Strengthening Health Care Systems: Better Health Across America

of Social Work & Social Welfare

Strengthening Health Care Systems:

Better Health Across America

American Academy of Social Work & Social Welfare

grandchallengesforsocialwork.org

Strengthening

Health Care Systems:

Better Health Across America

Teri Browne

University of South Carolina

Sarah Gehlert

University of South Carolina

Christina M. Andrews

University of South Carolina

Bradley J. Zebrack

University of Michigan

Virginia N. Walther

Mount Sinai Hospital

Gail Steketee

Boston University

Peter Maramaldi

Simmons College and Harvard University

Barbara L. Jones

University of Texas at Austin

Robyn L. Golden

Rush University Medical Center

Bonnie Ewald

Rush University Medical Center

Susan R. Bernstein

Mount Sinai Hospital

Audrey L. Begun

The Ohio State University

Heidi L. Allen

Columbia University

Susan Guth

Society for Social Work

Leadership in Health Care

Abigail Ross

Fordham University

Megan Moore

University of Washington

Joseph R. Merighi

University of Minnesota

Grand Challenges for Social Work initiative

Working Paper No. 22

November 2017

Grand Challenge: Close the Health Gap

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Grand Challenges for Social Work Initiative

The Grand Challenges for Social Work are designed to focus a world of thought and action on the most compelling

and critical social issues of our day. Each grand challenge is a broad but discrete concept where social work

expertise and leadership can be brought to bear on bold new ideas, scientific exploration and surprising innovations.

We invite you to review the following challenges with the goal of providing greater clarity, utility and meaning to

this roadmap for lifting up the lives of individuals, families and communities struggling with the most fundamental

requirements for social justice and human existence.

The Grand Challenges for Social Work include the following:

• Ensure healthy development of all youth

• Close the health gap

• Stop family violence

• Eradicate social isolation

• End homelessness

• Promote smart decarceration

• Reduce extreme economic inequality

• Build financial capability for all

• Harness technology for social good

• Create social responses to a changing environment

• Achieve equal opportunity and justice

• Advance long and productive lives

Executive Committee

Co-Chairs

Marilyn Flynn

University of Southern California

Michael Sherraden

Washington University in St. Louis

Edwina Uehara

University of Washington

Richard P. Barth

University of Maryland

John S. Brekke

University of Southern California

Darla Spence Coffey

Council on Social Work Education

Rowena Fong

University of Texas at Austin

Sarah Gehlert

University of South Carolina

J. David Hawkins

University of Washington

Charles E. Lewis Jr.

Congressional Research Institute for Social

Work & Policy

James E. Lubben

Boston College

Ronald W. Manderscheid

National Association of County Behavioral

Health & Developmental Disability Directors

Angelo McClain

National Association of Social Workers

Yolanda C. Padilla

University of Texas at Austin

Karina L. Walters

University of Washington

Patricia White

Hunter College

James Herbert Williams

Arizona State University

Gail Steketee (ex officio)

American Academy of Social Work & Social

Welfare and Boston University

Sarah Christa Butts (staff)

University of Maryland

Michele Clark (staff)

University of Southern California

Lissa Johnson (staff)

Washington University in St. Louis

Grand Challenges for Social Work initiative

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Strengthening Health Care Systems:

Better Health Across America

Teri Browne, Sarah Gehlert, Christina M. Andrews, Bradley J. Zebrack,

Virginia N. Walther, Gail Steketee, Peter Maramaldi, Barbara L. Jones, Robyn L.

Golden, Bonnie Ewald, Susan R. Bernstein, Audrey L. Begun,

Heidi L. Allen,

Susan Guth, Abigail Ross, Megan Moore, and Joseph R. Merighi

In this Grand Challenges for Social Work paper, we explore how social work leadership can

strengthen health care systems in the United States over the coming decade toward the goal of

improving health across the country. This paper complements existing papers related to the

Close the Health Gap Grand Challenge: Health Equity: Eradicating Health Inequalities for

Future Generations and Reducing and Preventing Alcohol Misuse and Its Consequences: A

Grand Challenge for Social Work. Eradicating health inequities in the United States requires

diverse strategies that target the multiple settings in which disparities are created and

perpetuated: in neighborhoods, communities and institutions, and the health care system itself.

The addition of this proposal to the others addressing this Grand Challenge will significantly

hasten our ability to close the nation’s health gap within the next decade.

Key words: American Academy of Social Work & Social Welfare; Bridge Model; care

transition; equity; Grand Challenge to Close the Health Gap; Grand Challenges for Social

Work; health care; health equity; health social work; Ida M. Cannon; leadership; medical

model; Patient Protection and Affordable Care Act of 2010; public relations; Richard C.

Cabot; social determinants of health; social entrepreneurship; training

HEALTH AND HEALTH CARE IN THE UNITED STATES

Health-care payer and provider systems in the United States have historically been grounded in

what has been termed a “medical model” of health care delivery. That model emphasizes

treatment of acute illness (Adler, Glymour, & Fielding, 2016) but focuses little attention on the

social and environmental context for health and wellness. A growing body of research suggests

that the medical model has failed to produce desired improvements in population health.

In the United States, the National Center for Health Statistics reports that life expectancy at

birth has declined for the first time since 1993 (Xu, Murphy, Kochanek, & Arias, 2016). The

10 leading causes of death remained the same in 2014 and 2015, and age-adjusted death rates

increased for eight of those 10 leading causes.

