(April 2001)

HEALTH CARE POLICY AND PRACTICE NETWORK

The Health Care Policy and Practice Network is responsible for Chapter programs on developments of concern to social workers in policy and practice. The HCPPN leadership and sub-committees sponsor and maintain active involvement in managed care, Medicaid managed care, research on the impact of professional social work in primary care and the CIR project to report on difficulties with managed care, both in health and mental health. The Network invites more than 400 enrolled members to meetings held approximately five times a year. More than 40 members attended the March meeting on long-term care - nursing homes (Care Centers), and home care. Changes resulting from recent legislation were considered. The impacts have been profound on patients as well as staff. The meeting of Sept. 26, 2000 was held to consider the role of social work leadership in hospitals that exemplify current trends that strengthen the role of social workers in hospitals.

The September meeting was recorded and the transcript follows. We look forward to readers' reactions to the material. E-Mail comments to HCPPN co-chairs, Terry Mizrahi or Gerard Beallor.

Jerry Beallor, Co Chair, HCPPN "Welcome everyone. The subject for this meeting tonight is Making Social Work work in a hospital setting in the year 2000." We're doing it because you will recall from earlier meetings that we have spent considerable time during the last few years stressing the problems and issues that seem to be tearing social work in hospitals apart and creating severe hardship for social workers and their clients. We've looked at the stressors that social workers have faced, but we haven't spent much time looking at the stressors that the institutions in which they work face. The speakers are: Sona Euster, Director of Social Work Services of New York Presbyterian Hospital, the New York Weill Cornell Center; Virginia Walther, Senior Assistant Director of the Department of Social Work Services of Mount. Sinai - NYU Health System, and Francis Gutieri, Director of Social Work Services at Bellevue Hospital Center of the NYC Health and Hospitals Corporation.

I will begin by asking our guests some questions to initiate the discussion. Later Terry Mizrahi will join in and those of you who joined us tonight are encouraged to further the dialogue.

QUESTION 1: Has the mission of your hospital changed? Has it's priorities shifted and if so how and how do you see that today compared, let's say, to a decade ago?

Sona Euster: I think in fact the reality is that the mission statement from 25 or 30 years ago and the mission statement today are very similar. And, basically, I think at many of these institutions the mission is patient care, teaching and research, and that has not changed. I think that priorities have changed based on the current health care system and the fiscal needs of the institution. Hospital administrators are ordinary people in extraordinary times. I don't know how any group of people can make the healthcare system function effectively right now. But there are real issues in terms of how do we insure access for people to healthcare? How do we make sure that we have an equitable distribution of resources? How do we make sure that people are treated with respect and dignity, and that they also can negotiate the complex health care systems? The healthcare systems are really struggling to keep their mission alive while managing to stay alive fiscally. If they go out of business they can't do anything about a mission no matter how wonderful it is.

Virginia Walther: I actually have had a chance to look at the Department of Social Work's mission statement recently, and it is almost verbatim, the same as it was when the institution was created. If you ask the social work profession what its mission within Mt. Sinai was in years past it would also look very much the same as today. What we have to do to be able to fulfill that mission is the area of great challenge. I agree with you about all the different stresses impinging on that goal, particularly financial ones.

Fran Gutieri: I essentially agree with what the others said. For the Health and Hospitals Corporation there was a period of a few years when there was real debate about the mission. As many of you are aware within our mission is included the very clear statement that patients receive care regardless of the ability to pay. About 5 years ago, there was a struggle going on within the hierarchy of the various facilities about whether they would be able to maintain that phrase. Luckily everybody agreed that it must be maintained. What is not incorporated into their mission but what is included now in practice throughout our facilities, is a very strong emphasis on helping to support the financial stability of the institution. We do this by encouraging patient cooperation in the financial counseling process and following up with them on the documentation needed to establish eligibility for Medicaid, Child Health Plus, PCAP, or whatever other benefits may be possible I think that the major difference for us is that everyone in health care,including social workers must be part of that message in a clear way to patients and families. Sometimes thathas been difficult for social workers, but it really is a very important thing now for all of us to understand.

