Is There a Social Worker in the House? Health Care Reform and the Future of Medical Social Work

As medicine has become increasingly sophisticated and technologically complex, medical education and medical care have come to rely on increased specialization (Moore & Showstack, 2003). Dividing providers into specialties, however, has also led to a fragmented care delivery system in which a patient might go to one clinic for a check-up, a mental health service provider for treatment of anxiety, another service provider for rehabilitation after addiction, urgent care for a toothache, a specialist for diabetes management, and an imaging center for cancer screening. Fragmentation leads to lapses in communication among providers, which can be costly in dollars (when care is duplicated) and in outcomes (when prescription errors occur, for instance, or when diagnoses fail to take mental health into account). This fragmentation has measurable consequences: The number of specialty physicians per population has been associated with higher mortality, shorter life span, and low birth rates (Shi, 1994). Recent health reform legislation aims to correct fragmentation by providing incentives to reorient health care around primary care and for existing practices to transform into medical homes (Kocher, Emanuel, & DeParle, 2010). The medical home offers a single place for the coordination of all outpatient care needs, including behavioral and dental health. The model imagines a site where patients access care easily, where interdisciplinary care teams understand each patient's history and needs, and where the method of payment reflects the coordination necessary for delivery of individualized care (American Academy of Pediatrics, 2002). Although definitions vary from single-site clinics to multiple-site primary care networks, the Agency for Healthcare Research and Quality (2011b) outlines five core medical home attributes: They must be patient-centered, comprehensive, coordinated, provide superb access to care, and have a systems-based approach to quality and safety. The medical home model purports to be a transformation of primary care that would set the foundation for a sustainable health care system by keeping people healthy. Medical home models must include a social lens that considers the whole person in the context of the person's larger environment; without it, medical homes may not be transformational enough to achieve a healthy population within an affordable health care system. Despite increased access to care, the traditional medical model has failed to resolve growing public health problems such as obesity, and health disparities exhibited among low-income and minority populations include greater risk for chronic disease, anxiety, substance abuse, and depression (Cooper et al., 2000; Mensah, Mokdad, Ford, Greenlund, & Croft, 2005; Piffath, Whiteman, Flaws, Fix, & Busht, 2001; Wells, Klap, Koike, & Sherbourne, 2001). Environmental health research demonstrates that upstream factors such as a lack of community resources, environments hostile to physical activity, social isolation, segregation, crime, and discrimination can increase susceptibility to health hazards and can lead to poor health outcomes (Lee, 2002; Merkin, Stevenson, & Powe, 2002; Sexton, 2000). Equipping primary care to achieve real gains in population health will likely require looking at old problems through a different lens, one that acknowledges inequality and incorporates social justice. Social workers can bring this lens; we now have a unique opportunity to ensure that care models adopted under health reform legislation truly improve outcomes for the communities that we serve. We work in hospitals and clinics nationwide, yet we are underrepresented in health policy development or practice redesign. This time must be different. SOCIAL WORK SHARES VALUES WITH THE MEDICAL HOME The conceptual principles of the medical home and the values of our profession are well-aligned. The medical home's emphasis on patient-centered care, for instance, asks practices and providers to build personal relationships with patients and to engage patients in making informed decisions about their own health. …