The United States likewise performs poorly if

In 2014 and 2015, the 10 leading causes of death in the United States were heart disease, cancer, chronic lower-

respiratory diseases, unintended injuries, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney

disease, and suicide (Xu et al., 2016).

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compared with other industrialized nations. In 2007, the United States ranked dead last among

17 peer countries for life expectancy among men and 16th out of 17 for it among women

(National Research Council & Institute of Medicine, 2013). Importantly, the report’s authors

note the following:

Large within-country health disparities in the United States may contribute in important

ways to the nation’s overall health disadvantage relative to other high-income countries.

Although studies reviewed in this report suggest that the health disadvantage relative to

peer countries persists even when the U.S. data are limited to non-Hispanic whites or

upper-income populations, the U.S. health disadvantage is clearly far greater among the

large proportion of Americans who live amid unfavorable health conditions. (p. 41;

emphasis added)

Health disadvantage is in large measure a product of social determinants. These determinants are

the “conditions in the places where people live, learn, work, and play” (Centers for Disease

Control and Prevention 2017, para. 1). They are estimated to contribute greatly to population

health—more so than health behaviors and medical care (Braveman & Gottlieb, 2014; Centers

for Disease Control and Prevention, 2017). Fortunately, enactment of the Patient Protection and

Affordable Care Act (ACA) in 2010 has drawn attention to the important role of social

determinants in population health outcomes.

Social determinants are mutable, and numerous efforts have attempted to shape them. Creating

social and physical environments that promote good health for all is one of the four overarching

goals identified by Healthy People 2020 (Office of Disease Prevention and Health Promotion,

n.d.). For example, the Centers for Disease Control and Prevention (2016; CDC) seek to address

social determinants of health through such efforts as Partnerships to Improve Community Health,

the Built Environment and Health Initiative, and the Racial and Ethnic Approaches to

Community Health (REACH) program. Likewise, the Innovation Center at the Centers for

Medicare and Medicaid Services (CMS) launched the Accountable Health Communities Model

to test interventions that address psychosocial barriers to outcomes (Alley, Asomugha, Conway,

& Sanghavi, 2016). Ongoing evaluation research and policy advocacy are essential to ensure that

such programs persist in the changing political environment.

Initiatives to address social determinants of health must be defined broadly enough to

incorporate the full range of social, economic, and environmental forces shaping health. Some

efforts have fallen short by focusing on individual behavior and demographics rather than on

the physical and social contexts in which people live. Disregarding those contexts will likely

produce errant interventions that negatively affect treatment choices and the outcomes of care.

For example, an assessment of the likely health outcome for a 65-year-old African American

woman diagnosed with breast cancer would typically take into account only her demographic

variables: income, race, and age. But her health care (e.g., the type and frequency of

chemotherapy and radiation) will be affected by the fact that she is raising two great-

grandchildren, aged 3 and 7, who have a parent in addiction treatment. Those obligations

require involvement with child care, a school, and the corrections office, which monitors visits

between the children and their parent. If the patient attends a church with a health ministry, its

services may reduce the need for community supports such as meal delivery and home health

care. If she lacks child care, visits to the radiation, medical, and surgical oncologists will be

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affected. Mental health services may be needed to address her worry about the fate of the

children should she not survive her breast cancer.

Characterizing this woman only by race, age, and income would omit critical information about

her social circumstances, potentially altering her treatment and worsening her outcomes. This

example demonstrates how the traditional medical model can influence treatment decisions

developed without considering the real world context, which determines whether patients can

benefit from the prescribed treatment.

HEALTH SOCIAL WORK

Health Social Work and the Roles of Social Workers

From its beginning, health social work has served as a bridge to connect physicians with patients

and their families. Dr. Richard Cabot hired the first medical social worker in the United States.

This woman, Garnet Pelton, was hired at Massachusetts General Hospital in 1905 and paid out of

pocket by Dr. Cabot. Dr. Cabot (1915) wrote that that social workers could translate physicians’

explanations of illness and treatment instructions in terms that individuals and families could

understand (Cabot, 1915). He also held that social workers were able to explain to physicians the

factors in patients’ social lives that might affect their health. Cabot (1912) asserted that

physicians and social workers had much to learn from one another (Cabot, 1912). Social

workers, he believed, should learn to be more systematic and scientific (Cabot, 1911). He

asserted that physicians should learn how to understand the nonsomatic aspects of health.

Ida Cannon, who trained at the Simmons School of Social Work and became the first director of

social work at Massachusetts General, worked with Cabot. Both recognized an important role

played by social workers: problem solvers who could understand health and medicine as well as

community resources and deficits. This recognition is germane in the United States today

because social workers are positioned to tailor recommendations, treatments, and referrals in

ways that match patients’ daily routines and lived reality. Cannon emphasized social work’s

agility in adapting to accommodate developments:

Basically, social work, wherever and whenever practiced at its best, is a constantly

changing activity, gradually building up guiding principles from accumulated knowledge

yet changing in techniques. Attitudes change, too, in response to shifting social

philosophies (Cannon, 1952, p. 9).

Social work demonstrated the ability to adapt to sociopolitical shifts when Medicare and

Medicaid legislation expanded hospital access for previously uninsured populations with

complex medical and social issues. It did so again in the mid-1980s, when federally imposed

cost-containment measures fundamentally changed health care delivery. This flexibility

positions health social workers well to deal with health reform’s changes in models of health

care delivery.

