Opportunities for Social Workers in the Patient Centered Medical Home

Abstract

The Patient Centered Medical Home (PCMH) has been hailed as one method of improving chronic care outcomes in the United States. A number of studies have underscored the importance of the social work role within the PCMH, yet little existing research explores the social worker as a driver of improved patient care. The Pennsylvania Chronic Care Initiative was created with a primary goal of increasing the number of practices that were recognized as PCMH by the National Committee for Quality Assurance. This article describes findings from in-depth qualitative interviews with representatives from seven primary care practices, in which the authors examined barriers and facilitators to implementation of the initiative. Barriers to implementation included small practice size, payer-driven care, not having a strong physician champion, variability within patient populations, and high implementation costs. Facilitators included having a social worker coordinate behavioral health services, clinical nurse case managers, preexisting models of outcomes-driven care, and being part of an integrated health delivery and financing system. Recommendations strengthening the role of medical social workers in primary care practices are discussed.

Social Workers as Behavioral Health Consultants in the Primary Care Clinic

“…In addition, as previously described, our health care teams currently receive some payment on a per member-per month basis to support populationbased health services, including those provided by BHCs. Perhaps more financially significant to the greater health system, however, are the cost savings that have been found to be associated with integrated care ( Hawk, Ricci, Huber, & Myers, 2015). Moving forward, BHCs may benefit from greater organizational support if they are able to provide direct, sitespecific evidence of cost savings associated with patients receiving BHC services (for example, less frequent utilization of the emergency department or reduced inpatient readmissions) ( Monson, Sheldon, Ivey, Kinman, & Beacham, 2012).…”

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

“…One of the most common uses for data is identifying needs, gaps and opportunities (Chandran et al., 2019 , 2011 ; Harper et al., 2018 ; Hawk et al., 2015 ; Health Research & Educational Trust, 2017b ; Henize et al., 2015 ; Heyman & McGeough, 2018 ; Klaiman et al., 2016 ; Mays & Scutchfield, 2010 ; Mikkelsen & Haar, 2015 ; O'Malley et al., 2017 ; Pires & Stroul, 2013 ; Reyes & Meyer, 2019 ; Scally et al., 2017 ; Shahzad et al., 2019 ; Spencer & Freda, 2016 ; Spencer & Hashim, 2018a ; The National Center for Complex Health & Social Needs, 2018a ). Often, using data to identify need involves finding specific locations or ‘hot spots’ in need of focused interventions (Health Research & Educational Trust, 2017a; Jacoby et al., 2018 ; U.S. Department of Health & Human Services, 2016 ).…”

“…Shared data systems require investment (Hawk et al., 2015 ; Wong et al., 2017 ). To make the most of these investments, collaborating organisations might consider engaging with partners, members of the community and front‐line workers or volunteers when designing their systems (Mikkelsen & Haar, 2015 ; Spencer & Hashim, 2018b ; The National Center for Complex Health & Social Needs, 2018c ).…”

Mutually Supportive and Inclusive Societies Driven by Community Social Workers in Japan: A Thematic Analysis of Japanese Comics

“…Capturing the essence of modern social work, person-centered care hinges on the belief that individuals can inherently understand and alter their situations [27]. CSWs exemplify a nuanced, patient-oriented, and intuitive methodology in this context.…”