The Social Determinants The Social Determinants of Healthof Health

The Way Forward!The Way Forward!

BCASW Education DayBCASW Education Day

September 20, 2013September 20, 2013

Vancouver, BCVancouver, BC

Learning ObjectivesLearning Objectives Gain an understanding of research supporting Gain an understanding of research supporting

the link between the Social Determinants of the link between the Social Determinants of Health and healthcare outcomes;Health and healthcare outcomes;

Identify how these Determinants can be used Identify how these Determinants can be used as the basis for assessments, interventions and as the basis for assessments, interventions and evaluation of outcomes;evaluation of outcomes;

Be introduced to an electronic standardized Be introduced to an electronic standardized psychosocial assessment tool which can be psychosocial assessment tool which can be used to communicate effectively and efficiently used to communicate effectively and efficiently with other care providers and to educate on with other care providers and to educate on the focus of social work practice in healthcare.the focus of social work practice in healthcare.

ContextContext

A brief history of social work in healthA brief history of social work in health Challenges facing Canadian healthcare Challenges facing Canadian healthcare

systemsystem Roles of social workers associated Roles of social workers associated

directly and indirectly with healthcaredirectly and indirectly with healthcare Challenges and opportunities facing Challenges and opportunities facing

social work in this milieusocial work in this milieu

BackgroundBackground Healthcare is the largest field of practice for Healthcare is the largest field of practice for

social workers (Holosko) and one of the social workers (Holosko) and one of the largest industries in Canadalargest industries in Canada

Health is one of the most important concerns Health is one of the most important concerns for Canadiansfor Canadians

Every Canadian is touched by healthcare Every Canadian is touched by healthcare issues – every Canadian will use the issues – every Canadian will use the healthcare systemhealthcare system

During the last two years of life, an individual During the last two years of life, an individual consumes more healthcare resources than consumes more healthcare resources than were used during all previous years of their were used during all previous years of their lifelife

The Cost of HealthcareThe Cost of Healthcare

Healthcare spending in Canada Healthcare spending in Canada reached $207 billion in 2012 (CIHI)reached $207 billion in 2012 (CIHI)

Percentage of GDP spent is 11.6%Percentage of GDP spent is 11.6% Largest costs are:Largest costs are:

1.1. Hospitals (29%)Hospitals (29%)

2.2. Drugs (15%)Drugs (15%)

3.3. Physician fees (14.4%)Physician fees (14.4%)

Health Spending by Health Spending by ProvinceProvince

In 2011 health care accounted for In 2011 health care accounted for 38% of provincial/territorial 38% of provincial/territorial spendingspending

Quebec spends least (30.1%)Quebec spends least (30.1%) Nova Scotia spends most (47.9%)Nova Scotia spends most (47.9%)

Average Annual Growth Average Annual Growth RateRate

Cost per Canadian 1975-Cost per Canadian 1975-20122012

Average Cost by CountryAverage Cost by Country

Value for Money?Value for Money?

Canada is second only to the US in Canada is second only to the US in per capita spending ($5948 per per capita spending ($5948 per person) (person) (CIHI 2012CIHI 2012))

Canada now ranks 10Canada now ranks 10thth among 17 among 17 countries in terms of outcomescountries in terms of outcomes

Japan, Switzerland and Italy ranked Japan, Switzerland and Italy ranked higherhigher

Conference Board of Conference Board of Canada ReportCanada Report

20132013 Canada maintains its “B” grade and Canada maintains its “B” grade and

6th-place ranking among 17 peer 6th-place ranking among 17 peer countries.countries.

The gap in life expectancy between The gap in life expectancy between Canada and the U.S. continues to Canada and the U.S. continues to widen; Canadians now live three widen; Canadians now live three years longer than Americans.years longer than Americans.

Life expectancy is a good indicator Life expectancy is a good indicator of overall health in a country.of overall health in a country.

GRADEGRADE Life expectancy Life expectancy BB Mortality due to diabetes Mortality due to diabetes CC Self-reported health status Self-reported health status AA Mortality due to musculoskeletal system diseases Mortality due to musculoskeletal system diseases

C C Premature mortality Premature mortality AA

Mortality due to mental disorders Mortality due to mental disorders BB Mortality due to cancer Mortality due to cancer CC Infant mortality Infant mortality CC Mortality due to circulatory diseases Mortality due to circulatory diseases AA Mortality due to medical misadventures Mortality due to medical misadventures BB Mortality due to respiratory diseases   Mortality due to respiratory diseases  

