Social Work in the Health Field

A Care Perspective, Second Edition

Lois A Cowles

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136413230
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book provides an introduction to social work practice in the field of health care. It addresses both physical and mental health, examines various settings such as primary care, home care, hospice, and nursing, and also provides histories of social work practice in traditional industry segments.

SECTION II:
SETTINGS AT THE THREE LEVELS OF INTERVENTION

Chapter 3

Social Work in Primary Care Settings

HISTORICAL BACKGROUND

The early work of social workers in settlement houses during the last quarter of the nineteenth century involved engaging the community in social action efforts to modify social and physical environmental conditions seen as detrimental to public health, including those related to housing, workplaces, sewage and water, and lack of education:

… their goal was to bridge the gap between the classes and races, to eliminate the sources of distress, and to improve urban living and working conditions. Like the public health reformers, with whom they frequently cooperated, theirs was the preventive approach. (Trattner, 1989:147)

In 1905, Dr. Richard C. Cabot hired social workers to work in his medicine clinic at Massachusetts General Hospital. These workers were to make home visits (Oktay, 1995:1891) to bring back to the medical and nursing staff an understanding of the conditions in the patient’s home, work, and community that were relevant to the patient’s health problem (Cabot, 1928:28); they also were to address those conditions whenever possible (Cannon, 1923:15, 30).

Social work in primary health care developed further during the Great Depression when the Social Security Act was passed in 1935, which called for social workers to be employed in the Maternal and Child Health Program and the Crippled Children’s Program (Oktay, 1995).

Before World War II, most Americans obtained medical care services through their family physician, primarily general practitioners and some internists and pediatricians. However, it was not until the 1960s when medical specialization was sufficiently widespread that concern began to emerge about the decline in what was termed primary care. This marked the beginning of multiple efforts by the U.S. government to promote a return to primary care, efforts that continue today (Donaldson et al., 1996:19-20).

Beginning in the 1960s, the federal government funded primary health care settings such as migrant health centers, neighborhood health centers, and homeless health care programs staffed by physicians who were repaying educational loans under the National Health Services Act (Oktay, 1995). Social workers were written into these federally funded neighborhood health centers as part of the federal antipoverty program and included as mandated staff in the first federally funded HMOs. Social workers have been widely employed in hospital outpatient clinics, as the DRG system has reduced inpatient care and hospitals have sought alternative forms of service opportunities (Oktay, 1995:1891).

In the late 1980s, the U.S. Department of Health and Human Services (DHHS), Division of Maternal and Child Health, began to support social worker training in public health concepts (Henk, 1989). Currently, the NASW and the Council on Social Work Education (CSWE)-sponsored Institute for the Advancement of Social Work Research has been cooperating with the National Institute of Mental Health (NIMH) to support research on social work in primary health care to help prevent and provide early intervention in mental disorders (Oktay, 1995:1891).

In 1990, 547 community, migrant, and homeless health centers were serving six million people, or about one-fourth of the nation’s medically indigent (National Association of Community Health Centers, 1993). In addition, government funds support Maternal and Child Health Block Grant programs, public health department primary care programs, such as well-baby clinics, prenatal care, immunization and screening programs, and child development programs for prevention of and early intervention in child developmental problems (Oktay, 1995:1889).

However, during the conservative backlash of the 1980s, federal funding to train primary care physicians and to support primary care services for underserved people dropped significantly, and few health care settings in the United States now provide true primary care, although many use the term to describe their services. That is, few first-contact settings provide health service that is comprehensive, coordinated, and continuous, although HMOs may come closest to providing primary care, since they have an incentive to keep people healthy and to avoid high-cost services (Oktay, 1995:1888).

To date, social work in public health is better established than social work in primary medical care settings, reflecting, perhaps, the reluctance of physicians in private practice to collaborate with professional groups that they fear the public may associate with “welfare” and child welfare. In addition, private physicians generally have been reluctant to acknowledge the skills of other professional groups in mental health because physicians traditionally have perceived mental health as a subspecialty of medicine, i.e., psychiatry. Public health, on the other hand, became a separate discipline from medical practice in the early 1900s, about the time that medicine transitioned from social medicine with a care orientation to a medical model with a cure orientation to disease caused by bacteria and viruses, rather than social environs, and located in the individual. About the same time, social work began to transition from a focus on social-environmental causes of human problems to a person-centered, mental health focus.

The history of public health itself is one that most of the public probably took for granted until the recent publication of the seminal work by Laurie Garrett (2000), which unveiled the historical rise and fall of the public health infrastructure. It is truly a tale of clashes between public interests and a range of private interests—political and economic, including the economic interests of physicians in private practice. Following is a prophetic passage from Garrett’s book, published the year before the September 11, 2001, terrorist attacks on the World Trade Center in New York City and on the Pentagon in Washington, DC, and the subsequent bioterrorist attacks involving anthrax spores delivered through the mail system to unsuspecting American citizens:

Public health in the twenty-first century will rise or fall, then, with the ultimate course of globalization. If the passage of time finds ever-widening wealth gaps, disappearing middle classes, international financial lawlessness, and still-rising individualism, the essential elements of public health will be imperiled, perhaps nonexistent, all over the world. Capital will be skewed away from social service infrastructures in such a scenario, particularly those that meet the needs of the poor. Few public health barriers will be in place to prevent global spread of disease, and ever more drugs will be rendered useless by microbial resistence. United Nations agencies, including the World Health Organization, will witness further deterioration in their funding and influence. And political instability will foster increasingly irrational nation-state and rogue activities including, perhaps, bioterrorism. (Garrett, 2000:588)

Stephen H. Gorin (2001) laid out some of the history of the public health system in the United States, describing how recent findings about the role of socioeconomic inequality as a major determinant of population health have revitalized the validity of public health, and how those findings imply that social work ought to be at the heart of addressing the problem of social inequality.

