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Recap of Dean’s Roundtable on Integrated Health

May 21, 2015

On May 21, 2015 Dean Laura Nissen of the Portland State University School of Social Work invited leaders in the local social work community for a shared dialogue about integrated health.

This Dean’s Roundtable on Integrated Health is one in a series designed to gather innovative and emerging trends in the social services sector.

Laura framed the discussion by describing the School’s interest in and commitment to integrated care and asking for insights and reflections around five key questions which prompted responses and dialogue amongst the group.

Trends and cutting edge issues for integrated health and social work

Roundtable participants discussed a wide array of issues related to the current status of integrated care in Oregon and SW Washington, ranging from issues of definition and organizational issues, to billing and reimbursement, and the unintended consequences of some aspects of the changes on patients. A summary of key issues that were identified follows here:

  • Participants emphasized the need to clearly define the difference between mental health and behavioral health because the focus on behavioral health has lead to an emphasis on behaviors and an assumption the state has a well-functioning mental health system. This has led to patients with mental health conditions being referred elsewhere. As a result of the lack of clarity, mind and body are still being separated.
  • An identified problem is the move from addressing conditions as chronic to treating them as acute and episodic. This leads to saying everything has been fixed, but then the patient is back later because the underlying issues have not been addressed. There is a need to move toward more holistic transdisciplinary approaches, with all contributing to best quality patient care. This includes assessing and addressing the social determinants of health, which act as barriers to healing.
  • Participants expressed their desire to create true integration of mental and behavioral health into medical care and billing models and there was an extended discussion of the challenges related to outdated billing and reimbursement models and issues related to credentialing. Funding streams have dictated how care delivered through fragmented and siloed systems at the state level. Now the systems are being integrated and there were recommendations for global payment approaches with incentives for providers who don’t send people back into healthcare systems. A participant mentioned that legislative bills are being proposed in the state to address the billing issues.
  • The Coordinated Care Organization structure was created very rapidly and systems are still catching up so it is important to understand the current stage of evolution.

Areas of social work knowledge and skills needed by new social workers in integrated care

Participants expressed views that social workers are typically well prepared for some of the responsibilities of integrated care, and have needs for skill development in other areas. As areas of strength, participants noted that social workers typically have proficiency with behavioral health care, appreciation for the chronic health conditions that often co-occur with behavioral and mental health conditions, and skills in coordinating care for patients with complex needs. Social workers also see and understand social features in the community that affect health practice (the social determinant of health) and they have advocacy as a core skill.

There was discussion of the opportunity available for Social Work to define what the profession does, rather than others defining it, so that social workers see themselves as peers and equals to other providers with important perspectives to share at the point of care. Students need to be able to explain to medical providers what they do and how they do it, e.g. how they work with suicidal patients. Social workers need to be competent and project competence. They need to promote themselves within existing frameworks. There is also a need for social workers to know how to advocate, influence leadership and policy in organizations, and “lead up,” to self-promote better. For example, there is a need to train healthcare systems to be able to know how social workers can contribute. To date, many primary care practices doing integrated care have hired psychologists and the ones who have social workers have reported that they are pleased with them.

Participants also described a list of specific skills that they want the School of Social Work to prepare students with, so that new social workers are able to:

  • Engage in interdisciplinary teamwork, seeing all members of the interdisciplinary team as having something to contribute to the well-being of patients.
  • Understand the attributes of well-functioning teams and the roles of social workers in relation to other professions and if necessary, support other team members.
  • Apply skills in principled negotiation in all settings.
  • Appreciate the challenges facing individuals with both a diagnosis of mental illness and chronic physical health problems, for example, what does diabetes mean to a person with depression? People cannot access mental health care if they are breathless because of asthma.
  • Be able to navigate constantly changing systems effectively and with diplomacy, remembering that we are guests in the healthcare system.
  • Be inspired to continue learning because the School can’t teach everything needed. A challenge is to learn the science of innovative project management because what we need to learn for doesn’t exist yet.
  • Use technology to engage patients and address access.
  • Be able to look at population data and research on health disparities and social determinants to then take steps to address.
  • Think in terms of population health, rather than individual patients in order to assess improvement over time.
  • Engage in quality improvement.
  • Complete thorough biopsychosocial-spiritual assessments and relevant documentation.
  • Possess healthcare and social work literacy in order to be able to look at research to get guidance about how to intervene.
  • Engage in Motivational Interviewing with patients.
  • Have SBIRT skills.
  • Be able to interview well.