BB

WHO Definition of WHO Definition of HealthHealth

““Health is a state of complete physical, Health is a state of complete physical, mental and social well-being and not mental and social well-being and not merely the absence of disease or infirmity”merely the absence of disease or infirmity”

Social Determinants of Health are the Social Determinants of Health are the economic and social conditions that economic and social conditions that influence the health of individual, influence the health of individual, communities and jurisdictions as a wholecommunities and jurisdictions as a whole

SDOH are about the quantity and quality of SDOH are about the quantity and quality of a variety of resources that society makes a variety of resources that society makes available to its members available to its members (D. Raphael, 2011)(D. Raphael, 2011)

Social Work’s RootsSocial Work’s Roots Social Workers as “sanitary visitors” in Social Workers as “sanitary visitors” in

US– took note of income, living conditions, US– took note of income, living conditions, education, employmenteducation, employment

Early training of US physicians and nurses Early training of US physicians and nurses included home visitsincluded home visits

UK social workers first called “almoners” UK social workers first called “almoners” referring to work with the poorreferring to work with the poor

Role was to “screen by a competent person Role was to “screen by a competent person of education and refinement who could of education and refinement who could consider the position and circumstances of consider the position and circumstances of patients” (patients” (Gehlert&Brown, 2012)Gehlert&Brown, 2012)

Further Elaboration of Further Elaboration of PurposePurpose

““The social worker seeks to remove those The social worker seeks to remove those obstacles, either in the patient’s obstacles, either in the patient’s surroundings or in his mental attitude, surroundings or in his mental attitude, that interfere with successful treatment, that interfere with successful treatment, thus freeing the patient to aid in his thus freeing the patient to aid in his recovery” (Ida Cannon, 1923)recovery” (Ida Cannon, 1923)

Treating the whole person: Social Work’s Treating the whole person: Social Work’s primary roleprimary role

Person in Environment (Keefler, Duder & Person in Environment (Keefler, Duder & Lechman, 2001)Lechman, 2001)

What is the Link?What is the Link? Strong empirical relationship between living Strong empirical relationship between living

circumstances and health and social problems circumstances and health and social problems in Canadain Canada

Countries with the greatest wealth are not Countries with the greatest wealth are not necessarily healthiest – US spends more per necessarily healthiest – US spends more per capita than any other country in the OECD but capita than any other country in the OECD but has poorer health has poorer health

The wider the income gap within a society the The wider the income gap within a society the higher its mortality and morbidity rates higher its mortality and morbidity rates (Picket (Picket & Wilkinson, 2009)& Wilkinson, 2009)

Medical care plays a limited role in reducing Medical care plays a limited role in reducing mortality in Western nations compared to mortality in Western nations compared to increased income, nutrition and public health increased income, nutrition and public health efforts (efforts ((Moniz & Gorin, 2010)(Moniz & Gorin, 2010)

Health and social problems are a result of Health and social problems are a result of adverse living circumstances and these are adverse living circumstances and these are shaped by public policy!shaped by public policy!

Half of all healthcare outcomes are linked Half of all healthcare outcomes are linked to the social determinantsto the social determinants

Only 15 % of outcomes are linked to Only 15 % of outcomes are linked to biology and genetics biology and genetics

Only 10% of outcomes are linked to Only 10% of outcomes are linked to environmental factorsenvironmental factors

One in 5 healthcare dollars is spent One in 5 healthcare dollars is spent addressing problems related to POVERTYaddressing problems related to POVERTY

Action taken to reduce health inequalities Action taken to reduce health inequalities will have economic benefits (Marmot, 2010)will have economic benefits (Marmot, 2010)

At every stage in life, health is At every stage in life, health is determined by complex interactions determined by complex interactions between social and economic factors, between social and economic factors, the physical environment and behavior. the physical environment and behavior. They do not exist in isolation from They do not exist in isolation from each other. each other.

It is the combined influence of the It is the combined influence of the determinants of health that determines determinants of health that determines health status health status

(Public Health Agency of Canada, 2011)(Public Health Agency of Canada, 2011)

What determines health?What determines health?

