ready and
willing to make a change.
Use the 5 R’s (Relevance,
Risks, Rewards, Roadblocks,
Repetition) to educate and
motivate a person who is not
ready to make a change
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Highlights how essential health
behaviors are to overall health
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Offers an opportunity to check on
health behavior “vitals” during
every visit
Using the 5A and 5R Handout the group will role play and practice how they
would assess a person’s health behavior “vitals” and apply the As and Rs from
the models.  Debrief to see what works and where more practice is needed.
How can Social Workers Function Effectively
in an Interdisciplinary Healthcare Team?
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Knowledge in:
Medical Literacy
Consultation Liaison skills
with medical problems
Population Screening
Chronic Disease Management
Care Management Skills
Educating medical staff about
integrated care
Evidence-Based Interventions
Group Interventions
Working within the fast-paced,
action-oriented ecology of
primary care 
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Ability to be:
Responsive
Committed to social justice
Commitment to the ethical practice of
social work
Commitment to social change
Functional independently and
collectively with others
Sensitive to relationships
Interact positively and
instructively with clients 
16
Group Activity
Building Skills for Effective Interdisciplinary
Practice
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Knowledge in:
Medical Literacy
Consultation Liaison skills
with medical problems
Population Screening
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Care Management Skills
Educating medical staff about
integrated care
Evidence-Based Interventions
Group Interventions
Working within the fast-paced,
action-oriented ecology of
primary care 
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Have students identify and briefly share their
knowledge on 
one
 of the skill topics listed
Discuss as a group how that skill might be applied
to different practice settings and clinical scenarios
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*Note: 
 
There are multiple leadership models. Blanchard
(2009) model was chosen because it applies to leadership
for individuals as well as self-leadership.
Defining Leaders and Leadership
?
?
When you think of
leaders
, who
comes to mind?
“Famous” Leaders
Presidents, patriots, world leaders, inventors, explorers, educators, authors,
religious leaders, activists
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“Everyday” Leaders
Not as visible or famous but may have enormous impact and be responsible for
incredible change
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Group Activity
Qualities of Leaders
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The goal is to record some of your personal strengths as a
leader.
Think about:
People who acted as leaders in your life
A time or situation when you acted as a leader
Identify the leadership qualities that you exhibited
 and posses
.
Are these qualities also present in the people you identify as
leaders?
The Good News
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7
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.
What 
qualities
 do 
all
 leaders have?
“A great leader is a person who 
listens
, and
asks the kinds of questions that gives those
around him or her 
a
 
chance to be heard
.” 
17
The Serve Model 
17
S
ee the future
Envision a picture of the preferred future
E
ngage and develop others
Invested in a cause, and inspire
others to collaborate toward success
R
einvent continuously
Lifelong learners who put
new information to good use
V
alue results and relationships
Progress and success can be
measured in outcomes and
partnerships
E
mbody the values
Talking the talk and walking the
walk
Connecting Leadership Capacity to Health
Using Leadership to Enhance Health 
18
As 
self-leaders
, we’re able to
draw on our leadership
qualities to increase our feeling
of competence and self-
determination which can
maximize our health.
Developing self-leadership skills
can help individuals to
participate more fully in a
“partnership” with healthcare
providers.
Patients who are self-leaders will
experience an “internal”
satisfaction with decision
making and taking actions that
enhance their health.
Group Activity
Identifying Leadership Qualities in Patients
Think about a patient that you’ve met and talked with
recently.
What leadership qualities did that person possess?
How were each observed?
Was the quality included as part of the discussion?
How could that one quality be used by the patient to enhance
their health?
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Serve Model 
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Revisited and Applied to Self-Leadership
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Know the changes they want
to make
Are optimistic that change is
possible
Identify steps to take toward
those goals
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Can I describe what it would
look like when the change is
made?
Am I recognizing what I’m
already doing, no matter how
small, toward achieving that
goal?
S
ee
 
the future
Envision a picture of the preferred future
S
ERVE
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1
9
Believing that change is possible is essential
Investing in details about the change is more likely to lead to
desired results
When practiced consistently, small changes have a big impact
E
ngage and develop others
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Aware of when they’re fully
engaged
Focus on goals that they care
about
Identify strengths that serve
to accomplish the goal
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Is the goal I set for myself
something that I want, or
what others want for me?
Does achieving the goal
engage me?
Do I have the skills and
support necessary to take
action?
E
ngage and develop others
Invested in a cause, and inspire
others to collaborate toward success
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RVE
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2
0
Having a positive and respectful self-relationship serves as the
foundation for change and helps to sustain the process.
Potential rewards for change efforts provides the motivation
needed to take action.
R
einvent continuously
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Approach change as a
learner
Allow for experimentation
Adapt and customize
Know what works for them
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D
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g
?
Do I take the time to explore?
Do I have the information I
need?
What past accomplishments
can I use or apply?
Can I translate failures into
opportunities?
R
einvent continuously
Lifelong learners who put new
information to good use
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2
0
,
2
1
Taking time to discover means that the plan has better
potential for success.
If a strategy or an approach works, do more of it.
If a strategy is not working, try something different.
Exceptions to problems exist, and if identified, lead to a path of
change.
V
alue results and relationships
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Take pride in
accomplishments
Have a sense of self-
acceptance
Value both personal choices
and partnerships to direct
their life course
H
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I
 
