Terry Mizrahi, Ph.D. 
Victoria
M. Rizzo, MSW, Ph.D
Perspectives from Health Care Providers
Psychosocial Problems and Social Work in Neighborhood Health Centers
(November/ December 2003)
By Terry Mizrahi, Ph.D., Professor, Hunter College of Social Work and Victoria M. Rizzo, MSW, Ph.D., Research Assistant Professor and Executive Director, Elder Network of the Capital Region Center for Excellence in Aging Services, University of Albany
Terry Mizrahi, Ph.D. Victoria
M. Rizzo, MSW, Ph.D
Aware that considerable health care is provided in neighborhood based health centers we undertook a study to learn more about them. Our specific interest was in ascertaining how and by whom the patients’ psychosocial problems were assessed and addressed - that is, which professionals handled those problems. We also wanted to learn more about the role of social workers and their value within primary health care settings.
The 27 New York City neighborhood health centers we studied were mostly located
in low-income communities. The demographic and social factors of these communities,
such as poverty, race and ethnicity, immigration status and age, resulted in
populations with disproportional levels of disease and poor health outcomes.
These were coupled with complex social, emotional, and environmental needs.
The communities were described as having a large and growing number of immigrant
groups from Central and South America, Asia, and Africa. The majority of patients
were women under the age of 65 and their children. Male patients were in the
minority and constituted an enrollment challenge. The most common medical problems
identified were asthma, diabetes, and hypertension.
What were the psychosocial problems?
Psychosocial services were broadly defined and included both enabling services
(foreign language interpretation, assistance in obtaining clothing, food, and
shelter, coordination of health care) and mental health services (adjustment
to illness counseling, treatment of mental illness).
Administrators, physicians, and social workers, the study participants, all
described the patients’ psychosocial problems as pervasive and with remarkable
consonance.
Of the 12 problems listed in the study, seven were identified as adversely affecting
a large number of patients. Of these “lacked of financial resources”
and “unsafe or unstable housing” were most frequently cited. Cultural
or ethnic practices of patients affected their health, compliance or utilization
of health care. These occurred very frequently and included issues related to
diet, alternative healing practices, and health beliefs among Latino/a, African
American and Caribbean groups. Other psychosocial problems identified were “suspected
child, woman or elder abuse;” “substance abuse”; “non-adherence
to medical treatment,” “adjustment to illness,” “emotional
distress/depression,” among others.
Are the patients’ psychosocial needs being met?
There was a mixed response to this question as the following quotes suggest.
One-third felt -
We are better able to meet their needs because they are expanding services and
providing more comprehensive services based on the needs of the community-daycare;
mother and children programs; vocational training, on-site; WIC; labs; pharmacy;
even the establishment of our own Medicaid HMO company (ADM).
But, 56% reported that they had done a better job in the past and only 64% thought
the future would be brighter.
We probably see 60-70% of the pregnant women we should see; maybe 10% of the
families who are very high risk for child abuse and neglect; and maybe 10% of
the older folks; and in pediatrics we’re missing a whole bunch of stuff…
There are a lot of people who aren’t properly evaluated…who can’t
get medication, who can’t be seen in psychotherapy and we can’t
get into outside agencies because they’re too high functioning; a lot
of people if we could get on meds and into case management, supervised by a
social worker, we could really make a little bit of money go a long way (SW)
[I’m not sure it will get better.] Ten years ago we were better off. We
had a smaller population to handle. I think the issues may have been a little
less demanding. The community was more homogeneous. I think the needs overall
have increased and there’s more of them, such as AIDS…it touches
our whole community…we surveyed that everyone had some relative affected
by AIDS; I think the increase in immigrants brings along with it different needs.
I think welfare reform, managed care, other policies that have impacted our
communities and as a result we need to do more for the patients and that has
become difficult for us to handle [ADM]
Who does meet these psychosocial needs?
Physicians:
We refer about 20% of our patients to social workers. They are very valuable
in our clinic, especially to the non-insured group, and those who cannot buy
the medicine, the instrument. With housing, they play an important role there.
No question they impact on the patients’ health. (Q: So, if you didn’t
have a social worker, what would happen to the healthcare?)
We would die. [emphasis added]
I think they [social workers] are crucial in a million different ways to the
center; mostly from my viewpoint as physician support, but also doing direct
counseling, and doing concrete services and providing contact between the patient
and the medical side here and the greater services in the community in New York
City, and the city government. Also they serve as advocates for our patients,
especially our Latino patients who don’t speak English, because most of
the social workers are Latino.
