Delivering the Triple Aim Via the Social Worker

Social workers have been important members of the American health care system since the early 1900s, providing psychosocial support, discharge planning assistance, and education to patients in acute care settings.¹ According to Rizzo and Seidman,² throughout the 20th century, social workers drew on models of health promotion and disease prevention to meet the needs of contemporary health-related social issues throughout the lifespan. This effort became ever so significant during the latter half of the 20th century, as American older adults began living longer and with more comorbidities. Since then, medical social workers have assisted patients in the planning, implementation, and monitoring of care, greatly promoting personalized services, improving patient strength and well-being, and helping patients achieve their medical goals.³

To develop appropriate clinical care, providers rely not only on diagnostic tests but also on verbal information provided by patients and caregivers, which is where the skill set of social workers—critical thinking, clear communication, detailed assessments, and knowledge of community resources—is exceptionally important to the care team in order to meet case management goals. Because social workers understand the psychosocial influences on a patient and barriers to disease management, they are uniquely positioned to expand their role in clinical and disease management settings to “help patients comprehend and manage all their intervention needs and their behavioral and attitudinal changes.”⁴

As hospitals and care teams evolve to meet the quality demands of the market and to address barriers to disease management among older adults, the concept of the Triple Aim framework from the Institute of Healthcare Improvement (IHI) has emerged to summarize the goals of high-quality, patient-centered care and to optimize health care delivery. IHI believes new models need to focus on three areas: “improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.”⁵ According to IHI, these three dimensions need to be addressed simultaneously at all levels of the system to initiate change.⁵ In order to achieve the three aims, “new care models will require comprehensive, coordinated case management—a challenging activity that is ever-evolving and in which social workers can play a significant role.⁴ 

Challenges to Disease Management in Older Adults

Christ and colleagues⁶ discuss three characteristics of older adult disease management that affect the role and function of the social worker. According to the authors, the prognosis for many serious illnesses now includes a longer chronic period characterized by more brief periods of exacerbation and remission. By nature, chronic condition frequency, severity, and outcomes are unpredictable. It is this unpredictability that makes it difficult to develop a truly effective disease management plan, especially in older adults, who often experience a greater pendulum of the ebb and flow of disease symptoms.

The authors also mention that, due to older adults living longer, chronic illness lasts longer, thus there is a combination of both curative and palliative care being provided.⁶ The prolongation of life through treatment is stressful for patients and their family members, all of whom will need assistance navigating the fragmented health care system in order to make informed care and end-of-life decisions. Throughout these processes, the social worker acts as navigator, educator, and grief counselor, often functioning as a mediator between patients and their family members as well as other members of the health care team. 

Christ and colleagues⁶ further discuss that the unforeseen amount of older adults requiring care has led to a push for services to be delivered at home. This shift to home- and community-based services has been seen as an opportunity to increase the quality of life of chronically ill patients. The downside to this type of care is the reliance on family members to be available to provide or supervise the care. Oftentimes, younger adults are not entirely prepared to be caregivers to their frail, older relatives and will need assistance and support as they cope with changes to their lifestyle and manage disease progression and care transitions. 

Characteristics of Successful Disease Management Interventions

For a variety of sociological reasons, today’s health care consumer searches for a more personalized health care experience through individual providers, treatment plans, or educational material. As a result of the current and future emphasis on positive health outcomes to define quality care, management of diseases and patient/caregiver education is a valuable area for research to determine best practices.

A study done by Munshi and colleagues,⁷ which addressed the barriers to improving diabetes management in older adults, identified that “attention between clinic visits lowers diabetes-related distress,” and “communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress” in older adults. The authors assessed 100 patients over 12 months and divided the study participants in two groups. The control group received equal amounts of attention by educators (via phone calls, but no diabetes-related advice or strategies unless solicited by the patient), and the intervention group received attention by an educator for the first 6 months (via phone calls and home visits to develop strategies to cope with identified barriers to “optimize patients’ ability to perform self-care and adherence to treatment plan”) and “no contact” for the second 6 months. Several measures, such as hemoglobin A1c (HbA1c) levels and Tinetti scores, were used to determine the efficacy of the interventions.

The study found that HbA1c levels of the intervention group decreased by 0.21% at the 12-month mark, and the “scores on measures of self-care, gait and balance, and endurance compared with the control group” improved as well. The results also showed improvement of glycemic control in both groups after contact with educators, and phone contact by an educator aware of a patient’s barriers to self-care showed an “additional benefit of maintaining functionality during the intervention period.”⁶ Conversely, there was no difference in emergency department utilization between the two groups. The authors concluded that “many patients with multiple comorbidities were on complex regimens that were clearly beyond [the patient’s] abilities.”⁷

In order for disease management interventions to be effective in elderly populations, it is recommended that support staff, including nurses and social workers, be fully integrated into the primary care team and personalize interventions (through phone calls and home visits) to match each patient’s motivation level, cognitive abilities, and disease stage. Social workers are in a unique position to provide a more holistic approach to meet these goals within a clinical setting.