D
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g
?
Do I acknowledge small
steps toward goals?
Have I set up rewards that
keep me motivated?
Do I give myself credit for
hard work and effort
required?
V
alue results and relationships
Progress and success can be
measured in outcomes and
partnerships
SER
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2
2
Sustaining change requires reinforcement and ongoing
motivation.
Reviewing goals that were accomplished reinforces the actions
that need to continue to sustain it.
The way that one change is accomplished can be applied to
other changes.
Social support networks provide multiple benefits in the
change process.
E
mbody the values
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Have clear sense of values
Aware of how daily actions
reflect values
Recognize that there are
numerous ways to enhance
health and vitality
H
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D
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g
?
How does my process of
making changes toward
health serve others around
me?
Do I share my experiences in
the change process to help
others?
Talking the talk and walking
the walk
E
mbody the values
SERV
E
W
H
A
T
 
W
E
 
(
M
A
Y
B
E
)
 
K
N
O
W
There are multiple options to show that we value our health.
We can decide to participate at any time.
If we commit to the value of optimal health, how we go about
living that value is up to us.
Relying on our leadership qualities is our own best asset to
change.
Group Activity
Applying the SERVE Model to Integrated Health
What opportunities do each of the 5 aspects of the SERVE
model offer to the patient and the social work provider?
Consider the following case example: 
A 48 year old Latina woman was referred to
the behavioral health specialist by the PCP.  The patient was diagnosed with Type 2
diabetes 3 years ago and prescribed oral medication and lifestyle changes.
 She
states that she hopes she will be able to lose weight and not need the medications
anymore but the report from the PCP indicates that her recent HbA1C indicates
that her condition is not well-managed. She is the primary cook for her husband,
and two children (ages10 and 12) and doesn't want to cook any special meals. She
says she tries to "cook healthy food and not too many sweets" but sometimes just
skips meals to help lose weight.  She has also started an exercise program, walking
about 30 minutes at least 3 times each week. Patient was treated briefly for
depression after the death of her Mother from a sudden heart attack last year but
currently is not taking medication for depression or seeing her counselor.
Group Activity
Understanding Why People Follow 
23
Instructions from
 a Gallop Poll
W
h
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l
i
f
e
.
How Did 10,000 People Respond? 
23
In some cases over 1,000 people had listed the exact same
words even though no categories or options were provided
Followers have a very clear picture of what they want and need
from the most influential leaders in their lives
T
h
e
y
 
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d
.
.
.
Trust
Compassion
Stability
Hope
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7
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s
Do these concepts
apply to social work
and healthcare today?
S
o
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i
a
l
 
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k
e
r
s
 
a
s
 
A
d
v
o
c
a
t
e
s
The Need for Advocacy
Jansson (2011) reports that patient care can be compromised by seven
common problems that often go unaddressed when healthcare consumers
and providers do not effectively engage in advocacy. 
24
B
o
t
h
 
h
e
a
l
t
h
c
a
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p
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w
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r
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c
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i
v
e
:
(1) funding for care,
(2) quality care based on acceptable guidelines,
(3) protection of their ethical rights,
(4) culturally competent services,
(5) access to services in their community,
(6) preventive services, and
(7) attention to their mental health needs.
A Call to Action
Patient advocates are needed to protect and support healthcare consumers
A
d
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2
5
Social work professionals are in a
strategic position to become leaders in
promoting the role of patient advocate:
by the nature of their values, their
commitment to social justice
their ability to effectively
communicate and engage individuals
representing diverse backgrounds
their application of the “person in
environment” or psychosocial
perspective 
25,26
Taking Action to Protect and Assist Patients
Social Workers serving as:
Care Managers
Medical Social Worker
Navigator or Health Coach
Discharge Planner
Regularly take advocacy actions:
Expedite referrals, gather
consumer information, help obtain
second opinions, mediate between
care providers, educate consumers
on self-care management, link to
inpatient and outpatient services.
Using Influence for Successful
Social Work Advocacy 
24
Influence in Interpersonal Exchanges. Advocates can exert
influence by drawing upon the following interpersonal experience:
E
x
p
e
r
t
i
s
e
:
 
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p
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:
 
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Successful Strategies for
Social Work Advocacy Engagement 
24
U
s
i
n
g
 
M
e
d
i
c
a
l
 
C
u
l
t
u
r
e
Portray advocacy as coming from concern about consumer’s well-being
Present concern from a medical ethics perspective to promote multi-
professional collaboration
Engage physician, “I bring this case to your attention so that we can provide
the best services possible”
E
m
p
l
o
y
i
n
g
 
P
o
w
e
r
-
D
e
p
e
n
d
e
n
c
e
Social worker is viewed as credible when others depend on expertise
Assume multiple functions beyond job description to enhance dependence
T
a
k
i
n
g
 
I
n
i
t
i
a
t
i
v
e
 
a
n
d
 
R
e
s
p
o
n
s
i
b
i
l
i
t
y
Initiate improvements in consumers’ health care and follow through with action
Participate in in-service training sessions, rounds, case findings, contribute to
medical records
Successful Strategies for
Social Work Advocacy Engagement (Cont’d)
24
D
e
v
e
l
o
p
 
P
o
s
i
t
i
v
e
 
T
r
a
c
k
 
R
e
c
o
r
d
Positive reputation demonstrates competency and trustworthiness.
A
p
p
r
o
p
r
i
a
t
e
 
A
s
s
e
r
t
i
v
e
n
e
s
s
Assert influence that will not compromise ability to engage in future advocacy.
D
e
s
i
g
n
 
C
o
m
m
u
n
i
c
a
t
i
o
n
 
S
t
r
a
t
e
g
y
Communicate skillfully with various audiences in different situations.
Consider audience and alter approach appropriately:
Physician/Administrator- Provide options and ask for preference.
Hostile audience- Create commonalities
E
n
c
o
u
r
a
g
e
 
C
o
n
s
u
m
e
r
 
E
m
p
o
w
e
r
m
e
n
t
Guide consumer confidence by informing of rights and encourage self-
advocacy.
Group Activity
Excessive Fatalism as a Barrier to Advocacy
J
a
n
s
s
o
n
 
(
2
0
1
1
)
 
h
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s
 
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s
p
o
s
s
i
b
l
e
.
 