Another enduring strength of the profession is its broad understanding that individuals are

embedded in social networks, neighborhoods, and communities. Implicit in this understanding is

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the recognition that those contexts influence knowledge, attitudes, beliefs, and behaviors, all of

which can influence health choices and participation in health care. Securing positive long-term

health outcomes requires the expertise of professionals who are familiar with the intricacies and

intersections of the complex social systems in which individuals are situated. Social workers are

trained to view health as part of the greater social context in which our patients live, work, and

play (Newman, Baum, Javanparast, O’Rourke, & Carlon, 2015). They are equipped with the

insights necessary to achieve population health goals.

In addition, social workers are uniquely trained to work across the continuum of health care

settings to successfully identify, facilitate, coordinate, and monitor services that an individual

requires to maintain optimal health. They also are trained to seek solutions and resources from

within the individual’s social context. The profession’s unique understanding of the

interdependent relationships among health, education, employment, criminal justice, education,

and other systems enables it to serve as the nexus from which resources are drawn to protect,

maintain, and restore health. Social workers routinely negotiate such systems to ensure that the

many needs of clients are addressed in ways intended to advance optimal health. This work is

done at the micro (individual), mezzo (health care system), and macro (socio-structural) levels.

For example, social workers coordinate supports across multiple systems to address the needs of

patients upon discharge, communicate with patients and caregivers to ensure that discharge

instructions are understood, and confirm that necessary resources are in place for optimal care.

Social workers serving in community settings know how to ensure access to services and

resources that enable individuals to remain within their home and community. Social workers

play an essential role in identifying nonmedical and social barriers that may impede an

individual’s ability to access health care services. They provide assistance in resolving these

barriers. Social workers also use their skills to prevent adverse health conditions by intervening

in community settings (e.g., schools, criminal justice) and by advocating for racial and

environmental justice.

Social Work and Health Reform

The ACA’s 2010 enactment created unprecedented opportunities to encourage the health care

system to be more responsive to the influences of social determinants on health. It created new

roles and opportunities for social work, including shifts toward preventive approaches to solving

social problems and expansions outside of traditional health-care settings. In addition, the act

established a wide range of demonstration programs and initiatives designed to improve health care

financing and population health by attending to social context. Examples include new payment

models tied to quality metrics and alternative payment strategies. Accountable Care Organizations

(ACOs), bundled payments, managed long-term services and supports, Medicaid Health Homes,

and Accountable Health Communities all represent the fruits of those new models. The models

require interdisciplinary collaboration and better care coordination. They provide important

opportunities for social workers to join delivery-system reform efforts in areas such as patient

navigation, care management, transitional care, and end-of-life care, as well as in efforts to

integrate behavioral and physical health services (National Association of Social Workers, 2016).

As we enter the next chapter in health social work’s history, the ACA faces the prospect of

repeal, major revision, or replacement. During the first half of 2017, congressional efforts

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proposed several significant changes to the act, including removal of the requirements that

individuals have health insurance coverage and that insurance policies provide essential health

benefits. A proposed cap on federal Medicaid funding to states would convert the program’s

funding stream to a block grant system. Assurances of insurability for people with pre-existing

conditions are also in jeopardy. Such changes would likely limit health care access and quality

for all Americans (Congressional Budget Office, 2017a, 2017b, 2017c). Fortunately, those

legislative efforts did not propose elimination of many initiatives that the ACA established to

improve care coordination and value: ACOs, bundled payments, and financial incentives and

penalties to improve care transitions. Now, as in 1965 when Medicare was enacted, social

workers are needed at the front lines of health care policy to protect the health care system, to

develop it in ways that make the system more responsive to social determinants of health, and to

advocate for changes that will afford everyone access to the system.

MODELS OF HEALTH SOCIAL WORK

Efforts in five key domains can inform models of health social work practice that will leverage

health care systems to address social and community factors shaping health outcomes: (1)

increasing screening and prevention, (2) addressing economic and environmental stressors in

health care, (3) improving care management and coordination, (4) promoting interventions

tailored for vulnerable populations, and (5) facilitating successful care transitions.

Increasing Screening and Prevention

Helping individuals engage in health screenings and preventative services is one of the many

important roles played by health social workers. Such screenings can include assessment of

loneliness and social isolation, which are increasingly linked to negative health outcomes (Holt-

Lunstad & Smith, 2016; Valtorta, Kanaan, Gilbody, Ronzi, & Hanratty, 2016), as well as efforts

to screen for material hardship and other negative social determinants. Moreover, social workers

deliver interventions that may prevent the physical consequences of such stressors.

In oncology settings, social workers help communities navigate the barriers to cancer screenings

and prevention (Burg et al., 2010). Social workers also play a critical role in addressing

psychosocial barriers to genetic cancer testing (Werner-Lin, McCoyd, Doyle, & Gehlert, 2016;

Young et al., 2017). Nephrology social workers help dialysis patients to be tested and listed for

kidney transplants (Browne, 2011). Social work scholars Jason Bird, Dexter Voisin, and Daryl

Wheeler have provided a large body of research on the connections linking community and

social factors with behaviors related to HIV prevention. That can also inform social work

practice (Bird & Voisin, 2011; Holmes et al., 2008; Marrazzo et al., 2014; Voisin, Bird, Shiu, &

Krieger, 2013; Wheeler, 2011).

Addressing Economic and Environmental Stressors in Health Care

Social work makes critical contributions to ameliorate the economic and environmental stressors

in health care systems, including stressors related to health disparities. Within health systems,

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social workers help individuals recognize and address the effects of stress experienced during

life transitions (e.g., divorce and job loss). These experiences may cause health to decline.