Roles and Responsibilities of Social Workers

Kramer⁸ studied the social worker’s role in managing older adults with chronic conditions who were near the end of life. This longitudinal study sampled older adults who were receiving comprehensive care from a community-based program that came to be known as the Care Wisconsin Partnership Program (CWPP), as well as their family members. Similar to the Program of All-Inclusive Care for the Elderly (PACE), CWPP employs an interdisciplinary team of health care professionals who work in collaboration with caregivers and participants who are frail and have several functional limitations but who wish to remain in the community rather than in a nursing home (NH).

Kramer⁸ used questionnaires, interviews, and focus groups to explore how social workers help participants and their caregivers through illness and the social workers’ specific role related to individual needs. According to the author, the sample of elders identified seven roles: (1) ensure that basic needs are met; (2) provide a meaningful, caring relationship; (3) complete organization tasks; (4) help make informed decisions; (5) prepare end-of-life care; (6) tackle problems; and (7) monitor elder. For these older adults, social workers were more than a mere point of contact, they were a safety net. By establishing rapport right at the beginning of the professional relationship, social workers quickly grow close to their patients, who, in turn, rely on the social worker for support and to “take the burden off.”⁸

Researchers also studied family members’ and caregivers’ perceptions about the social worker’s role. In the aforementioned study, family members acknowledged all of the roles identified by the older adults and also added: (1) provide intellectual and social stimulation; (2) address grief and bereavement; (3) provide emotional support; (4) facilitate transitions; (5) facilitate independence; and (6) serve as central care managers. Caregivers identified three roles and responsibilities that social workers embody as they assist them throughout care processes: (1) facilitate transitions; (2) facilitate family communication; and (3) prepare family for future and for death. Caregivers often rely on social workers to help them solve or escalate issues regarding care; they see the social worker as their primary point of contact and, often, a person they can trust. It is not uncommon for caregivers to form a closer bond with the social worker, more so than with any other member of the care team. For the social worker, forming this bond is imperative for the success of the care plan as they customize interventions to better address the needs of patients and family members. 

For continuity of care, the role of the social worker is indispensable, especially in relation to care transitions. Social workers are often the first point of contact, making sure that services continue and assessing shortfalls and gaps.⁸ As indicated by Sims-Gould and colleagues,⁹ “not only is it necessary to ensure that patients are medically stable, but an awareness of their psychosocial (for example, substance abuse, fear, anxiety), environmental, and socioeconomic characteristics is also vital to properly support their transitions.” Social workers possess the skills and training to address all of these barriers to care.

The Future of Social Workers in Disease Management

According to Fennell and Rieder Bennett,⁴ current managed care approaches have “not achieved coordinated care, [because] in actual operations it appears to emphasize fiscal goals.” Unfortunately, the impact of “chronic illness on patients’ physical, emotional and social lives is persistent and affects their reporting, compliance, and coping,” pointing to an even greater need for social workers to be involved in every stage of chronic disease testing, education, and management to provide a holistic approach to care and management of chronic diseases. 

For social workers to position themselves effectively, they need to be familiar with different models of interventions that have been developed to work with patients, which could include the chronic care model (a holistic framework, is interdisciplinary, has planned follow-up), the Stanford Self-Management Program (is community based, encourages self-confidence to control symptoms), and PACE (promotes independence, is interdisciplinary, prevents/delays NH placement and unnecessary hospitalizations). Other models identified from the literature include the disease-specific outpatient care model (eg, dialysis), mental health provision in primary care, and outpatient palliative care, which, according to Reckrey and colleagues,¹⁰ can inform the integration of social work into home-based primary care programs. 

Alvarez and colleagues¹¹ also mention the Bridge model, a social work-led model that combines care coordination, care management, and patient engagement to reduce hospital readmissions. The Bridge model is based on rigorous care management and coordination in which social workers follow patients from the hospital until well after discharge. The Bridge model is evidence-based and has proven to be successful. There are now several Community-based Care Transitions Programs (CCTPs) using the Bridge and are funded by the Centers for Medicare & Medicaid Services (CMS). Recent research indicates that “outcomes from participation in the CCTP indicate a 25% reduction in 30-day readmissions among Bridge clients, reducing CMS spending by $245,000 per Bridge Coordinator per year.¹² 

Also worth mentioning is the PACT (Preventable Admissions Care Team) model in which social workers work together with patients and caregivers to identify the risks associated with readmissions. According to the Council on Social Work Education, “PACT has been successful in reducing readmissions by 40% and emergency department visits by 50% for high-risk patients across different populations.”¹² The significant reduction in these rates could not be possible without intensive social work case management, extending to over a month after discharge in PACT. 

The future of social work in population health management of older adults also includes the Accountable Care Organization (ACO).¹³ CMS defines ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.”¹⁴ Because the organization is accountable for the care and outcomes of its enrollees, the skill set of social workers is crucial for its success. According to Collins,¹⁵ “social workers can provide case management for the most medically fragile ACO enrollees, helping them transition among different levels of care, stabilize their social environments and adhere to their care plans.” Social workers are the point of contact for patients requesting supportive services such as meals and transportation. Even when not requested, social workers conduct a social needs assessment, and outcomes of this assessment may include referrals to programs like meals on wheels or city-sponsored transportation programs for medical appointments, helping frail elders better access services in the community rather than waiting until after discharge. This coordinated care is what could make or break ACOs, and could result in bigger share savings.  