2
4
You are a newly graduated MSW and the only social worker working in a primary care setting
with 3 PCPs, 2 medical residents and 3 nurses. You have considerable experience and
interest in health, mental health and substance use problems. The program director
intimidates you and after your first team meeting, where you did not offer any input about
issues that concerned you, you decided that any of your ideas would not be valued by the
group and the only way to keep your job was to be compliant with the medical staff who
appear to have all of the power. While you initially believed that your social work
perspective would complement the medical services offered at the agency, you do not feel
that it is possible to change the agency structure or policies and therefore have become
more apathetic that the system can work to benefit what you observe as client needs.
C
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s
Importance of Relational Leadership in
Collaboration 
28
Relational leadership is dispersed throughout an organization,
focusing on process rather than individuals.
For IH, this type of leadership is essential to creating successful
settings and relationships:
IH offers exciting possibilities for healthcare—as an evolving model,
there is no preexisting formula for how IH should operate
IH organizations are likely to prioritize “learning” and generating
knowledge about the best ways to function
Simultaneously, IH models will require significant change for all
stakeholders—patients, providers, payors
Relational Leadership Mirrors the Spirit of
Care Prescribed by IH
 
27
Both consider the partnership/relationship essential to success
Patient and Provider
Provider and other providers (multidisciplinary team)
All with the community
Movement beyond traditional top management leaders and
compliance of followers, the power structure is inclusive
Can traditional
primary care embrace
this paradigm?
An Italian Feasibility Study Offers Hopeful
Evidence about Collaboration
 
29
P
r
o
j
e
c
t
 
L
e
o
n
a
r
d
o
Tested the feasibility of including nurse
“care managers” trained in an
empowerment self management model into
the primary care/family practice setting to
support patients with chronic conditions
Historically Doctors worked  as single
practitioners in their office without a nurse
P
a
t
i
e
n
t
 
S
a
t
i
s
f
a
c
t
i
o
n
 
S
u
r
v
e
y
s
“My Care Manager and my
GP work together to help me,”
“My Care Manager tells my
Doctor about the things I
need”
P
h
y
s
i
c
i
a
n
s
 
r
e
p
o
r
t
e
d
:
Care Managers as the “ambassadors” of the
project, collaborating with the community and
“angels” supporting the patients to achieve
better health
85% “My communication and relationship
with the patient was improved”
78%  Satisfaction that “the quality of my time
with the patient was improved”
C
a
r
e
 
M
a
n
a
g
e
r
s
:
Care Managers (96%) felt
comfortable working in the GP
office and Doctors
Defining Collaboration 
27
“Collaboration is a process of social interaction which has it’s
foundation that each individual is responsible for the group’s success
and achievement of a common goal”
With collaboration, new opportunities to achieve extraordinary
outcomes become possible
For IH, the goal of collaboration is to provide the most clinically
effective care to patients at the most efficient cost possible
While IH settings will vary with the amount of collaboration, ideally as
collaboration increases, shared decision making would also increase
T
o
 
f
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c
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l
i
g
e
n
c
e
 
(
E
I
)
Emotional Intelligence (EI) as the Key to
Collaboration 
27
S
o
c
i
a
l
 
W
o
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k
e
r
 
t
r
a
i
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i
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g
 
r
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s
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e
m
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i
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i
n
t
e
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l
i
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e
n
c
e
Two Areas of Competence Related to Emotional Intelligence:
O
N
E
P
e
r
s
o
n
a
l
 
C
o
m
p
e
t
e
n
c
e
1
.
 
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e
l
f
 
A
w
a
r
e
n
e
s
s
Understand/manage emotions
s
e
l
f
 
c
o
n
f
i
d
e
n
c
e
2
.
 
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e
l
f
 
M
a
n
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n
t
Adaptive, optimistic, manage
response to conflict
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Empathy, sensitivity to verbal
and non verbal cues, keen
sense of others
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Persuasion, conflict
management, collaboration
Group Activity
Emotional Intelligence
Discussion Questions:
Development and mastery of 4 domains of emotional intelligence
related to personal competence (self awareness and self
management) and social competence (social awareness and
relationship management) can contribute to your ability to
effectively collaborate as a social worker.
1.
Considering the 4 domains of EI, in which one are you
strongest?
State how you developed that strength.  How might you leverage this
strength in an IH environment to enhance your collaboration with the PCP?
2.
What is your weakest EI domain?  How can you develop
additional dimensions in this area?
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Ethical Standards for Integrated Health
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p
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:
While the various professional disciplines
represented in Integrated Health do not
share one set of ethical codes, most share
a common purpose – to protect both
healthcare consumers and providers 
28
In the spirit of collaboration, “professional
pride” should yield to opportunities to
focus on the complexity of heath conditions
and the need for collaboration by
practitioners to improve patient care and
provider satisfaction 
28
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Informed consent
Confidentiality
Relationships with patients
Relationships with colleagues
Scope
 of practice
Informed Consent
 
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Part of the registration protocol,
patients give one consent for all care
Necessary for the provision of any
healthcare treatment
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An important part of the therapeutic
relationship; related to the patient’s
self-determination about their treatment
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The streamlined medical consent may
not be adequate for the BHP.
Careful consideration and respect for
differing consent needs.
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Practice how you would explain to the
patient your role and find out whether
they understand about their right to
understand the treatment options and
freely choose to participate..
Confidentiality
 