Sona Euster: The things that seem to change are that the ways of achieving that mission are being redefined. To deliver excellent quality care to patients doesn't necessarily mean we're going to continue certain sets of people providing certain sets of services. I think there's a lot of debate about what that high level of care now encompasses, and how is social work going to fare in this new climate.

QUESTION 2: Have your social work programs expanded? Have new ones, new programs been added? Have you been reorganized? What has happened to the social work dept. as the hospital has done these things that you describe?

Virgina Walther: When I came to Mt. Sinai almost 20 years ago, it was the same debate. The city was in dreadful shape. Was the City going to survive; were hospitals going to survive, and was social work going to survive? We've gone through these challenging times of re-evaluation of our missions, our goals and objectives before, but I will say that as an assistant director of social work I am doing things and learning new skills I would not have dreamed that I would do. I manage three quarters of a million dollars worth of grants. I had never written a grant; never even though I wanted to write a grant. I'm learning about diversified financing. I am much more savvy about budgets. These kinds of things keep us alive. On the other hand, we are changing as we see new populations emerging, as we watch trends in healthcare. I think that the real challenge is to stay ahead of the 8-ball and not to wait till it hits you in the face. But that's not new. There is so much going on not only with the financing of healthcare, but with the shift from inpatient to ambulatory care which is wonderful and with the high technology that's emerging. But it means really to me looking at the opportunities, and not staying fixed in time about old ways of doing business. We are not smaller, but we're very different. We're funded differently; our roles are different. We are much more comprehensive and the expectations for staff at all levels, what kinds of knowledge base that people need, what kinds of skills are very, very different than 20 years ago.

Fran Gutieri: We are smaller in regard to the inpatient services because hospitals have closed beds and enture units.Ten years ago there were 220 staff in social work and discharge planning at Bellevue;at the present time we're probably about 160. However, that has been primarily because of the loss of those inpatient beds. And we have similarly done as you have at Mt. Sinai. We have looked to grants to be able to fill in gapsand reach new populations. The administrative struggle is dealing with the erosion around the "core," while being able to introduce effectively new initiatives that may be tied to requirements of granting agencies that preventflexible application of these new position, for example, funding for HIV/AIDS rape crisis domestic violence often prescribe specifically how staffmay be assigned. I think that these changes can both enrichand complicate the professional life of social workers. In the past social workstaff in hospitals identifies primarily with their departments; now they identify with their interdisciplinary teams, with their colleagues in the grant funded programs, and less to with their social work departments. They have many channels of accountability.

Sona Euster: I think that that's one of the opportunities; but it's also one of the challenges. Whether there exists a dept. of social work in an institution or it's gone, the reality is that one of the challenges of this whole concept is "matrix-management." The professional staff really has to take on leadership roles within their product line, service line, disease cluster, something or other care center, whatever euphemism the institution is going to be using. And that's a critical shift. Social Workers need to be autonomous practitioners within that team. And the constituency they need to think about it is not the patient and the family alone anymore; it's, the entire team; it's the insurance companies; it's the community resources; it's the finance dept. It's not enough that we as managers have learned about budgets; the staff has to know about budgets. The staff has to understand what it means if the institution is down 150 discharges as we were in July. Those kinds of things have to make sense to the social work staff.

Virginia Walther: I remember when I started in social work and my first job was in Chapel Hill and there were two or three researchers. People talked about research, and there were two or three people who did research. And now when I interview people I talk about the need to be able to be a researcher in that one can talk about outcomes articulately. We need to articulate the value-added piece of our work. It's not enough to be doing good things for people: We need to explain it terms that show how we help to keep this hospital alive.

Fran Gutieri: This fact is something that is taking the schools a while to catch up toand it is a problem for us in the recruitment of staff.

Sona Euster: I think we're discussing this problem with several of the schools. This is going to be an important shift at the graduate educational level because there is a need for workers to be able to be independent practitioners within their teams. We all came through at a time when there was a lot of nurturing and support for staff: Supervision, and review on a weekly basis of everyone's work was the norm. That is a luxury that I really don't know if any department can do anymore. We expect staff to be able to be up and running much earlier.

