The Evolving Role of Social Workers in Integrated Care Programs Serving Patients with Complex Care Needs

Background and Purpose: Growing evidence demonstrates the impact of models that integrate primary care and behavioral health services on patient outcomes and implementation efficacy. Provision of integrated care (IC) services requires a set of specialized skills which are often satisfied by interprofessional teams of physicians, nurses, health coaches and behavioral health professionals, including social workers. There remains, however, some degree of ambiguity and a lack of research surrounding the specialized role and unique contributions of social workers in IC teams. This paper helps to fill this gap by characterizing the evolving functions of social workers in IC teams and elucidating how their role is both distinct and overlapping with other health professions, including nurses and community outreach workers.

Methods: The qualitative data herein are part of a larger mixed-methods, longitudinal study that aimed to explore the role of interprofessional teams, health systems, and multilevel factors that influence health and improve access to healthcare services for health literacy among vulnerable populations. As part of that study, 52 providers and staff of IC management programs embedded within two urban public safety-net hospital systems serving adult patients with complex care needs were recruited for in-depth interviews. This paper draws from longitudinal interviews with 27 providers (n=54) including social workers (n=5), primary care providers (n=7), nurses (n=7), health coaches (n=3), and community outreach workers (n=5). Demographic questionnaires indicated that the majority of providers were female (74%) with an average age of 36 (13.8 SD) (33.3% identified as White; 33.3% Black/African American; 18.5% API; 7.4% Hispanic/Latinx; 7.4% Other). The interviews elicited provider perceptions of their specific roles within the program, their effect on patient outcomes, and the care coordination processes and interactions with other providers and organizations. Interviews were transcribed verbatim and coded thematically using Atlas.ti qualitative software, guided by the principles of constructivist grounded theory.

Results: We found that social workers, who were previously considered “medical social workers,” shifted to functioning in the role of “Behavioral Health Clinicians” (BHCs) as primary care clinics adopted an IC model for their care management programs targeting patients with complex care needs. Social workers, who were previously focused on case management, therefore identified themselves as consultants who answer psychosocial and behavioral health-related questions for medical providers; intensive case management and patient outreach/engagement functions shifted to nurses and community outreach workers. BHCs increasingly conduct mental health assessments; provide group and individual therapy and targeted, brief mental health interventions; and link patients to long-term mental health and substance use services.

Conclusions and Implications: Findings, which will be shared with practitioners during report-backs, highlight the value and increased application of social workers’ specialized training in behavioral health for improving patient health behaviors and outcomes. By developing a deeper understanding of the contributions and roles of social workers embedded in IC settings, social work researchers can generate more research that evaluates the impact of social work intervention efforts on the health and well-being of vulnerable populations.