28
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How much and what type of
information to be shared with whom?
Some information can be treated with
different levels of privacy on a “need to
know basis” (keep certain information
from non-provider staff) or just between
the PCP and BHP (separate notes
protected from being released as part
of the general medical record)
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Able to let patient know that there are
options to keep some discussions
completely confidential (BHP/patient)
Need to review exceptions to
confidentiality regarding danger to self,
others, homicidal or suicidal ideation or
intent, child abuse reporting.
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Patient must be informed as to the
nature of the relationship between
PCP and BHP as well as with other
IH team members, how information
is shared
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Consider what you would say to a
patient who wants you to keep in
confidence information that they
have been using an illegal drug
Relationships with Patients
 
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Protection of the patient/provider
relationship. Based on trust that the PCP
holds the patient welfare above his/her
self interests and will advocate for their
health needs
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The therapeutic relationship is built on
trust and respect; social workers should
not engage in dual or multiple
relationships with clients or former clients
in which there is a risk of exploitation or
potential harm to the patient
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Both put patient needs first
Less formal restrictions for PCPs who may
choose to treat relatives or co-workers
(multiple relationships permitted for PCP)
BHPs can model a different way to think
about the patient/providers relationship
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Practice what you would share with your
patient as to why you would not initiate
conversation with them if you saw them in
public
Relationships with Colleagues
 
28
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May work in collaboration with other allied
health professionals and hire them if they
are appropriately trained and licensed
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Respectful of colleagues and avoid
unwarranted negative criticism of them in
communication with patients and other
professionals
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I
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There are ideological differences (PCPs
trained as leaders /decision makers
whereas BHPs trained as facilitators
/consensus builders)
May pose some need for discussion so
both are comfortable
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What strategies could a BHP take to
address their discomfort regarding power
differential in primary care
What actions might a BHP take to build a
collaborative relationships with colleagues
Scope of Practice
 
28
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Patient/Physician relationship is contractual --
-both are free to enter or decline the
relationship
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Social worker should provide services and
present themselves as competent only within
the boundary of their education, licensure,
relevant professional experience
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BHPs may be asked to perform duties that
they see as outside their area of expertise
(physical symptom or medication
management)
IH must address special concerns regarding
the level of psychiatric care which can be
managed in a primary care setting (including
a collaboration with psychiatric specialist)
Both PCP and BHP can learn from the
expertise of the other which will result in
better integration of patient care
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What are the advantages and disadvantages
of treating patients with mental health or
substance use disorders in primary care?
What issues might be better served in
specialty care?  What safeguards might you
build into a primary care setting to allow more
patients with severe diagnoses to be treated
in that environment?
Group Activity
Four Quadrant Model
Given a clinical case example, use the Curtis and Christian Four
Quadrant Clinical Integration Model 
30
 and answer the following
questions:
1.
What specific needs and goals are a priority for the patient at this
time?
2.
Which quadrant offers the best opportunities for the patient to receive
the care they need?
3.
Given the setting where the patient is being served, how might that
setting be modified to enhance care?
A final note…
Thoughts?
Comments?
References:
The Role of Social Work in Integrated Health
1. Bowen, J., Stevens, D. Sixta, C., Provost, L., Johnson, J., & Woods, D. (2010). Assessing Chronic Illness Care. 
J Gen Internal
Medicine, 25
(4), 586-592. Doi: 10.1007/#11606-010-1358-1
2. Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., Bonomi, A. (2001). Improving chronic illness care:
Translating evidence into action. 
Health Affairs, 20
, 64-78. r
3. Gehlert, S. (2011). The conceptual underpinnings of social work in health care. In S. Gehlert & T. Browne (Eds.), 
The handbook
of health social work (1-22). 
New Jersey: John Wiley& Sons.
4. Spencer, M. S. (2008). A social worker’s reflections on power, privilege, and oppression. 
Social Work, 53
(2), 99-101.
5. Philips, S. D., Burns, B. J., Edgar, E. R., Mueser, K. T., Linkins, K. W., Rosenheck, R. A.,…McDonel Herr E. C. (2001). Moving
assertive community treatment into standard practice. 
Psychiatric Services, 52
(6), 771-779
6. Ell, K. (1996). Social work and health care practice and policy: A psychosocial research agenda. 
Social Work, 41
(6), 583-592.
7. Larkin, G. L., McKay, M. P., & Angelos, P. (2005). Six core competencies and seven deadly sins: A virtues-based approach to
the new medical guidelines for graduate medical education. 
Surgery,
 
138
(3), 490-497. Doi: 10.1016/j.surg.2005.03.013
8. Mola, E., DeBonis, J., A., & Ginacane, R. (2008). Integrating patient empowerment as an essential characteristic of the discipline
of general practice/family medicine. 
The European Journal of
 
General Practice, 14
(2), 89-94.
9. Hoge, M. A., Paris, M., Adger, H., Collins, F. L., Finn, C. V., Fricks, L.,…Young, A. S. (2005). Workforce competencies in
behavioral health: An overview. 
Administration and Policy in Mental Health, 32
(5/6), 593-631. Doi: 10.1007/s10488-005-3259-x
10. Vourlekis, B. S., Ell, K., & Padgett, D. (2001). Educating social workers for health care’s brave new world. 
Journal of Social
Work Education, 37
(1), 177-191.
11. Miller, B. F., & Auxier, A. (2012). Integrated care policy. In R. Curtis & E. Christian (Eds.), 
Integrated care: Applying theory to
practice 
(281-295). New York/London: Routledge Taylor &Francis
 