Virginia Walther: I think that's a challenge for the administrative people. While I'm trying to put a positive spin on this, I don't think the old method of supervision was great. I don't know of another profession where a worker went through an hour-long supervision weekly with the same person with the same skills. To me the change forced us to be much, much more creative and much more respectful of autonomous staff. We've always said that we wanted to be autonomous, but then we said you'd better be in my office every week. That never made a whole lot of sense. I do think it makes a lot of sense in terms of continuing education, to respect the value of knowledgeable peers and what they bring to one another.

Fran Gutieri: The danger is that people are so busy that supervision may be too vague and ill defined. Staff also vary in their comfort level with the newer models of supervision and often need more regular support and guidance. I think that it depends on the organization to really make a commitment to appropriate and effective continuing eduacation.

Sona Euster: I did a series of focus groups a little bit over a year ago in a variety of different settings, outpatient, acute care; where they have wonderful skills and were doing great things. The participants raised this issue of having confidence, of needing to take leadership and yet not really feeling very supported by their professional organizations, schools, etc. I teach a course in clinical practice and healthcare here (at Hunter) and one of the classes in my courses is on leadership. I ask the students what their views are in terms of social workers as leaders and they're blank. It's like a whole new world is opened to them. I tell them that there are people in the Congress who social workers; people who are high up in hospital administration have been clinical social workers.

There is a set of skills that make someone an autonomous clinician. There's an overlapping set of skills for leadership. It's almost like we need to really enable and give permission to people to be leaders. I think younger social workers or newer social workers are frightened to take on a leadership role. One, they don't have the skills, and two, they're afraid of some the responsibilities.

Virgina Walther: When you said that you're not taught that you can be administrators or managers, I think that may be true. But what I'm suggesting is that even as clinicians, there's a tremendous role for leadership on the part of the social worker. I think that the social worker on the oncology or on the cardiac service should see him or herself as a leader of that team.

Fran Gutieri: There are so many roles for social workers, if you know hoe to articulatewhat we are doing. I think some doctors understand what social work can do. The physicians are always looking for problems to be solved; to the extent to which we own that problem-solving role, we will have a strong impact at the team level, at the program level and within the larger institution.Thereis a lack of confidence on the part of social workers, sometimes just from lack of experience, butmay also be a need for more skills development.

Virginia Walther: My other role is that I have a dual faculty appointment in the School of Medicine. So, I'm course director in medicine for fourth-year medical students. But, I've got to tell you that as medicine is shifting into the ambulatory care arena the medical students, they get it. They can tell people all sorts of things and it is the interface between knowledge and confident behavior that is the biggest deal. Most of those variables are socially determined variables. If there is ever an opportunity for any social worker to be able to be articulate and to have power, as it were, this is it. And they get it. It's really upsetting to me as a medical educator to see that when problems are presented relating to smoking, to heart disease, and to social behavior, the first thing the doctors want to do is refer to the social worker. From a medical education point of view they may need social workers; but maybe we let them need us too much. I think that the climate is very right, and we've got to teach these young social workers to go in there, and speak with authority. And for God's sake not only do it, but tell them that you did it, and explain how you did it. It's so often we just do it and we never say this is how I did it; articulating the principle involved -- this is what is important.

Sona Euster: When we do that, we are chipping away at the old image of our profession step by step.

Terry Mizrahi (co-chair, HCPPN): I'm doing research on a national study of social work directors in hospitals. 700 social work department director or the person responsible for social work in that facility. With a 50% response rate from a range of hospitals and auspices, regardless of and even independent of the structural changes in the larger hospital, there was a range of responses from the social workers as to whether they saw themselves as proactive people who were positive about the future, or whether they saw themselves as negative and frustrated with no opportunity.

Those who we identified as a positive, optimistic, proactive social work leader asserted that they were making a difference. Some use the word "influence." " I'm at the table; I go to the meetings; I make sure I chair the ethics committee. I make sure that my social workers are out there. We've gotten lots of grants. We've shifted to the community. We're part of case management teams." Even if these leaders have lost the structured department, they are reconfiguring social work roles.