Medicaid Health Homes and ACOs, funded by the Medicare Shared Savings Program, represent

important initiatives in which social workers can lead interventions to improve patient access to

community resources. Through that leadership, social workers can reduce social isolation and

discrimination, which adversely affect health outcomes (Allen, 2012). Social workers can

advance efforts to address these stressors through ACOs (Gehlert, Collins, Golden, & Horn,

2015).

Research by Gehlert and colleagues on epigenomic neighborhood factors and health

disparities offers further insights into social work’s possible roles in addressing social

determinants that can lead to health disparities (Gehlert & Coleman, 2010; Gehlert et al., 2008).

To, wit, social work can help contextualize individuals and communities in order to facilitate

identification of specific factors that influence health.

Improving Care Management and Coordination

The social work profession leads efforts to better coordinate health care. Kathleen Ell, at the

University of Southern California’s Suzanne Dworak-Peck School of Social Work, has

demonstrated how care coordination and patient navigation interactions can improve community-

based cancer services, particularly for racial and ethnic subpopulations (see, e.g., Ell et al., 2010,

2011, 2012). The Chicago Cancer Navigation Project is another example of successful social

work leadership in patient navigation. The project helps to manage and coordinate care for

vulnerable populations (Markossian, Darnell, & Calhoun, 2012; Tejeda et al., 2013). At Mount

Sinai Hospital in New York City, social workers have played a key role in establishing and

managing a Medicaid Health Home. Through the innovative Health Home model of care

coordination, health care providers can receive an enhanced Medicaid match rate by providing

care-coordination and wrap-around services for enrollees with specific chronic conditions.

Promoting Interventions Tailored for Vulnerable Populations

Vulnerable populations are more likely to suffer chronic health problems (Centers for Disease

Control and Prevention, 2013). Social workers can lead research and interventions to promote

health parity. The REACH-Detroit program offers an example of an integrated model of health

care led by social work to reduce health disparities. One of 24 such programs initially funded

by the CDC, REACH-Detroit began in 2000 and is overseen by Michael Spencer at the

University of Michigan School of Social Work.

Now funded by the National Institutes of

Health, the program evaluates the effectiveness of community health workers, particularly their

effectiveness in aiding communities of color. Training is an important part of the program.

Sessions for medical providers offer instruction on cultural humility and promoting

The network of scholars engaged in the Grand Challenge to Achieve Equal Opportunity and Justice also has

identified roles that social workers can play in addressing health disparities. For information on the network’s

efforts, see http://aaswsw.org/grand-challenges-initiative/12-challenges/achieve-equal-opportunity-and-justice/.

For additional information on REACH (Racial and Ethnic Approaches to Community Health)-Detroit, see

http://www.reachdetroit.org/about/index.php.

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communication skills so that communication is comprehensible. Training is also provided for

fitness instructors. Physical activity classes, walking clubs, and healthy eating programs are

offered in the community, with an eye to safety. Research has shown that REACH leads to

positive outcomes (Spencer et al., 2013; Tang et al., 2014).

Facilitating Successful Care Transitions

Care transitions are a prime target for social work intervention and can be improved in several

key ways. Transitions from one care setting to another, in particular transitioning home after a

hospitalization, often create complexities that can result in inadequate in-home care, hospital

readmissions, and high costs for health systems and payers. Every year, 2.6 million older adults

are readmitted to hospitals within 30 days of discharge, and these readmissions account for $26

million in Medicare spending each year (Centers for Medicare & Medicaid Services, 2016). Just

over half of these transitioning patients had no physician contact after discharge (Jencks,

Williams, & Coleman, 2009). The ACA offers incentives to reduce unnecessary hospitalizations

and readmissions. Examples include value-based payments, the Hospital Readmission Reduction

Program, and the move toward bundled payments for episodes of care. In addition to spurring

significant research, these incentives have drawn attention to how payers, hospitals, and

community-based providers can ease care transitions, improve patient experiences, and reduce

unnecessary hospitalizations (admissions and readmissions).

Transitional care that supports individuals and families before and after a hospitalization is a

critically important factor in positive health outcomes. It is also important for preventive primary

care and for care-management efforts. Historically, the health-care and community services

available at transition points have been delivered through differing funding streams by disparate

professions with widely dissimilar training. Often, those delivering these services have not

“spoken the same language” nor held contractual obligations to foster collaborative relationships

with providers in other professions. Although ACA incentives have helped to address this

fragmentation, the changing dynamics make the system especially complicated for patients and

families to navigate on their own. Transitional-care social workers can serve as a critical hub for

the coordination of health and social services. They also can integrate a person-in-environment

perspective within health systems navigation and use client-centered interviewing skills to

support patients and families after a hospitalization.

The conceptualization of health as an individual experience occurring within social context has

led the social work profession to develop and participate in several transitional-care models that

address context. These are models of care in which medical professionals (doctors, nurses, and

physician assistants) collaborate closely with social workers, case managers, community care

workers, and others to engage needed services that support recovery and continuing health.