Group.
12. Keigher, S. M. (1997). What role for social work in the new health care practice paradigm? 
Health and Social Work 22
(2), 149-
155.
13. Hunter, C. L., Goodie, J. L., Oordt, J. L., & Dobmeyer, A. C. (2012). 
Integrated behavioral health in primary care: Step-by-step
guidance for assessment and intervention
. Washington, D.C.: American Psychological Association.
References:
The Role of Social Work in Integrated Health (Cont’d)
14. O’Donohue, W. T., Cummings, N. A., Cucciare, M. A., Runyan, C. N., Cummings, J. L. (2006). 
Integrated behavioral health care:
A guide to effective intervention
. New York: Humanity Books.
15. O’Donohue, W. T., Cummings, N. A., & Cummings, J. L. (2008). The unmet educational agenda in integrated health. 
J Clin
Psychol Med Settings, 16
(1), 94-100. Doi: 10.1007/s10880-008-9138-3
16. Miller, J., & Beverly, K. (1998). Can we assess suitability at admission? A review of MSW application procedures. 
Journal of
Social Work Education, 34
(3), 437-453.
17. Blanchard, K., & Miller, M. (2009). 
The secret: What great leaders know and do.
 San Francisco: Berrett-Koehler Publishers, Inc.
18. Houghton, J. D. (2001). 
The relationship between self-leadership and personality: A comparison of hierarchical factor
structures.
(Unpublished doctoral dissertation). Faculty of Virginia Polytechnic Institute and State University, Blacksburg, VA.
19. DeJong, P., & Berk, I. K. (1998). 
Interviewing for solutions
. California: Brooks/Cole Publishing Company.
20. Proschaska, J. O., Norcross, J. C., & DiClimente, C. C. (1994). 
Changing for good: A revolutionary six stage program for
overcoming bad habits and moving your life positively forward. 
New York: Avon Books.
21. Berg, I. K., & Reuss, N. H. (2000). 
Solutions step by step.
 New York: Norton W.W. & Company, Inc.
22. Walter, J. L., & Peller, J. E. (1992). 
Becoming solution-focused in brief therapy.
 New York: Brunner Routledge.
23. Rath, T., & Conchie, B. (2008). 
Strength’s based leadership: Great leaders, teams, and why people follow
. New York: Gallup
Press.
24. Jansson, B. (2011). 
Improving healthcare through advocacy: A guide for health and helping professionals. 
Hobboken, NJ: Wiley.
25. Brill, C. K. (2001). Looking at the social work profession through the eye of the NASW Code of Ethics. 
Research in Social Work
Practice, 11
(2), 223-224.
26. Dodd, S. (2000). An empirical study of the role of social workers in ethical decision making in the hospital setting. (Doctoral
dissertation). Retrieved from Dissertation Abstracts International. (UMI Number 3018071)
27. Sherlock, J. J. (2012). Leadership in integrated care. In R. Curtis & E. Christian (Eds.), 
Integrated care: Applying theory to
practice 
(269-280). New York/London: Routledge Taylor & Francis Group.
References:
The Role of Social Work in Integrated Health (Cont’d – 2)
28. Boice, D. S. (2012). Ethics in integrated care. In R. Curtis & E. Christian (Eds.), 
Integrated care: Applying theory to practice
(125-143). New York/London: Routledge Taylor & Francis Group.
29. Aquilino, A., DeBonis, J. A., Mola, E., Musilli, A., Panfilo, M., Rollo.R. (2009, October). ProjectLeonardo: Final report of a study
to evaluate the feasibility and effectiveness of a model of disease and care management in the primary healthcare system for the
management of patients with chronic conditions. 
Il Sole 24 Ore,
 Special Health (Sanita`) Supplement, Pp. 3-66.
30. Christian, E., & Curtis, R. (2012). Introduction to integrated care. In R. Curtis & E. Christian (Eds.),
Integrated care: Applying
theory to practice 
(3-19). New York/London: Routledge Taylor &Francis Group.
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Changes in healthcare have led to shifts in the role of social work. From historical perspectives in medical social work to addressing current challenges in integrated health, social workers play crucial roles in patient care. The module emphasizes the importance of effective communication, teamwork, personal leadership qualities, emotional intelligence, and ethical standards in integrated health practice. Understanding these aspects is vital in navigating the complexities of modern healthcare systems.


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  1. The Role of Social Work in Integrated Health Module 2 Judith Anne DeBonis PhD Department of Social Work California State University Northridge

  2. Module 2 The Role of Social Work in Integrated Health By the end of this module students will: Understand the changing role of social work in healthcare Recognize the importance of clearly communicating the social work role as it relates to IH Practice skills necessary to work as an effective team member Realize the value of their personal leadership qualities in IH Be aware of the positive impact of practice and policy advocacy actions on IH Learn how emotional intelligence and relational leadership can support the need for collaboration in IH Identify special issues related to ethical standards apply to IH

  3. Definitions, Primary Care Teams, Functions and Benefits

  4. Significant Shifts and Changes in Healthcare Changes in healthcare have impacted the role and responsibilities of both providers and patients. These changes have also resulted in a call for new roles, new models of treatment, and new professional competencies and training 1 For example increases in the number of patients who have chronic health conditions requires a different model of treatment and more collaboration between patients and providers.2 Social Work has been interested in chronic care for close to 100 years 3

  5. Historical Role of Social Work in Healthcare As early as 1915, medical social work was defined as a specific form of social case work focused on the relationship between disease and social maladjustment.3 With an emphasis on the social impediments to health, social workers were charged with providing some occupation or experience for the person jolted out of his regular plan of life by chronic disease, to offset what he has lost and to make him feel that he has still a useful place in the world. 3 It is an important part of the social worker s function to concern herself with the social problems arising directly out of the nature of the medical treatment. Harriet Bartlett 3 Do these concepts apply to social work and healthcare today?