The issue of lack of direct reimbursement for social work services—the primary barrier to incorporating social workers into primary care practice—should also be addressed. According to Reckrey and colleagues,¹⁰ “this lack of reimbursement for social work services contributes to the perception that such services aren’t an integral part of medical care,” when, in reality, it can be quite the contrary. Because social workers understand the psychosocial influences on a patient and the barriers to care, they are uniquely positioned to expand their role in a clinical and disease management setting to assist patients in understanding their disease, managing their needs, motivating them, and overcoming barriers to behavioral and attitudinal changes.

If we want to achieve the goals of the Triple Aim, we must be proactive. This means introducing social work into the process as early as possible. Understandably, this would mean extra costs for the organization. However, we believe that the benefits outweigh the costs; there would be significant savings in many areas as a result of intensive social work case management. This need is now more apparent in primary care, where the costs of adding social work to the scope of practice can be prohibitive. Nonetheless, there must be opportunities for funding social work services in the primary care sector as we expand population health management initiatives across the continuum.

Conclusion

Social workers have long been considered essential members of evaluation and treatment teams for the elderly in order to facilitate the use of community resources and the integration of patients’ care goals. Recent research in this area suggests that health programs can benefit from strong social work collaboration to identify barriers to self-care, coordinate medical care, and prevent hospitalizations and long-term, NH placements (therefore controlling costs) in conjunction with programmatic supports and analysis of utilization. Social workers can fill the support gaps in patient navigation; and their skills, knowledge, and collaboration with patients and clinical teams can greatly empower, educate, and support patients through the progression and care of chronic diseases. 

1. Beder  J. Hospital Social Work: The Interface of Medicine and Caring. New York, NY: Routledge; 2006.

2. Rizzo V, Seidman J. Health Promotion and Aging. http://bit.ly/2brIorD. Masters Advanced Curriculum Project. CSWE Gero-Ed Center, National Center for Gerontological Social Work Education. Published 2009. Accessed August 31, 2016.

3. National Association of Social Workers. (2013). NASW Standards for Work Case Management. https://www.socialworkers.org/practice/naswstandards/casemanagementstandards2013.pdf. Published 2013. Accessed August 31, 2016.

4. Fennell PA, Reider Bennett S. Chronic illness. In: Encyclopedia of Social Work. 20th ed. New York, NY: Oxford University Press; June 2013. http://bit.ly/2by5iPs. 

Accessed August 31, 2016.

5. Institute for Healthcare Improvement. The IHI Triple Aim. IHI Web site. http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx. Accessed August 31, 2016.

6. Christ G, Diwan S, Jen S. Section 2: the role of social work in managing chronic illness care. CSWE Gero-Ed Center, National Center for Gerontological Social Work Education. http://www.cswe.org/File.aspx?id=25465. Accessed August 31, 2016.

7. Munshi MN, Segal AR, Suhl E, et al. Assessment of barriers to improve diabetes management in older adults. Diabetes Care. 2013;36(3):543-549.

8. Kramer BJ. Social workers’ roles in addressing the complex end-of-life care needs of elders with advanced chronic disease. J Soc Work End Life Palliat Care. 2013;9(4):308-330.

9. Sims-Gould J, Byrne K, Hicks E, Franke T, Stolee P. When things are really complicated, we call the social worker: Post-hip-fracture care transitions for older people. Health Soc Work. 2015;40(4):257-265. 

10. Reckrey JM, Gettenberg G, Ross H, Kopke V, Soriano T, Ornstein K. The critical role of social workers in home-based primary care. Soc Work Health Care. 2014;53(4):330-343.

11. Alvarez R, Ginsburg J, Grabowski J, Post S, Rosenberg W. The social work role in reducing 30-day readmissions: the effectiveness of the bridge model of transitional care. J Gerontol Soc Work. 2016;59(3):222-227.

12. Council on Social Work Education. The Role of Social Work in the Changing Health-Care Landscape Principles for Public Policy. http://www.cswe.org/File.aspx?id=78367. Published October 2014. Accessed August 31, 2016.

13. Ashery RS. Primary health care. In: Encyclopedia of Social Work. 20th ed. New York, NY: Oxford University Press; June 2013. http://dx.doi.org/10.1093/acrefore/9780199975839.013.301. Accessed August 31, 2016.

14. Center for Medicare and Medicaid Services. Accountable Care Organizations (ACO). CMS Web site. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/aco. Updated January 6, 2015. Accessed August 31, 2016.

15. Collins S. Accountable care organizations (ACOs): opportunities for the social work profession. Practice Perspectives. https://www.socialworkers.org/assets/secured/documents/practice/health/ACOs%20Opportunities%20for%20SWers.pdf. Published September 2011. Accessed August 31, 2016.