Social Workers:
I do a lot of education, linking them [patients] with benefits, supporting people,
helping them learn how to negotiate the system, advocating with health care;
there are a lot of things that I try to link them to… My role is mostly
supporting, guiding and connecting - giving people what they need to get the
services they need.
[I have so many roles]…Domestic violence counseling, substance abuse referrals,
home attendants, help with PCAP applications, HIV pre/post test counseling,
food pantry and mental health referrals, help with housing applications, Spanish
translation; not enough staff that speak Spanish. We have WIC, geriatric programs,
and do outreach to neighborhood schools. I do short-term counseling with prenatal
patients, especially high-risk.
Administrators:
It is not understood that for a lot of people, healthcare is more than just
a question of physical illness. It could have a whole mental, psychosocial component
to it; there’s just too much fragmentation to try to treat these folks
for their physical problems while ignoring the psychosocial stresses. If someone
has high blood pressure and they have a very stressful life, all the medication
in the world isn’t going to help…. The physician sees the patient
in the center, but nobody knows what the patient’s home situation is like.
So, social service and outreach programs bring those services to the healthcare
team are important in terms of treating the patient on a holistic basis.
So, is there a question about the value and contribution of social work?
Most physicians and center directors, many of whom were trained in business
or public administration, articulated the value of the affective/interpersonal
component of health care as follows:
The social worker’s role is to provide hope [emphasis added].You
don’t want to give people the impression that they are going through the
bottom. You always want them to feel that there is a way out of their situation,
that there is something beyond the immediate trauma that they’re experiencing.
And it is the social worker who is able to engage them to do that. She provides
hope and she provides an ear, because sometimes people just need someone to
listen to them...
Social workers are extremely valuable. Social workers are indispensable; without
them you couldn’t survive. There are so many problems that patients face;
they come in with all kinds of stress in their lives and they need someone to
talk to; otherwise doctors are too quick to give them psychotropic drugs. Social
workers talk to them and do short-term counseling.
… I’ve had a lot of patients who have built a positive relationship
with the social worker on site and it has made a real difference … My
guess would be that this impacts on their health care. People, who don’t
understand the psychological component of their illness, use medial services
more and end up in the emergency room more.
Administrators/directors’ views of social work are critical in their hiring
and utilization. In order to advocate for the financial and professional support
needed to recruit and retain credentialed social workers in a time of shrinking
resources, they must justify all their requests for funding to their affiliated
hospital system, to other public and private funders.
Current literature and experience provide ample support to the fact that unattended
psychosocial problems can negatively affect health status and health outcomes
such as preventable hospitalizations, misuse of emergency room care, and decreased
quality of life with an increase in mortality and morbidity. These outcomes
in turn generate higher health care costs. Prevention on the other hand, especially
among untreated males, could result in considerably savings.
Hardly any of the administrators or physicians (or social workers) thought that
there were sufficient numbers of social workers to address the needs; nor did
they think that other lesser-trained staff could perform most of these psychosocial
functions. On the contrary, perspectives ranged from viewing social workers
as “miracle workers” to “toilers against all odds.”
One administrator stated that the role of the social worker was “instilling
hope.”
Where do we go from here?
So many staff in the health centers confirmed the value of social work yet a
huge contradiction exists. Public and private funders are reluctant to acknowledge
and reimburse social services beyond limited, clinically diagnosed, professional
mental health services. This suggests that the Bush Administration’s allocation
of funds to expand and build more neighborhood health centers, as an avenue
to health care access for those medically uninsured, is incomplete at best.
There has been minimal articulation of increased resources for existing Centers
to fund the uninsured and his Administration is proposing major cuts and changes
in Medicaid that may exacerbate the budget crises of many existing Centers.
Current and proposed funding will not address the lack of reimbursement mechanisms
for services that address psychosocial problems. While NHC’s are “holding
their own” in providing quality services to their clients, despite current
financial constraints and increased numbers of financially indigent patients,
they are doing so, largely because of their commitment to this patient population.
This will be harder to sustain in the future, if the numbers of served uninsured
increase, as the revenues generated decrease. The challenge for patients, their
allies and advocates, is to communicate the necessity for increasing the scope
and size of the professional social work staff’s funding given patient
needs and social values.