Several groups around the country have made pioneering efforts to integrate social workers into

transitional care efforts. The social-work-led Bridge Model of transitional care involves a

collaboration among an academic medical center, a health policy organization, and several

community-based Aging Network organizations. Bridge social workers combine care

coordination, case management, and patient engagement, using a comprehensive set of tools and

psychotherapeutic techniques to assess for gaps in care, improve self-efficacy, and enhance

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patient activation (Boutwell, Johnson, & Watkins, 2016). Research on the model suggested an

association between Bridge services and increased primary-care follow-up appointments. In

addition, the model was associated with a 20% reduction in hospital readmissions among

Medicare beneficiaries who received home health care after hospital discharge. The Bridge

Model also supports individuals transitioning back to community treatment following an

inpatient psychiatric stay or a short-term rehabilitative stay. Continuing to identify ways to

integrate social work into transitional care efforts is imperative. Doing so will enable social

workers to increase the impact of these programs and will foster opportunities for partnerships

between community-based organizations and nearby health systems.

The Department of Social Work Services at Mount Sinai Hospital has had a long-standing

leadership role in addressing the social determinants of health and in facilitating successful care

transitions. The New York Academy of Medicine sections on Social Work and Health Care

Delivery recognized the current leadership team of Mount Sinai Hospital’s social work

department for the success of social work interventions in improving health outcomes and

reducing medical costs. The team has led multiple ACA-funded initiatives. Mount Sinai has four

social-work initiatives that address care transitions: care coordination in a ACO for Medicare

fee-for-service recipients, a CMS-funded program focusing on hospital discharge transitions to

prevent 30-day readmissions among Medicare fee-for-service beneficiaries, an emergency

department project funded by the CMS Innovation Center, and a program funded through the

Robert Wood Johnson Foundation to improve health outcomes of women after childbirth.

CLOSING THE HEALTH GAP: SYSTEM-LEVEL STRATEGIES FOR SOCIAL WORK

Social workers can help close the health gap in the United States through six system-level

strategies: increasing social work leadership in health care, providing leadership training in

schools of social work and practice sites, enhancing public relations, embracing social

entrepreneurship, transdisciplinary and interprofessional education and training, and research.

Increasing Social Work Leadership in Health Care

In addition to fostering our professional capacity to improve health services and health outcomes,

the social work profession must continue to advocate broadly for the implementation of socially

oriented models of health care. True leadership in the transformation of health care systems

requires the profession to advance a vision for an effective health-care system that serves all

Americans and to offer concrete recommendations for how this can be achieved. That vision

should parallel the one elaborated through the ACA—a vision for the transformation of health

care from a crisis-oriented and medically grounded system to one that is focused on prevention,

well-being, and comprehensive care. Existing health-care systems are actively searching for

solutions to major cost and care challenges. Perhaps more than ever before, they are open to new

ideas and messages. This is a unique window of opportunity for social workers to actively set the

nation’s health-care agenda.

Crucially important decisions are being made by state health-insurance commissions and CMS:

Which services are covered at what price, and who will be paid to provide them. It is essential

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that social work actively influence those decisions. At the national level, social work

representatives are needed on the Medicare Payment Advisory Commission and the Medicaid

and CHIP Payment and Access Commission. Representation on all leadership bodies associated

with the state-administered health exchanges is especially important. At the state level, the

profession should strive for representation on every state Medicaid Advisory Committee as well

as on mental-health and addiction service boards at state and county levels.

There is critical need to develop new social work leaders who possess the political sophistication to

engage in high-level professional advocacy. Unfortunately, a 2-year graduate education simply

does not allow the depth of skills training that such leadership requires. Accordingly, there is need

for leadership-development programs in health policy, programs similar to those offered in the

fields of medicine and public health. Such programs would train early- and mid-career

professionals who have excellent potential to provide health leadership in advocacy and health

management efforts at all levels of government. The programs would complement existing efforts

like the Society for Social Work Leadership in Health Care’s annual Leadership Institute. The

Leadership Institute brings together experienced social work leaders and educators for an intensive,

interactive program designed to develop or enhance participants’ leadership knowledge and skills.

Health-policy leadership programs can also build on recent efforts by the Council on Social Work

Education and the National Association of Social Workers. Through the Social Work HEALS

(Social Work Health Care Education and Leadership Scholars) initiative, the two organizations are

collaborating to strengthen leadership training for health social work students.

Leadership Training in Schools and Practice Sites

Leadership training for individuals in schools of social work and in social work practice sites is a

precursor to effective advocacy concerning the value of social work in health care. The rarity of

such training seems to echo Richard Cabot’s comment about the importance of being systematic

rather than resting on the moral high ground. In this context, a systematic approach entails learning

how to engage with health powerbrokers in federal, state, and local government; the health care

industry; and funders of research and community demonstration projects. In addition, social work

faculty and students can foster leadership training within their academic institutions by working

closely with university and hospital administrators to identify opportunities. This type of training

should begin early. Partnerships with academic schools/colleges of communication, with

institutional or private marketing-and-communications departments, and with lobbying

organizations may offer additional ways to obtain such specialized leadership training. Moreover,

academic and industry leaders could provide especially helpful advice on ways to increase

awareness of social work and social determinants of health within the health care industry.

Recent national social work meetings have begun this process by assembling the best minds in

the field to grapple with how to promote the impact of social work on the nation’s health. New

energy to advance these goals was evident in the following recent events:

• A 2014 meeting brought together experts in health social work and policy with

leaders from the Society for Social Work and Research, the Council on Social Work

Education, the National Association of Social Workers, the American Academy of

Social Work & Social Welfare, and the Society for Social Work Leadership in

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Health Care. Participants developed recommendations for ways to maximize social

work’s contributions to the implementation of the ACA (Andrews et al., 2015).

