Introduction

In recent years, evidence has suggested that an inter-professional [IP] approach to primary care improves health outcomes.¹ Medical social workers have been integrated into primary care settings to address complex medical and psychosocial needs among patients.² Social workers facilitate case management, provide counseling and psychotherapy, and help patients navigate the healthcare system to obtain needed services.² Incorporating social workers into an IP team in teaching settings can be challenging.³ A major barrier to integrating social workers into primary care is an incomplete understanding of the social worker’s role among medical providers, leading to underutilization of social work expertise.⁴ The extent to which the social worker is integrated into primary care settings impacts the social worker’s ability to provide quality care to patients.⁴ There is a need for clarity of the roles and capabilities of a social worker in an academic IP team.⁵

Goals and Objectives

We sought to understand views about the role of the social worker within the residency practice at the Northwell Health Division of General Internal Medicine. Personnel changes afforded us an opportunity to conduct a needs assessment with providers to re-think the role of social work as we reorganized our interprofessional team. Interviews and focus groups of medical residents and faculty members assessed (a) understanding of social workers’ professional roles in the primary care setting and (b) expectations for partnership, collaboration, and assistance in addressing the social determinants of health.

Methods

This qualitative project included 30-minute focus groups with Internal Medicine Residents (PGY-1, PGY-2, and PGY-3) during their ambulatory rotations as well as individual interviews with pharmacy and physician faculty and one resident. All participants answered the same open-ended questions using an interview guide designed to articulate the role of a social worker and barriers to integrating social workers into IP teams. Participants were recruited by convenience sampling. Focus groups were co-led by two or more members of our project team (AR, RS, DJC) and conducted virtually using a videoconferencing platform. Participants provided verbal consent to have the interviews audiotaped. Data analysis included content analysis of group/interview transcripts in an iterative process including all researchers. Two raters reviewed each interview to identify emergent themes that occurred across participants. The Northwell Health IRB reviewed this project and determined this to constitute quality improvement.

Results

A total of 11 residents took part in three focus groups—two additional faculty members and one resident were interviewed individually for a total of 14 participants. Themes of focus groups and interviews included best practices for collaborating with social workers, suggestions to optimize the activities of social workers in primary care settings, perceptions about the social worker role, barriers to collaboration, and education and training about the role of social work (see table). The social worker role was perceived by participants to be a “resource hub” and a “link to community resources.” Social workers were noted to “address needs outside the scope of [the medical] clinician’s role” and serve as a patient advocate. For patients with barriers to care including insurance problems, social workers were perceived as key navigators.

Residents noted that much of their experience interacting with social workers occurred during their inpatient rotations, and they appreciated the role social workers played in facilitating safe discharge and communicating with outside facilities including rehabilitation centers. Collaboration with social workers was also noted to be an important part of outpatient practice. One participant noted that social workers adapted “services to be culturally inclusive for patients.” Social workers facilitated transportation to appointments, arranged treatment for substance use disorders, and helped patients struggling with difficult environmental situations including domestic violence. Though one respondent shared that “we tend to get social work involved when things are going badly,” several participants noted wishing they had engaged social workers earlier.

Residents and faculty noted several barriers to working with social workers, including communication challenges. The time pressures of ambulatory care made it hard to include the social worker on an emergent basis—for example, when “people come in for one problem and then their one problem becomes 10 problems and you don’t have time for...a family meeting or a social meeting.” One participant noted appointment no-shows and late arrivals to be a barrier to involving interprofessional team members in medical visits. Pandemic-related increases in social distancing and remote work presented an additional layer of communication challenges.

Participants noted receiving some information about the role of social workers during orientation, but as one attending mentioned, “you’re learning a lot of things [during orientation] and you don’t have a good understanding of how things work in other ways… [so] it gets lost.” Participants wanted to know more about, “the things that social work can make happen.” One participant requested a “sheet saying exactly the things that a social worker might be able to [do]…” There was a consensus however that the best training about social workers came from direct, frequent interactions, and “actually sending the patients to the social worker for a specific reason.”

Participants had several suggestions to improve collaboration with social workers in primary care. They requested enhanced integration of social workers into the interprofessional team and more consistent interactions. It was also recommended that the practice establish dedicated social work appointments “scheduled for that specific purpose” of addressing social needs. Finally, more comprehensive pre-screening of patients for social needs was recommended to identify patients who would benefit from social work involvement.

Discussion

Obtaining perceptions about the role of social workers among primary care professionals is key to identifying staff training needs about the ways social workers support medical care and can serve as full members of the IP team. Social workers are perceived as a “resource hub,” and advocates for patient needs and experts in overcoming barriers to healthcare such as insurance, transportation, and applying for home-based services. Few participants associated the social worker role with behavioral health and counseling. We found this perspective interesting since the practice has a respected and well-utilized social worker providing psychotherapy to our patients, suggesting a training need to clarify the distinctions between medical and psychiatric social work. Many residents received training about the social worker role during orientation and requested ongoing exposure to a social worker’s responsibilities in the ambulatory setting. Time constraints serve as one of the biggest barriers to working with social workers. Limitations of this project include the small sample of stakeholders at a single training site. Team meetings, preventative pre-screenings, and “warm handoffs” between the patient, provider, and social worker are needed to ensure coordination of care, and are also challenging due to time constraints. Ensuring that residents and social workers understand each other’s roles and responsibilities can help foster collaboration to serve patients’ medical and social needs.