Coordination, Integration, and Collaboration: A Clear Path for Social Work in Health Care Reform

The need for change in our health care delivery system is well known, well researched, and well documented by people inside the social work field and out. The Patient Protection and Affordable Care Act (EL. 111-148) (now more commonly known as the Affordable Care Act [ACA]) creates a framework for addressing that need through innovative programs and policies that shift health care's attention from acute, disease-focused episodes to person-centered, coordinated care. We recognize the enormous opportunities afforded by the ACA to improve and expand the continuum of care to include more chronic care and focus less on acute care. Social workers are ideally educated and positioned to address the challenges of health care reform's shifting focus, enhancing the quality and efficiency of health care delivery systems, particularly for the nation's most vulnerable populations. Our current health care delivery system can be described in one word: fragmented. Older adults and others with chronic conditions receive health care in fragmented settings, from fragmented providers, funded by fragmented payment systems. One older adult can receive care in a number of settings: home, primary care or specialty care, hospital, emergency room, and nursing home and residential care. In each of these settings, the older adult encounters multiple providers, with each provider facing challenges unique to her or his care setting, discipline, and therapeutic goal. Meanwhile, each older adult experiences nonmedical life circumstances that affect his or her ability to adhere to a medical plan of care. The often complicated health and social needs of older adults, combined with the variety of settings in which they receive services, demand a system-level rethinking of how care is delivered. Paying for the services accessed in multiple settings from multiple providers adds an additional level of complexity. Many services are available for older adults, but the systems for funding and providing these services are not unified. Health care for this population is funded through Medicare, Medicaid, private health insurance, and private payment. Long-term care is paid for through Medicaid; private payment and long-term care insurance; and a patchwork of federal, state, and local funding through the Administration on Aging and various titles of the Social Security Act. The two "systems" are internally disorganized and do not communicate well with each other--much less with the "outsiders," the beneficiaries for whom the services are intended. This fragmentation puts vulnerable older adults and their caregivers at increased risk for declines in health and functioning, unmet psychosocial needs, unnecessary health care costs, and needless suffering. Attempting to navigate the rules, regulations, and nuances of our multifaceted health care system can leave even the most savvy clients and caregivers exhausted, burned out, and defeated. The ACA provides the opportunity for a radical shift in the way we care for patients and their families because it recognizes that the patient should be at the center of medical care. One way the ACA does this is to shift the priority from episodic acute care to incentivized comprehensive care across an entire continuum. Meeting this challenge requires improved coordination of care over time and across multiple settings provided by professionally educated social workers who can act as a bridge between the outdated medical model and the social model. Social workers have a significant impact on the quality of life of patients as they participate in the health care system. Social workers are educated and trained to look at the whole person, broadly assessing how that individual, within the context of their support system, is faring medically, socially, psychologically, functionally, and economically. They are aware of services in the community, know how to access them, and understand how to enhance the usefulness of these services for optimal client support in the community. …