Research That Matters (January 17 - 20, 2008)

Background and Purpose: Neighborhood health centers (NHCs) provide a range of social services to low income and uninsured populations to address the psychosocial problems that may cause or exacerbate common, but costly, medical and psychiatric conditions. While there is a growing literature about the impact of social factors on health care use and outcomes, little has been reported about how physicians (MDs), administrators (ADs) and social workers (SWs) perceive and address non-adherence and the psychosocial problems that impact the non-adherence behaviors. Reimbursement structures for social work in NHCs create barriers for the delivery of interventions that address non-adherence. A critical step to make the case for the expansion of reimbursable social work services in NHCs is to understand the: 1) extent of non-adherence; 2) types and intensity of psychosocial problems that impact non-adherence; and 3) role of social workers in addressing non-adherence.

Methods: Using a mixed method design, semi-structured interviews were conducted with ADs, SWs and MDs in NHCs in New York City. Closed-ended questions were analyzed using SPSS. A content analysis was conducted for qualitative questions guided by grounded theory methodology. These data were then categorized for use in the quantitative analyses. To identify the extent of agreement/disagreement of respondents within and across settings we conducted chi-square and t-test analyses. Participants were asked to identify: 1) the frequency of non-adherence in their settings; 2) 11 specific psychosocial problems that may influence non-adherence; and 3) the extent to which each respondent type addressed psychosocial problems. We also developed a list of psychosocial functions performed in NHCs and asked respondents to identify who performed them.

Results: Of a possible 81 respondents in 29 NHCs, 75 participated with a response rate of 92.5%. Approximately half (51.4%) of the respondents identified non-adherence as a very frequent problem. Of the 11 identified psychosocial problems, six were identified as very frequent problems that adversely affect NHC patients, ranging from 61% of respondents for “lack of financial resources” to 42% of respondents for “unsafe or unstable housing”. Half (50%) of the respondents reported no social work involvement in “non-adherence”. Social workers were identified as the exclusive provider of services for eight of the psychosocial problems, ranging from 57.7% for “no one at home” to 40.8% for “inability to maintain insurance.” However, 42% of respondents reported no social work involvement for “cultural practices affecting health”.

Conclusions and Implications: The majority of ADs and MDs reported no SW involvement with non-adherence issues. Yet, all respondents identified SWs as the professionals who handle the psychosocial problems ranked the highest, all of which impact non-adherence. This finding suggests that social workers are addressing non-adherence, but it is invisible to the rest of the staff. Unless the provision of these interventions is made visible, they are not likely to be included in budgetary and professional deliberations. To make a case for the reimbursement of social services in NHCs, social workers must measure and make visible their interventions to address non-adherence.