Recommended sites for continued learning and networking

Participants recommended a variety of locations and strategies for social workers and social work students to build relationships, continue learning, and stay in touch with new developments, including the following:

  • University system grand rounds and team meetings in community settings, as well as trainings from physicians in community and professional development opportunities at OHSU and Volunteers of America.
  • Networking, possibly on a regional basis among social workers in integrated care, especially social workers in small organizations and rural areas and in Eastern Oregon.
  • The Oregon Physicians and Psychiatrists conference is open to social workers.
  • NASW does some relevant training, as well as having an advocacy voice in Salem. Specifically, there is a bill being considered right now related to how social workers and social work students are described in legislation.
  • There is a need for an intentional learning collaborative for social workers in behavioral health and a need to revive the Association for Social Work in Health Care systems, which previously provided trainings.
  • Field placements are important and there is a need to support/develop field instructors to be able to work with students to do integrated care. There was a recommendation that the School of Social Work work with CCOs to collaborate with primary care to develop people that will be supervising people in practices.
  • There was a recommendation for a quarterly integrated behavioral health forum that could travel to sites and offer ongoing education, speakers, networking and shadowing.

Other issues for future consideration

  • Laura is working with CCOs to help them to understand and value what social workers do. Currently, social workers see many Medicaid patients and don’t get reimbursed. It will not be possible to continue providing the services needed unless they are reimbursed appropriately. There is research showing that including social workers reduces the costs of health care.  A two-year study of interventions with over 900 high ER users showed that the project saved $2.3 m. One option could be savings sharing arrangements.
  • Where the funding comes from affects what can be delivered and a challenge is how to include informal supports. Oregon continues to have fragmented systems and agreements need to be reached about how to braid funds and create data collection systems that address the whole person.
  • CCOs are struggling with capacity. It could be useful to look at CCO transformation plans and where they are investing. They are all required to have a community needs assessment and change plans and these could be great teaching tools.
  • A challenge with field students is that MSW supervision takes billable hours away from the organization, which is tough when funding is tight. Having a CDC III certification as well as MSW is helpful for billing and increasingly, LCSWs are getting a CDC III.
  • Not all medical practices have a social worker to provide field instruction, so there is a need to make arrangements for supervision. Change in QMHP reimbursement would allow students to do billable hours.
  • SW can play important roles in systems change because it happens outside the clinic and social work roles have traditionally been outside, in the community.
  • In pediatric practice, behavioral health has to include a physical health code. It would be preferable to avoid diagnosis and focus on what the child and family needs and how to provide it.

Community Attendees

  • David Casey, OHSU - Family Clinic Scappoose
  • E. Dawn Creach, Children's Health Alliance/Foundation
  • Pam English, OHSU Family Medicine
  • Daren Ford, OHSU/PSU
  • Susan Hedlund, OHSU
  • Lexy Kliewer, LifeWorks Northwest
  • Jennifer Levi, Providence Health and Services
  • Dr. Alicia Moreland-Capria, Volunteers of America-Oregon
  • Jenell Neufeld, Providence Medical Group
  • Dan Reece, Oregon Health Authority Transformation Center
  • Demetrio Sanchez, OHSU
  • Ricardo Sanchez, OHSU
  • Rebekah Schiefer, OHSU Family Medicine
  • Myong O, OHSU Family Medicine at Richmond Clinic
  • Jennifer Schlobohm, OHSU Family Medicine at Richmond Clinic
  • Jessica Stockton, OHSU Family Medicine Richmond Clinic

School of Social Work Attendees

  • Bill Baney
  • Kurt Bedell
  • Laura Heesacker
  • Jess Jamieson
  • Pauline Jivanjee
  • Michele Martinez Thompson
  • Laura Nissen