My colleague, Julie Abramson, says social workers need to respond to MDs: "Hey Doc, no I'm not a miracle worker. We did it together." Otherwise they'll pat you on the back when you send a patient off to the nursing home; but if some else is still sitting there languishing, you're to blame. You need to teach them what you did, and the complexities of both system and clinical work. My last comment is around the concept of autonomy. I think that it's a bad term to use-- autonomous worker. Because, nobody is autonomous. Physicians have lost their autonomy as a profession. I would rather us use the word "interdependence and mutuality." Let me just say what I mean. The model of autonomy includes the way physicians used to be, which also means they were not accountable, nor collaborative. They were trained for "self-reliance." Now they have been criticized for that-for going it alone. As a result they don't have any allies. Nobody feels sorry for them and nobody understands their stresses because they never asked for help before. That's a professional paradigm that is dead. Social workers should fight for equality, equity and comparability as far as I can see. We're equal collaborators. We're colleagues. We all make a difference on that team and we're all necessary. Without us, you doctors can't do your job, and we can't do our job without the other professions.

QUESTION: How have your programs expanded? What new ones have been created?

Sona Euster: One can sort of almost extrapolate from what we've already said in terms of the shift in the treatment process; the fact that there are less in-patients and less in-patient days and more ambulatory programs. What we've been trying to do is stay ahead of the curve and it's very difficult. We have looked at what doesn't work for the institution or what doesn't work for patients and families. And one of the major issues is the social work disconnect in the continuum of care. We began to change in pediatrics because it's just more manageable. We know that we have chronically ill children who, five years ago, could in the space of six weeks, have five different social workers. If they went into the ER they had one. If they got admitted to one in-patient unit they had another one. If they got into a different in-patient unit, they had still another one. If they got admitted into the ICU they had a different social worker. We've tried to really look at this and develop some continuity of care models. We did a study, we didn't call it research, but we got pediatric social workers involved in tracking admissions, looking at diagnoses of kids that were admitted. Did they use our clinics before they were admitted? Were they seen by private physicians, etc.?

And then we divided pediatrics, not by geography, but by diagnostic groups. And so we have a social worker who is responsible for all of the kids with asthma and pulmonary disease. We have a social worker who's responsible for neurological problems. We have an oncology pediatric social worker and they follow those families wherever they get care, in the clinic, in the ER, in the PICU, on the unit. And we did some satisfaction surveys before and after with patients and families and with nursing and medical staff. And we have been able to track a lot of very important changes, for one, families now know who to contact in this huge institution. They may not remember the doctor's name, but they know who the social worker is. If they're panicked about an asthma attack, for example, they will call the social worker before they'll just hightail it to the ER. As a result we've decreased unnecessary ER visits and admissions. The important thing is to really look at your institution and figure out where the gaps of service are for the client and for the staff as well. Hy Weiner ( a professor of social work in health care) used to say "Look to the pattern of unmet needs." And that's really all we're still doing. But you need to do it continuously. That's how you stay ahead of the curve.

Virginia Walther: We have also been trying to look at how to meet the needs of our internal customers, (as much as I hate the word customers,) or colleagues - the physicians, the nurses, the case managers, the finance people- talking to them about what would help them. It is amazing how many good ideas can emerge from those kinds discussions and it's so critical for social workers to be comfortable working with their finance colleagues, and to become knowledgeable about that aspect of our work.

One of the problems that we dealt with was that social workers had been assigned by geographic unit, whereas the house staff were in teams that were following patients on more than one floor. And so, in talking to them we realized that what they really wanted was to have a worker assigned with the team who would go with them wherever the patient was. Now that seems very sensible, but we really had not looked at it until we heard it directly from them. And it does make a difference because if they'd feel better about social workers, they will include that person more collegially and he or she can be more effective.

QUESTION: How do you keep loyalty? How do you keep the identity and how do you keep the visibility of this critical mass of people called social workers if you're so decentralized?