  6. Current Role of Social Work in Healthcare Little consensus in the literature as to the role of social work in healthcare A wide variety of descriptions reflecting a range of responsibilities and functions. Including broad conceptual roles such as the promotion of equality of opportunity, the advancement of social change, and the task of challenging injustice4 Responding to the call for increasing accountability, application of evidence- based practices, and cost effectiveness, there is movement in Social Work: 1. Shift to adapt and integrate as behavioral health specialists in primary care settings 2. Shift to community-based treatment models implementing evidence-based practices which serve consumers in a cost effective manner, while providing more comprehensive and integrative quality of care. 5 3. Shift to expand Social Work to include research as an important aspect of the social work role. 5,6

  7. Then: Social Work Looked to Medicine as the Model Profession Medical Social Work did not meet the criteria for a profession: Social Work had a professional spirit but members did not have sufficient individual responsibility, lacked a written body of knowledge and educationally communicable techniques 3 Initially social work viewed medicine as a model profession and an intrapersonal approach as more professional than one focused on social and environmental factors3

  8. Now: Medical Professionals Look to Social Work to Guide Training Tenets and principles of social work are being incorporated into the competencies and training of other healthcare providers physicians, residents, nurses. Several examples: 7 Well-trained residents/physicians are those who further the quality of care and the humanistic mission of the medical profession. Residents are required to be: Ethical, compassionate, effective at creating therapeutic relationships with patients Able to educate and empower, providing useful information to patients and families 8 Skilled at working collaboratively with interdisciplinary healthcare teams A shift in attitude toward the relationship between physician and patient- stressing collaboration, the importance of positive interactions, and the role that all contributing parties serve in meeting the patient s goals. 1 Interpersonal Communication Process Vs. Outcomes Systems Based Practice 7

  9. What Social Work Tenets and Principles Contribute to Integrated Health Includes a wide range of settings, organizations, populations where social workers practice. Focuses on a broad range of health, mental health, as well as the social and economic aspects of the lives of individuals, groups and communities 9 Has lead to a health paradigm that more readily acknowledges a range of psychosocial contributions to the etiology, course and outcome of illness.10 Importance of a therapeutic relationship Collaboration Communication skills Resilience Advocacy Justice 7 Client Empowerment Self-Determination Social work s value to healthcare delivery remains its comprehensive view of social and psychological circumstances as they interact with health and illness, and its flexible range of helping interventions to deal with the personal, interpersonal, and environmental barriers. 10

  10. Role of Social Work in Primary Care Defining Primary Care the provision of collaborative, accessible healthcare services by clinicians who are accountable for Primary Care Refers to Family Medicine, pediatrics, geriatrics, internal medicine not specialty care Often the first line of entry to the healthcare system for patients their medical home addressing a large majority of personal healthcare needs Role of Social Workers in PC Prevention Health Promotion Service Delivery Design Acute and Chronic Care Treatment Rehabilitation Long-Term Care 12 developing a sustained partnership with patients practicing from a biopsychosocial systems perspective in the content of family and community 7

  11. Specific Functions: A day in the life of social workers in Primary Care Behavioral health practices must be adapted to adhere to the fast pace of a primary care setting See patients for 15-30 minutes to conduct a focused assessment and to develop a treatment plan. This information is then discussed with the Primary Health Provider (PHP) and details a behavioral health change plan. Implement, monitor, or change the intervention, using one to four 15-30 minute appointments. Behavioral Health Discuss medication side effects with patients, remind patients of skills used to reduce anxiety Arrangement for patients for AA Groups, Anger Management Groups, etc. Meet with patients during crisis situations, determining suicidality (and need for referral to community services for those patients who are already reintegrated back into their communities. Referrals, where applicable, for patients needing psychiatric services One on one and group therapy sessions Charting Sit in with presentations on issues relating to patient care (medications, nutrition) Attention to self-care 14 Use the 5 A s Assess- Gather information on symptoms, emotions, thoughts, and behaviors Advise Describe treatment options to patients Agree- Patients decide on their course of action Assist- Help patients learn new information, develop new skills, solve problems, and overcome barriers Arrange- Specify when the patient will follow-up with the provider.13

  12. Group Activity Using the 5A and 5R Brief Intervention Models Using Brief Interventions: Highlights how essential health behaviors are to overall health Helps identify when a person is ready to make a change so that appropriate assistance can be offered Offers an opportunity to check on health behavior vitals during every visit Combining the 5 A s with the 5 R s: Use the 5 A s (Assess, Advise, Agree, Assist, and Arrange) when the person is ready and willing to make a change. Use the 5 R s (Relevance, Risks, Rewards, Roadblocks, Repetition) to educate and motivate a person who is not ready to make a change Using the 5A and 5R Handout the group will role play and practice how they would assess a person s health behavior vitals and apply the As and Rs from the models. Debrief to see what works and where more practice is needed.

  13. How can Social Workers Function Effectively in an Interdisciplinary Healthcare Team? Skills Knowledge in: Medical Literacy Consultation Liaison skills with medical problems Population Screening Chronic Disease Management Care Management Skills Educating medical staff about integrated care Evidence-Based Interventions Group Interventions Working within the fast-paced, action-oriented ecology of primary care 15 Characteristics Ability to be: Responsive Committed to social justice Commitment to the ethical practice of social work Commitment to social change Functional independently and collectively with others Sensitive to relationships Interact positively and instructively with clients 16

  14. Group Activity Building Skills for Effective Interdisciplinary Practice Skills Knowledge in: Medical Literacy Consultation Liaison skills with medical problems Population Screening Chronic Disease Management Care Management Skills Educating medical staff about integrated care Evidence-Based Interventions Group Interventions Working within the fast-paced, action-oriented ecology of primary care 15 of the daily care necessary to keep the condition under good control. Put Skills and Knowledge into Action Have students identify and briefly share their knowledge on one of the skill topics listed Discuss as a group how that skill might be applied to different practice settings and clinical scenarios Role play an interaction related to the skill highlighting the social work Characteristics that were observed (from the previous slide) Example: A student is working to increase their knowledge about diabetes as a chronic condition. The role play might offer a chance for the student to discuss with a patient who has been managing diabetes for many years, the challenges and stress

  15. Social Workers as Leaders *Note: There are multiple leadership models. Blanchard (2009) model was chosen because it applies to leadership for individuals as well as self-leadership.

