1. Demoratz, Michael PhD, LCSW, CCM

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A change of terminology is occurring as social workers elevate their expertise in identifying and addressing psychosocial issues (e.g., depression) and recognize the influence of these factors on health status (Carter, Zawalski, Sminkey, & Christopherson, 2015). That term is "social worker case manager." Among those of us who specialize in end-of-life care, this title is becoming standard, in part, because it is commonly used in widely deployed software for recording information and managing cases. But the change is more powerful than the words alone. By referring to themselves as social worker case managers, these professionals honor and embrace their roots as advocates who see the whole patient as they provide holistic services to individuals, particularly during crucial episodes along the care continuum.


There is a deep and historic connection between social work and case management, both of which are grounded in advocacy. Among the more than 42,000 certified case managers (CCMs) in practice today, about 6% are social workers, a percentage that has grown over the years even as the population of CCMs has expanded. Further supporting growth in the ranks of social worker case managers, the Commission for Case Manager Certification (CCMC) and the National Association of Social Workers (NASW) are collaborating to address the growing demand for health care case managers by giving more social workers the opportunity to become CCMs (NASW, 2018a).


Given the aging of the population and the increase of chronic conditions (Centers for Disease Control and Prevention, 2017) and comorbidities (especially depression), there is a strong need for social worker case managers to take their place at the hub of the interdisciplinary team to work closely with the nurse case manager. This dyad brings together social work and nursing, two highly complementary practices, to address both the psychosocial and clinical needs of the individual. In emergency departments, for example, this dyad has been shown to be effective in preventing unnecessary admissions, improving discharge planning, reducing costs, and increasing patient satisfaction (Bristow & Herrick, 2002). Moreover, when the dyad works within an interdisciplinary team, physicians and other care providers are further encouraged to engage in a holistic approach that looks beyond a single care episode. The Veterans Health Administration, for example, has implemented an integrated case management model to foster a team approach that brings together nursing, social work, primary care, mental health, specialty care, and community care as part of a "veterans-centric" approach to care delivery.


The social worker-nurse case management dyad is further empowered through the common mission to identify and provide the resources that people need to achieve their physical and psychosocial goals (Harkey, 2017). This shared ground is illustrated through codes of ethics, particularly around the guiding principles of advocacy and autonomy. The NASW's Code of Ethics (NASW, 2017) states, "Social workers promote clients' socially responsible self-determination. Social workers seek to enhance client's capacity and opportunity to change and to address their own needs" (pp. 5-6). Similarly, the Code of Professional Conduct for Case Managers, adopted by the CCMC, obliges CCMs to adhere to the principle of autonomy to support the person's right to self-determine a course of action (CCMC, 2015). The American Nurses Association's (ANA's) Code of Ethics for Nurses requires nurses to include patients/clients or their decision makers in discussions and to respect individual's decision-making processes (ANA, 2015). These ethical requirements show the extent of the individual's needs and the importance of interdisciplinary professionals working closely together to meet those needs.


To take their place, shoulder-to-shoulder with their nurse case manager colleagues, social workers must embrace their expertise in psychosocial issues. Social workers understand that addressing psychosocial factors-from mental health issues (depression, anxiety, addiction) to access to resources-can energize people to doing what is right for themselves. Social worker case managers are also uniquely positioned to address the social determinants of health that are increasingly in the spotlight: where and how people live and work, as well as socioeconomic status, education, environment, employment, social support, and health care access (Heiman & Artiga, 2015).


Across the mosaic of influences on people's physical and mental health, there is another common thread: individuals' stories that encompasses their personal and family history, their relationships and support system, beliefs and cultural influences, psychosocial issues (including past traumas), and so forth. By engaging people around their story, the social worker case manager empowers individuals to find their voices to express their goals and priorities. Working with the patient, the social worker case manager may discover that the person's wishes may be different from what is expressed by the family/support system or assumed by clinicians. For example, in end-of-life care, family members may be reluctant to end aggressive care for their loved one. But the loved one's intention, as expressed in an advanced directive, becomes the empowered voice that needs to be heard and respected.


In my work in hospice, I have witnessed the power of simply asking the question-What does your loved one want?-and listening to the answers. This interaction can ease the transition to end of life, with quality and dignity for the individual and greater peace of mind and alleviation of anxiety, fear, guilt, and other negative emotions for the family/support system. A similar emotionally charged transition can occur when an individual is catastrophically injured or diagnosed with a debilitating disease. Making decisions about ongoing care and treatment as part of a long-term care plan must also address psychosocial factors, from the individual's mental health (depression as a comorbidity is common with severe/chronic illnesses and life-changing injuries) to the extent of the person's support system. Social worker case managers, with their therapeutic counseling expertise and strong communication skills, can intervene as advocates for both the individual (the primary responsibility of any case manager) and the support system. They are cognizant that unaddressed psychosocial issues among family caregivers (i.e., when someone is burned out, physically or emotionally) have a direct impact on the individual (Harkey, Young, Carter, & Demoratz, 2017).


To bring the best of what they do to the interdisciplinary team, social workers need to embrace both the fullness of their expertise and their role as case managers who can and do serve a variety of patients and their families across the health and human services spectrum. The NASW defines social work practice as the application of "social work values, principles, and techniques to one or more of the following ends: helping people obtain tangible services; counseling and psychotherapy with individuals, families, and groups; helping communities or groups provide or improve social and health services; and participating in legislative process" (NASW, 2018b, p. 1). Nowhere does that practice definition specify that such services are provided only to individuals and families in financial need; yet, social workers frequently encounter that misperception among individuals, families, and even other professionals.


The best referral for a social worker case manager to clients and their families should focus on the services -not the title of the person providing them. Within a hospital system, for example, an interdisciplinary team member might ask, "Would you like to speak with someone about the resources that are available to you at this stage of your life?" This type of "referral by question" recognizes the unique contribution of the social worker case manager worker as a go-to person for providing help to clients in articulating their needs and finding available resources. Social worker case managers complement nurse case managers, who with their medical knowledge and relationships with physicians are in a perfect position to identify risks associated with various treatment plan options.


Close collaboration between the social worker case manager and the nurse case manager recognizes that it is beyond the capacity of one discipline alone to meet the multifaceted needs of the individual, especially in complex cases. This helps interdisciplinary teams work together under a care plan that calls for specific care resources and treatment at the optimal time. That care plan is best informed when the patient's full story is known: not only the clinical, which requires the expertise of the nurse case manager, but also equally important the psychosocial. By owning the psychosocial, social worker case managers are highly valued members of the team who are making a difference in outcomes across the health and human services spectrum.




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