Sona Euster: Well, I think even if you don't have a dept., you don't necessarily have to be decentralized. This matrix management business, however the institution defines it, is reinventing the wheel. When I started in healthcare social work, I had two loyalties. I had the service that I worked on and I had the dept. of social work. It's no different now than it was then. And I needed to be nurtured, frankly, in both of those arenas. And I needed to give back to both of those arenas. And I think that's how one holds the loyalty. If you have a department, you have to provide them with some benefits. You subscribe to an organization or a journal; if you don't get any benefit you drop your subscription. I think that even though we're not doing, weekly hour long supervision, we have to nurture our staffs, and we have to encourage professional growth and development. We have to provide them with professional activities that stimulate them.

Virginia Walther: And we have to help them to fly their programs as self directed practitioners. When I started out in social work, the pattern was that the social work supervisors/ administrators would get very defensive about any complaint about their workers. At times they would get into a struggle with whoever was making that complaint. It's important to listen seriously, to the feedback we're getting from all these customers, whether its patients and families or the doctors or other administrators. And the workers needto understand that they represent all these constituencies. They have to be able to function out there effectively with multiple levels of accountability. And they need to know that the professional department will back them up with the resources they need, with trainingand with support. But critical evaluation of our work is always essential.

Fran Gutieri: Part of our difficulty is that we had a very rich supervisory structure, and we've had to give that up. On the other hand, the nurses have a much stronger continuing education program.

Virginia Walther: At Mt. Sinai, we actually have a formal continuing education program with outside speakers, and internal speakers, acknowledging the expertise of our own staff. We recognize clinical expertise of people who are not in the administrative hierarchy but who may be better clinicians than I will ever be. And we make these clinical social workers available to staffgofor contracted supervision, for preceptoring. We encourage them to make a contract and tap into the clinical expertise that's abundant in oursocial work departments. I don't feel that social work is decentralized although some of the department's staff are decentralized into care centers; the social workers are on different funding streams and budgets. But we never lost the idea that the professional social worker's home is the Department of Social Work That has tremendous value to the care centers, to social workers,and to the profession.

QUESTION: So what do you see in a smaller hospital? (to the audience/participants)

(PARTICIPANT RESPONSES): We have minimal staff and people are very busy. We've lost our social work department and we're under the auspices of nursing along with several other different professions. Our hospital has case management that has always been an issue. Social workers are doing the same thing that some of the case managers are doing. It depends on which floor or which service you're on. The kind of support you talk about in your larger departments with a lot of social workers, it is different. In our hospital, we had layoffs. It makes it difficult. Even our social work covers cases, so her time is not as an administrator, really. She has some administrative duties, but when you have to cover, when your workers are out, you can't do much supervision and education.

Phyllis Erlbaum-Zur: I've experienced 20 years of social work practice loving my work every working day. But these days I'm also experiencing the part of the profession that has such a poor ego. It's always hard for me to reconcile to that. We mourn, we grieve; we can't let go of anything. And, we have more meetings. When you think about how many meetings we have where we lament what's happening to social workers: Imagine if we had the same meetings on treating dual diagnosis or how to deal with Medicaid Managed Care. My feeling is that I constantly want to learn, enhance my skills, etc. I remember a social worker saying to me 'It used to be that we practiced social work,' but I have to tell you I've never given in to this and overall I have led departments that remain viable. But it's hard. And I just had to say to the social workers (in my setting): let's talk about changing modalities. Maybe this kind of supportive therapy is not going to work in a nursing home model (where I am). Maybe now crisis intervention is the modality and we have to really then develop standards of practice. Just like doctors meet on new techniques, we have to constantly be moving.

The other thing I have seen, is changes in the social work department at Jewish Home & Hospital. Most recently, my department changed: It was social work and admissions and I held on to it for a very long time. And, finally I personally made a decision to join in the division of it and led the changes instead of being caught in a hostile takeover. I still feel we have retained a social work model. The Dir. Of Volunteers is a social worker, so is the Dir. of Resident Services, So we have social workers in leadership positions who are not a part of a centralized dept, but who can really direct an agency or service.