  16. Defining Leaders and Leadership leaders

  17. Famous Leaders Presidents, patriots, world leaders, inventors, explorers, educators, authors, religious leaders, activists Abraham Lincoln Walt Disney Dalai Lama Rev. Martin Luther King, Jr. Mahatma Gandhi Mother Teresa Bill Gates Rosa Parks

  18. Everyday Leaders Not as visible or famous but may have enormous impact and be responsible for incredible change Teachers Parents Neighbors Boy Scout Leaders Team Coach Veterans

  19. Group Activity Qualities of Leaders Instructions The goal is to record some of your personal strengths as a leader. Think about: People who acted as leaders in your life A time or situation when you acted as a leader Identify the leadership qualities that you exhibited and posses. Are these qualities also present in the people you identify as leaders?

  20. The Good News All leaders have a cause that motivates them to act. Leaders will sacrifice and persevere to achieve their vision. No one is born a leader but leadership capacity and qualities can be developed 17

  21. What qualities do all leaders have?

  22. The Serve Model 17 ee the future Envision a picture of the preferred future ngage and develop others Invested in a cause, and inspire others to collaborate toward success einvent continuously Lifelong learners who put new information to good use Progress and success can be measured in outcomes and partnerships alue results and relationships mbody the values Talking the talk and walking the walk

  23. Connecting Leadership Capacity to Health

  24. Using Leadership to Enhance Health 18 Developing self-leadership skills can help individuals to participate more fully in a partnership with healthcare providers. Patients who are self-leaders will experience an internal satisfaction with decision making and taking actions that enhance their health.

  25. Group Activity Identifying Leadership Qualities in Patients Think about a patient that you ve met and talked with recently. What leadership qualities did that person possess? How were each observed? Was the quality included as part of the discussion? How could that one quality be used by the patient to enhance their health? Consider how you would incorporate this information into your next visit with the patient.

  26. Serve Model 17 Revisited and Applied to Self-Leadership Self-Leaders How Am I Doing? Can I describe what it would look like when the change is made? Know the changes they want to make Are optimistic that change is possible Am I recognizing what I m already doing, no matter how small, toward achieving that goal? Identify steps to take toward those goals eethe future Envision a picture of the preferred future

  27. WHAT WE KNOW 19 Believing that change is possible is essential Investing in details about the change is more likely to lead to desired results When practiced consistently, small changes have a big impact

  28. ngage and develop others Self-Leaders How Am I Doing? Is the goal I set for myself something that I want, or what others want for me? Aware of when they re fully engaged Focus on goals that they care about Does achieving the goal engage me? Identify strengths that serve to accomplish the goal Do I have the skills and support necessary to take action? Invested in a cause, and inspire others to collaborate toward success ngage and develop others

  29. WHAT WE KNOW 20 Having a positive and respectful self-relationship serves as the foundation for change and helps to sustain the process. Potential rewards for change efforts provides the motivation needed to take action.

  30. einvent continuously Self-Leaders How Am I Doing? Approach change as a learner Do I take the time to explore? Do I have the information I need? Allow for experimentation Adapt and customize What past accomplishments can I use or apply? Know what works for them Can I translate failures into opportunities? Lifelong learners who put new information to good use einvent continuously

  31. WHAT WE KNOW 20,21 Taking time to discover means that the plan has better potential for success. If a strategy or an approach works, do more of it. If a strategy is not working, try something different. Exceptions to problems exist, and if identified, lead to a path of change.

  32. alue results and relationships Self-Leaders How Am I Doing? Take pride in accomplishments Do I acknowledge small steps toward goals? Have a sense of self- acceptance Have I set up rewards that keep me motivated? Value both personal choices and partnerships to direct their life course Do I give myself credit for hard work and effort required? Progress and success can be measured in outcomes and partnerships alue results and relationships

  33. WHAT WE KNOW22 Sustaining change requires reinforcement and ongoing motivation. Reviewing goals that were accomplished reinforces the actions that need to continue to sustain it. The way that one change is accomplished can be applied to other changes. Social support networks provide multiple benefits in the change process.

  34. mbody the values Self-Leaders How Am I Doing? Have clear sense of values How does my process of making changes toward health serve others around me? Aware of how daily actions reflect values Recognize that there are numerous ways to enhance health and vitality Do I share my experiences in the change process to help others? Talking the talk and walking the walk mbody the values

  35. WHAT WE (MAYBE) KNOW There are multiple options to show that we value our health. We can decide to participate at any time. If we commit to the value of optimal health, how we go about living that value is up to us. Relying on our leadership qualities is our own best asset to change.

  36. Group Activity Applying the SERVE Model to Integrated Health What opportunities do each of the 5 aspects of the SERVE model offer to the patient and the social work provider? Consider the following case example: A 48 year old Latina woman was referred to the behavioral health specialist by the PCP. The patient was diagnosed with Type 2 diabetes 3 years ago and prescribed oral medication and lifestyle changes. She states that she hopes she will be able to lose weight and not need the medications anymore but the report from the PCP indicates that her recent HbA1C indicates that her condition is not well-managed. She is the primary cook for her husband, and two children (ages10 and 12) and doesn't want to cook any special meals. She says she tries to "cook healthy food and not too many sweets" but sometimes just skips meals to help lose weight. She has also started an exercise program, walking about 30 minutes at least 3 times each week. Patient was treated briefly for depression after the death of her Mother from a sudden heart attack last year but currently is not taking medication for depression or seeing her counselor.