Settings of Social Work in Primary Health Care

Primary Medical Care

Social workers in primary care may be found in hospital outpatient clinics, HMOs, neighborhood health center clinics, and group medical practices (Miller, 1987:323). In addition, social workers are firmly entrenched in many of the family practice residency training centers throughout the United States, functioning in accordance with the American Academy of Family Physicians (Hess, 1985:57; Zayas and Dyche, 1992). Other sites of social work in primary care include hospital emergency rooms, free clinics, public health departments (Ell and Morrison, 1981:35S), and family planning clinics (Kerson and Peachey, 1989).

The Specter of Rising Social Inequality

“Public health in the twenty-first century will rise or fall, then, with the ultimate course of globalization. If the passage of time finds ever-widening wealth gaps, disappearing middle classes, international financial lawlessness, and still-rising individualism, the essential elements of public health will be imperiled, perhaps nonexistent, all over the world. Capital will be skewed away from social service infrastructures in such a scenario, particularly those that meet the needs of the poor. Few public health barriers will be in place to prevent global spread of disease, and ever more drugs will be rendered useless by microbial resistance.” (Garrett, 2000:588)

The idea of integrating social work services into primary care practice has long received conceptual support both from the medical and social work communities. In the Health Maintenance Organization Act of 1973, the federal government mandated that social work services be integrated into health maintenance organizations as an essential profession to achieve the objectives of health promotion and early intervention (Badger et al., 1997:22).

Primary Prevention

According to Bloom (1995:1898), major settings of social work in primary prevention include public schools; workplaces (e.g., employee assistance programs, accident prevention programs); recreational settings; social agencies that provide social support and skills training and education, such as self-help groups, and social and coping skills training (e.g., family life education, parenting training, assertiveness training, caregiver support, suicide prevention, grief support); and health settings, such as HMOs with prevention-oriented services.

For example, by the 1999-2000 school year, the number of school-based health centers increased sevenfold to a total of 1,380, according to a nationwide survey conducted by the Center for Health and Health Care in Schools at George Washington University. These school-based centers are usually operated by a local hospital or health center and provide early care to prevent or treat common health problems of children and teens, as well as chronic health conditions. Staffed by teams of nurses, physicians, and mental health professionals, they typically provide annual physical exams, offer family counseling, and work with school staff to intervene with student problems (American Public Health Association, 2001b).

Health Promotion

A recent text (Poland, Green, and Rootman, 2000) addresses the following settings of health promotion: home and family, school, workplace, health care institutions, clinical practice, the community, and the state. The rationale for the settings approach to health promotion reflects an ecological perspective, which recognizes that health is a product of the person-in-environment or reciprocal interaction of the two spheres:

The ecological perspective presents health as a product of the interdependence between the individual and subsystems of the ecosystem. Subsystems for health promotion may include family, peer groups, organizations, community, culture, and physical and social environment. (McLeroy et al., 1988:16, cited in Poland, Green, and Rootman, 2000)

Primary Health Care Concepts

In the literature, the fields of primary medical care, public health, preventive medicine, and health promotion are sometimes discussed as separate disciplines, sometimes as overlapping, and sometimes as parts of a common whole. They are presented here as parts of a conceptual whole that includes the following:

1. Professions providing primary medical care, such as family practice, internal medicine, pediatrics, physician assistants, and nurse practitioners

2. Settings of primary medical care practice, including individual and group practices of any of the previous professions, outpatient clinics located in hospitals, neighborhood health centers, freestanding clinics, and HMOs

3. The field of public health

4. Primary prevention, that is, efforts to prevent the occurrence of health problems

5. Health promotion programs

Primary Care

Technically, the term primary care refers to the emphasis on the patient’s first entry into the health care system. The HMO Act of 1973 endorsed support for primary health care in the United States (Miller, 1987:321). In 1978, the World Health Organization named primary health care as the key to attaining health care for all people by the year 2000 (Oktay, 1995:1887) and identified its key concepts as including the terms practical, affordable, acceptable to the community, accessible and community based, and the gateway to continuity of the health care system (WHO, 1978:25). The 1978 Assembly of the World Health Organization on Primary Care “emphasized the promotion of health, the prevention of disease, and the integration of mental and physical health services; and advocated a holistic a...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Foreword
• Preface
• Acknowledgments
• Abbreviations
• Section I: Introduction and Overview
• Section II: Settings at the Three Levels of Intervention
• Section III: Health Service Delivery and Financing
• References
• Index