Virgina Walther: I've heard this argument for 20 years. The one thing I tell people when I hire them is that there's one thing that is not allowed: I don't want to hear "we used to", or "we always have". Because if you want to go into a field with that kind of stability, don't go into social work and healthcare. Some of the changes are fabulous. Who wants there to be a trillion in-patients? Isn't it wonderful that we have to redefine our roles beyond discharge planning on in-patient services? Nobody said it would be easy. It is hard. Social work is hard, but as long as I feel like I'm not compromising our principles, it is OK. I think it is much more difficult to do this when you don't have role models at the top.

Participant Speaker: I think I know one of the reasons that we have this ego problem. The first day I walked into social school it was said, 'Don't come in here if you want to make a lot of money'. And I really think that that's where a lot of the ego problems come from And I think that sometimes that is where a lot of my colleagues at my stage of the game are coming from. We accept the fact that we work very hard and get burned out young, and don't have much to show for it. I don't think that we're taught that we should go in there and say this is how much money I deserve and how much money I should be making for what I'm doing. And I think social workers are scared to talk about money. We're afraid to say for this amount of work you need to pay me this amount because this is what I'm worth.

Fran Gutieri: I know that I can't promise people the salaries, but I can promise, for the most part, that there are opportunities for major influence, that there are opportunities to do what actors would call their craft, which social work really is, it's an art and a science. And I could teach you how to manage the day to day problems with support and administrative back up if you need it. I'm very serious about that, because if you love what you do every day of your life maybe that's the exchange.

QUESTION TO THE PARTICIPANTS: Think of what it is that you've been doing, in terms of either a new program or education, or grant, that interests you so that you'd like to tell this group about it.

Sona Euster: We recently decided in the dept. that social work is profoundly influential in the institution, we're not as visible as we might be. And it came up actually in a conversation with my boss who was talking about monies that a philanthropist gave to make services in the emergency department smoother for patients. My comment was that I think that a person who has money would never even think about giving money to social work because they don't even know we exist. So we've pulled together a departmental group and we decided that we wanted to do a departmental newsletter.

I think that there are a number of things about this that are important to recognize, one is that a newsletter makes the profession visible. I'm talking about the kinds of things that we can help with. It is directed toward hospital professional staff. This is not for patients and family. That's number one.

Number two, it empowered the committee, I think that the committee felt that they really reflected upon their own practice in terms of what they'd want to write about, what they'd want to talk about, and what their contributions were. And I think that it was a wonderful partnership in terms of administration because we could have not done anything like this within our own budgets. The layout, the slickness, the printing, the mailing, all that kind of stuff we don't do. It's just a wonderful vehicle for us; we're very, very excited about it. Staff work on it, and though staff could say that they're too busy to do this, we told them that we would be doing this and we asked for staff tovolunteer, to participate. And we got them. Certainly the meetings that we have had around setting this up and related stuff was on work time. But I have to be honest with you, I can't imagine that most of the people who wrote articles wrote them during the day. The fellow who's the managing editor who really worked with me once we got the rough draft, comes in and we'd meet 7:30 in the morning over a cup of coffee. But I think that the feeling was that people were excited enough about the project that the time was not a drawback for them.

Fran Gutieri: In the last three years at Bellevue, we feel very good that Social Work took responsibility for the continuum of care standard that became very prominent in the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) regulations. We were able to have chairmanship of the committee, do all of the in-service training for the hospital, and to participate in its implementation.

CONCLUDING REMARKS AND SUGGESTIONS

The New York City Chapter of NASW now has other committees like this formed, where you can have more of a network and meet up with people who can provide support and educate on the latest issues. Some have suggested that there is nothing to stop a group of hospitals that are located in a geographic region from pulling together and having a social work speaker or consultant there once a month. Using the talent from within each hospital it could be done very inexpensively yet very effectively. It was also suggested that that for social workers at hospitals that may not be resource rich, New York City's Chapter of the NASW, consider developing a continuing education program with them. This needs to be explored further.

EVERYONE THANKED THE SPEAKERS FOR THEIR THOUGHTFUL AND INSPIRING COMMENTS.

Again, we look forward to readers' reactions to the material. Also, we would welcome suggestions. E-Mail comments to HCPPN co-chairs, Terry Mizrahi or Gerard Beallor.