• In 2015, Boston University’s School of Social Work created the Center for

Innovation in Social Work and Health, which has engaged 88 regional, national, and

global transdisciplinary experts in exploration of the impact of social work and health

in several domains, including education, policy, community, and global health.

• In September 2016, Social Innovation for America’s Renewal: Ideas, Evidence,

Action, a conference held at Washington University in St. Louis, provided a forum to

examine the policy implications of each of the Grand Challenges for Social Work,

including the Grand Challenge to Close the Health Gap. Efforts to address that

challenge have focused on eradicating health inequalities.

• Through its Leadership Academy, the National Association of Deans and Directors of

Schools of Social Work sponsored a November 2016 keynote address by Dr. Sally

Bachman, director of Boston University’s Center for Innovation in Social Work and

Health. Given in conjunction with the Council on Social Work Education’s meeting

in Atlanta, Georgia, the address outlined recent and emerging developments in health

policy.

• In January 2017, approximately 50 academic and practice leaders in social work and

health attended the national Social Work and Health Convening 2017: State of

Research and Training, which was sponsored by the University of Chicago.

These events highlighted the opportunities for providing social work leaders with broad spectrum

leadership training that enables them to effectively advance a social-work health agenda as they

engage with interdisciplinary colleagues representing academic, industry, health-practice,

government, and funder interests. We must continue and expand upon such efforts.

Social work faculty, administrators, and senior practitioners in medical and health-care systems

will also benefit from training on communicating with the media about health care news that

requires a knowledgeable social work response. Rather than deferring to other health

professionals, social work faculty members and senior health practitioners must learn to speak

effectively about their knowledge and must form relationships with media representatives so that

they become go-to respondents when important health stories break. Social work writers can

raise awareness of critical health issues by contributing op-eds. These efforts all require training

that enables social workers to speak clearly with knowledge and confidence in professional

responses and outreach to the media. Likewise, training in public speaking will benefit social

For information on the Center for Innovation in Social Work & Health, see http://www.bu.edu/ssw/research/the-

center-for-innovation-in-social-work-and-health/.

Information on Social Innovation for America’s Renewal may be found at https://csd.wustl.edu/events

/ConferencesAndSymposia/Pages/Grand-Challenges-for-Social-Work-Policy-Conference.aspx.

Information on Social Work & Health Convening 2017 may be found at https://chas.uchicago.edu/page/social

-work-and-health-convening-2017.

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workers who give longer talks in public or academic settings covered by the media. A

willingness to make time for media interviews is also required in such settings.

Public Relations

Now is a critical time for the social work profession to articulate clearly its unique contributions

to improving health care and reducing the influence of adverse social determinants of health. The

profession should communicate to key policy makers the ways in social workers can help to

improve health care quality and value. The profession must go beyond identifying the roles and

activities that social workers execute well; it must link these interventions to address tangible,

specific needs within health care systems. Moreover, the profession must articulate clear,

consistent messages about how social workers can identify and meet these needs, especially as

part of transdisciplinary health-care teams. A language that communicates these roles across the

profession can be used effectively to convey the importance and value of social work to policy

makers, insurers, other health-care professionals, the public, and other essential stakeholders.

Key targets for advocacy include insurers and managed care organizations; federally qualified

health centers; hospitals; patient-centered medical homes; large, private physician practices; and

behavioral health programs. Social work leaders would benefit greatly from close collaboration

with marketing and public relations firms in deciding how to publicize the profession’s work to

improve health in America.

Social action, advocacy, and policy practice are at the core of the social work profession.

Although grassroots political efforts can be meaningful and effective, professional lobbying

organizations have greater influence on government in the long term, given their networks of

relationships, longevity, and nuanced understanding of the political system (Hamilton, 2014). In

presenting an analysis of data from the Senate Office of Public Relations, the Center for

Responsive Politics (2017) reports that companies, unions, and other organizations spent more

than $35.3 billion to lobby Congress and federal agencies during the last decade. During 2016

alone, a total of $3.32 billion was spent on lobbying entities of the federal government. The

National Association of Social Workers and the Council on Social Work Education spent

approximately .001% of that amount ($320,000) to promote the interests of the social work

profession (Center for Responsive Politics, 2017). In an era when lobbying has a profound

impact on the legislation and subsequent policies (De Figueiredo & Richter, 2014), it is

imperative for social work to increase its lobbying efforts, particularly at the federal level. New

and innovative entrepreneurial relationships have the potential to strengthen social work’s

lobbying power, enabling the profession to positively influence the nation’s health care systems.

To bring advocacy actions to scale, social work should develop a centralized lobbying institute

designed and staffed by professional lobbyists. The institute would train and coordinate cohorts

of social work leaders to influence lawmakers and federal agencies.

National attention to social determinants of health, and to the importance of addressing them in

health care settings, could also be raised through a forthcoming consensus study released by the

National Academies of Sciences, Engineering, and Medicine. Such studies and associated

workshops provide independent, objective analysis on health-related issues. Reports that result

from the consensus study process are well respected. They synthesize the state of affairs and

recommend actions to address the analyzed issue. Recent reports have covered such topics as the

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obesity epidemic, underage drinking, adjustments to Medicare payments for social risk factors,

and reducing racial and ethnic disparities in access to health care.