  37. Group Activity Understanding Why People Follow 23 Instructions from a Gallop Poll What leader has the most positive influence in your daily life? Now please list 3 words that best describe what this person contributes to your life.

  38. How Did 10,000 People Respond? 23 In some cases over 1,000 people had listed the exact same words even though no categories or options were provided Followers have a very clear picture of what they want and need from the most influential leaders in their lives They Need... Trust Compassion Stability Hope Given that there are more than 170,000 words in the English language, this was impressive!

  39. Taking an idealistic vision Taking an idealistic vision can be much harder work but the payoffs are enormous Do these concepts apply to social work and healthcare today?

  40. Social Workers as Advocates

  41. The Need for Advocacy Jansson (2011) reports that patient care can be compromised by seven common problems that often go unaddressed when healthcare consumers and providers do not effectively engage in advocacy. 24 Both healthcare professionals and consumers must engage in advocacy to increase the odds that consumers will receive: (1) funding for care, (2) quality care based on acceptable guidelines, (3) protection of their ethical rights, (4) culturally competent services, (5) access to services in their community, (6) preventive services, and (7) attention to their mental health needs.

  42. A Call to Action Patient advocates are needed to protect and support healthcare consumers Social work professionals are in a strategic position to become leaders in promoting the role of patient advocate: Advocates must be willing to speak on behalf of the patient, act as their representative, and coach the patient and the family to advocate on their own behalf 25 by the nature of their values, their commitment to social justice their ability to effectively communicate and engage individuals representing diverse backgrounds their application of the person in environment or psychosocial perspective 25,26

  43. Taking Action to Protect and Assist Patients Social Workers serving as: Regularly take advocacy actions: Care Managers Expedite referrals, gather consumer information, help obtain second opinions, mediate between care providers, educate consumers on self-care management, link to inpatient and outpatient services. Medical Social Worker Navigator or Health Coach Discharge Planner

  44. Using Influence for Successful Social Work Advocacy 24 Influence in Interpersonal Exchanges. Advocates can exert influence by drawing upon the following interpersonal experience: Expertise: Tactfully display personal knowledge, credentials, and suggest evidence-based practices Coercion: Cite adverse implications for consumer dissatisfaction, potential reputational losses Rewards: Praise physician for helping a consumer and promise to go the extra mile in the future Charisma: Become admired for putting patients first or being a team player by displaying qualities of leadership, moral authority to motivate others to follow Authority: Hold leadership positions in departments or persuade administrators to serve as intermediaries

  45. Successful Strategies for Social Work Advocacy Engagement 24 Using Medical Culture Portray advocacy as coming from concern about consumer s well-being Present concern from a medical ethics perspective to promote multi- professional collaboration Engage physician, I bring this case to your attention so that we can provide the best services possible Employing Power-Dependence Social worker is viewed as credible when others depend on expertise Assume multiple functions beyond job description to enhance dependence Taking Initiative and Responsibility Initiate improvements in consumers health care and follow through with action Participate in in-service training sessions, rounds, case findings, contribute to medical records

  46. Successful Strategies for Social Work Advocacy Engagement (Cont d)24 Develop Positive Track Record Positive reputation demonstrates competency and trustworthiness. Appropriate Assertiveness Assert influence that will not compromise ability to engage in future advocacy. Design Communication Strategy Communicate skillfully with various audiences in different situations. Consider audience and alter approach appropriately: Physician/Administrator- Provide options and ask for preference. Hostile audience- Create commonalities Encourage Consumer Empowerment Guide consumer confidence by informing of rights and encourage self- advocacy.

  47. Group Activity Excessive Fatalism as a Barrier to Advocacy Jansson (2011) has described that excessive fatalism can impede a social worker s involvement in advocacy by undercutting the belief that change is possible. 24 You are a newly graduated MSW and the only social worker working in a primary care setting with 3 PCPs, 2 medical residents and 3 nurses. You have considerable experience and interest in health, mental health and substance use problems. The program director intimidates you and after your first team meeting, where you did not offer any input about issues that concerned you, you decided that any of your ideas would not be valued by the group and the only way to keep your job was to be compliant with the medical staff who appear to have all of the power. While you initially believed that your social work perspective would complement the medical services offered at the agency, you do not feel that it is possible to change the agency structure or policies and therefore have become more apathetic that the system can work to benefit what you observe as client needs. Comment on this case based on your thoughts about the social work role in Integrated Health. What strategies recommended by Jansson could be used to combat fatalistic thinking? Given a scenario that you believe might lead you to feel powerless and hopeless, what resources, knowledge, and personal capacities do you have that could assist you? In what ways does fatalistic thinking impact providers, patients, families, agencies?

  48. Social Workers as Collaborators

  49. Importance of Relational Leadership in Collaboration 28 Relational leadership is dispersed throughout an organization, focusing on process rather than individuals. For IH, this type of leadership is essential to creating successful settings and relationships: IH offers exciting possibilities for healthcare as an evolving model, there is no preexisting formula for how IH should operate IH organizations are likely to prioritize learning and generating knowledge about the best ways to function Simultaneously, IH models will require significant change for all stakeholders patients, providers, payors

  50. Relational Leadership Mirrors the Spirit of Care Prescribed by IH27 Both consider the partnership/relationship essential to success Patient and Provider Provider and other providers (multidisciplinary team) All with the community Movement beyond traditional top management leaders and compliance of followers, the power structure is inclusive Can traditional primary care embrace this paradigm?

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