A group of social work researchers, policymakers, and practitioners have proposed such a study

to examine the profession’s role in equipping the health-care delivery system to meet increasing

population health challenges. In January 2017, the National Academies and the National

Research Council approved Integrating Social Needs Care into the Delivery of Health Care to

Improve the Nation’s Health. When funding is secured and the study launched, the

interdisciplinary committee will gather information, deliberate on consensus findings, generate

recommendations, and write the report. When the report is released, the social work community

should identify ways to build upon it and to implement its recommendations. Social work should

partner in this effort with other stakeholders across the country, perhaps through a national

campaign similar to nursing’s Campaign for Action, which has built upon the consensus report

titled The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011).

Social Entrepreneurship

Social entrepreneurship is another way for social workers to contribute to the dialogue on health

care delivery. In his seminal work, Dees (1998) posited that intention distinguishes social

entrepreneurship from other enterprises. A mission-driven social impact is pursued with the same

intensity, creativity, discipline, and focus associated with traditional business models. Social

entrepreneurial models go beyond the status quo, seeking new solutions with the potential for

transformative, sustainable change that will benefit society as well as traditionally vulnerable and

underserved populations (Dees, 1998; Peredo & McLean, 2006). The tenets of social

entrepreneurship offer great promise for social work, a profession driven by the values of social

justice and the inherent worth and dignity of the individual (National Association of Social

Workers, 2008).

Finding ways to maximize mission-driven social impact is especially important at times when the

demands for social work services increase but tenuous financial or political conditions preclude

innovation and co-opt social workers in the task of maintaining the viability of current health-care

systems. As a model for service delivery, social entrepreneurship enables social workers to

consider new and creative approaches to attaining mission objectives (Seelos & Mair, 2005;

Thompson, Alvy, & Lees, 2000). The Brides Project in Ann Arbor, Michigan, is an example of

such an approach. Social workers identified an untapped commercial market for recycled wedding

gowns and used profits to fund psychosocial support services for cancer patients.

As a paradigm for health social work, social entrepreneurship offers unprecedented opportunities

to foster new partnerships in mission-related investing (Germak & Singh, 2009; Linton, 2013;

Nandan, London, & Bent-Goodley, 2015), both investment from foundations (e.g., the Bill &

Melinda Gates Foundation’s vaccine innovation) and private sources (e.g., microfinance

opportunities in developing countries). Approaches to developing initiatives (Dees, Emerson, &

For information on the campaign, see http://campaignforaction.org/.

See http://www.thebridesproject.org.

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Economy, 2001) and instructive case studies (Alvord, Brown, & Letts, 2004) are readily

available in the literature and on foundation web pages such as that of the Rockefeller

Foundation (Rockefeller Foundation, n.d.).

Transdisciplinary and Interprofessional Education and Training

As we have suggested, social workers have essential knowledge and skills to contribute to the

development of new models of care in health care systems that continue to embrace patient- and

family-centered care, collaborative practice, and attention to health inequities. Training within

interprofessional health teams enables social work practitioners to provide leadership within the

nation’s changing health care systems. Such training deliberately educates social work students

and practitioners in how to speak clearly and effectively about what the social work profession

brings to the table. It also enables the profession to specify how we can contribute to creating a

more patient-centered care that is responsive to the social and environmental contexts greatly

influencing health outcomes. Moreover, such training enables all members of interprofessional

medical teams to learn from each other about the integral and complimentary role each plays in

serving patients. The Institute of Medicine (2001; Levit, Balogh, Nass, & Ganz, 2013) and the

World Health Organization (1998, 2010) have recommended interprofessional education to

create graduates capable of joining and promoting team-based models of health care delivery.

Their recommendations parallel the Council on Social Work Education’s 2015 Educational

Policy and Accreditation Standards, which emphasize that social workers should develop skill in

relationship building, interprofessional collaboration, and communication. The standards also

emphasize the importance of the ability to apply multidisciplinary theory in provision of

assessments, interventions, and evaluations of outcomes. Social work can serve a critical role in

the development of these models.

Social workers provide leadership in the development of interprofessional education programs

that can improve health systems in several ways. Such training can enhance communication

between interdisciplinary team members and emphasize the unique and common roles, values,

ethical concerns of each profession (Jones & Phillips, 2016; Dauenhauer, Glose, & Watt, 2015).

Interprofessional education can build professional confidence and creativity; advance

professional equity and shared-decision making (Chan, Chi, Ching, & Lam, 2010; Nimmagadda

& Murphy, 2014; Sims, 2011). Interprofessional training can also enhance patient and

community care outcomes (Addy et al. 2015; Taylor et al., 2016; Terry et al., 2015). Social work

educators and practitioners must continue to lead the way in innovative interprofessional

education (Jones & Phillips, 2016). Recommendations for such social work leadership include

the following:

• Introduce interprofessional education early in undergraduate social work programs,

• develop collaborative interprofessional field experiences,

• provide service-learning and shadowing experiences with other disciplines,

• coteach and cocreate courses,

• lead campus-wide initiatives,

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• bring together social work practitioners and educators to create learning experiences

that mirror current practice needs, and

• evaluate these initiatives (Jones & Phillips, 2016; Taylor et al., 2016).

To demonstrate the value of social work in health systems, social work students at all levels also

must be trained in how to conduct transdisciplinary and translational research (Gehlert, Hall, &

Palinkas, 2017).

Social Work Research

Although several high-quality studies have documented how social workers can improve health

outcomes, particularly in the areas of care coordination and transition management, more work is

needed to comprehensively document social workers’ effectiveness in health care systems.

Researchers should develop and test entirely new models for improving health, models in which

social workers play key roles. At the individual level, interventions are needed to help patients

achieve their own goals for healthier living—particularly interventions that are sensitive and

responsive to the broader family, community, social, physical, and cultural contexts in which

patients live. At the community level, social workers have the opportunity to develop

interventions that foster understanding of community health needs, to work collaboratively with

communities in organizing for change, and to advocate for resources and environmental change

that can promote better community health.

The social work profession must demonstrate that it has the capacity to achieve good health

outcomes for patients while also bringing down health care costs. As team-based care and

bundled payments become more common in health care settings, social work researchers will be

challenged to conduct studies that demonstrate the contribution of social work interventions in

support of cost effectiveness and positive patient outcomes. Design and implementation of such

studies should be a priority within the social work research community. There is a need for the

profession to train and hire more health economists and health services researchers in schools of

social work—that is, investigators who can conduct and collaborate with social work students,

professionals, and faculty in these areas. Our outcomes and findings are more likely to have

impact for the health care field—and the many different kinds of health professionals working in

it—if we initiate projects with researchers from these fields.

Greatly needed are social work practice-based research networks that promote the creation of

coordinated, community-based studies in multiple real-world settings (Gehlert, Walters, et al.,

2015). Widely used by other health professionals, practice-based research networks bring

together practitioners and researchers for the purpose of advancing research. Led by the Society

for Social Work and Research and other key stakeholders, including the National Association of

Social Workers, the Society for Social Work Leadership in Health Care, and the Council on

Social Work Education, such a network could serve as a national coordinating body through

which to share resources, coordinate cross-state efforts, and develop a vision for enhancing the

profession’s role in shaping health care policy over time.

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CONCLUSION

Social work has an important role in strengthening health care systems and improving health

equity in the United States over the next decade. This paper complements two others released

as part of efforts to address the Grand Challenge to Close the Health Gap: Health Equity:

Eradicating Health Inequalities for Future Generations (Walters et al., 2016) and Reducing

and Preventing Alcohol Misuse and Its Consequences: A Grand Challenge for Social Work

(Begun et al., 2015).

It does so by elaborating a set of strategies for increasing health equity

within health care systems. Eradicating health inequities in the United States requires diverse

strategies that target the multiple settings in which disparities are created and perpetuated: in

neighborhoods, communities, and institutions, and within the health care system itself. Our

suggestions, along with other Grand Challenge efforts, provide a call to action for social work

practitioners, leaders, educators, and researchers. Through coordinated action, the profession

can close the nation’s health gap within the next decade.

For information on the Grand Challenge to Close the Health Gap, see http://aaswsw.org/grand-challenges-

initiative/12-challenges/close-the-health-gap/.

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ABOUT THE AUTHORS

TERI BROWNE,

is Associate Professor in the University of South Carolina College of Social Work.

ARAH GEHLERT is Dean of the University of South Carolina School of Social Work and President of the

American Academy of Social Work & Social Welfare.

HRISTINA M. ANDREWS is Assistant Professor in the University of South Carolina College of Social Work.

RADLEY J. ZEBRACK is Professor in the University of Michigan School of Social Work.

IRGINIA N. WALTHER is Assistant Professor in the departments of Preventive Medicine, Obstetrics,

Gynecology and Reproductive Science, and Pediatrics at Mount Sinai Hospital.

AIL STEKETEE is Professor in the Boston University School of Social Work and Vice President of the

American Academy of Social Work & Social Welfare.

ETER MARAMALDI is Professor in the Simmons College School of Social Work and Adjunct Professor in

the T. H. Chan School of Public Health at Harvard University.

ARBARA L. JONES is University Distinguished Teaching Professor in the Steve Hicks School of Social

Work and Co-Director of the Institute for Collaborative Health Research and Practice at the University of

Texas at Austin.

OBYN L. GOLDEN is Professor in the Department of Health Systems Management and Director of Health

Population Health and Aging at Rush University Medical Center.

ONNIE EWALD, is Project Coordinator with the Health and Aging Department at Rush University

Medical Center.

USAN R. BERNSTEIN is Assistant Professor in Environmental Medicine & Public Health at Mount

Sinai Hospital.

UDREY L. BEGUN is Professor in the Ohio State University College of Social Work.

HEIDI L. ALLEN is Associate Professor in the Columbia University School of Social Work.

USAN GUTH is Board Director with the Society for Social Work Leadership in Health Care.

BIGAIL ROSS is Assistant Professor in the Fordham University Graduate School of Social Service.

Corresponding author. Email: browne@sc.edu.

STRENGTHENING HEALTH CARE SYSTEMS: BETTER HEALTH ACROSS AMERICA 23

Grand Challenges for Social Work initiative

Working Paper

MEGAN MOORE is Assistant Professor in the University of Washington School of Social Work.

OSEPH R. MERIGHI is Associate Professor in the University of Minnesota School of Social Work.

ACKNOWLEDGMENTS

Sandra Audia Little at the University of Maryland School of Social Work designed the cover. Chris

Leiker at Washington University’s Center for Social Development provided editorial support.

SUGGESTED CITATION

Browne, T., Gehlert, S., Andrews, C. M., Zebrack, B. J., Walther, V. N., Steketee, G., … Merighi, J. R.

(2017). Strengthening health care systems: Better health across America (Grand Challenges for Social Work

initiative Working Paper No. 22). Cleveland, OH: American Academy of Social Work & Social Welfare.

CONTACT

American Academy of Social Work & Social Welfare

Sarah Christa Butts, Executive Director

academy@aaswsw.org