Why is Jason in the hospital? Why is Jason in the hospital? Because he has a bad infection in his leg.Because he has a bad infection in his leg. But why does he have an infection? But why does he have an infection? Because he has a cut on his leg and it got infected. Because he has a cut on his leg and it got infected. But why does he have a cut on his leg? But why does he have a cut on his leg? Because he was playing in the junk yard next to his apartment Because he was playing in the junk yard next to his apartment

buildingbuilding and there was some sharp, jagged steel there that he fell on. and there was some sharp, jagged steel there that he fell on. But why was he playing in a junk yard? But why was he playing in a junk yard? Because his neighbourhood is kind of run down. A lot of kids play Because his neighbourhood is kind of run down. A lot of kids play

therethere and there is no one to supervise them. and there is no one to supervise them. But why does he live in that neighbourhood? But why does he live in that neighbourhood? Because his parents can't afford a nicer place to live. Because his parents can't afford a nicer place to live. But why can't his parents afford a nicer place to live? But why can't his parents afford a nicer place to live? Because his Dad is unemployed and his Mom is sick. Because his Dad is unemployed and his Mom is sick. But why is his Dad unemployed? But why is his Dad unemployed? Because he doesn't have much education and he can't find a job.Because he doesn't have much education and he can't find a job. But why ...?But why ...?‘‘Toward a healthy future’ (www.phac-aspc.gc.ca)Toward a healthy future’ (www.phac-aspc.gc.ca)

Social Determinants of Social Determinants of HealthHealth

1. Income and Income Distribution1. Income and Income Distribution

2. Education2. Education

3. Unemployment and Job Security3. Unemployment and Job Security

4. Employment and Working Conditions4. Employment and Working Conditions

5. Early Childhood Development5. Early Childhood Development

6. Food Security6. Food Security

continuedcontinued 7. Housing7. Housing

8. Social Exclusion8. Social Exclusion

9. Social Safety Network9. Social Safety Network

10. Health Care Services10. Health Care Services

11. Aboriginal Status11. Aboriginal Status

12. Gender12. Gender(York University SDOH Across the Lifespan Conference 2004)(York University SDOH Across the Lifespan Conference 2004)

Wealth = Health!Wealth = Health!

Poor Canadians are twice as likely to die as Poor Canadians are twice as likely to die as affluent Canadians 10 years after suffering a affluent Canadians 10 years after suffering a heart attack despite having similar access to heart attack despite having similar access to quality medical carequality medical care

The risk for almost any ailment from mental The risk for almost any ailment from mental illness to infant mortality to asthma falls with illness to infant mortality to asthma falls with each rung on the socioeconomic ladder a each rung on the socioeconomic ladder a person climbsperson climbs

In Ottawa a study poor people are twice as In Ottawa a study poor people are twice as likely to be hospitalized for mental illness likely to be hospitalized for mental illness than those in higher income groupsthan those in higher income groups

Income and Income Income and Income DistributionDistribution

Health improves with each rung of Health improves with each rung of the socioeconomic ladder climbedthe socioeconomic ladder climbed

Whitehall StudiesWhitehall Studies

Diabetes mortality, males, urban CanadaDiabetes mortality, males, urban Canada

02468

101214161820222426

1971 1976 1981 1986 1991 1996 2001

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

ASMR x 100,000

Wilkins, R. (2007). Mortality by neighbourhood income in urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar.

Heart Attack Admission Rates by Heart Attack Admission Rates by Area Income, Ontario, 1994 - Area Income, Ontario, 1994 -

19971997

4614

8090

11837

1393513115

0

2000

4000

6000

8000

10000

12000

14000

Highest IncomeQuintile

2nd Quintle Middle Quintile 4th Quintile Lowest IncomeQuintile

Source: Alter, D. A. et al. (1999). Effects of socioeconomic status o access to invasive cardiac procedures and on mortality after acute myocardial infarction. NEJM, 341, 1360-1367.

Figure 1-1. Life Expectancy of Males and Females by Income Quintile of Neighbourhood, Urban Canada,

2001

79

78.6

77.8

77.1

82.8

82.8

82.6

82.3

80.974.7

70 75 80 85

Q1 - Richest

Q2

Q3

Q4

Q5 - Poorest

Life Expectancy in Years

Females

Males

Wilkins, R. (2007). Mortality by neighbourhood income in urban Canada from 1971 to 2001. Statistics Canada, Health Analysis and Measurement Group (HAMG). HAMG Seminar, and special compilations.

EducationEducation

Strong factor in achieving Strong factor in achieving employment and therefore incomeemployment and therefore income

38% of university grads rated their 38% of university grads rated their health as excellent compared to 19% health as excellent compared to 19% of those with less than high schoolof those with less than high school

Ability to understand goals of Ability to understand goals of treatment and follow directiontreatment and follow direction

Unemployment and Unemployment and Employment SecurityEmployment Security

Unemployment and Unemployment and underemployment linked to poor underemployment linked to poor healthhealth

Link between unemployment and Link between unemployment and incomeincome

Unemployment and self esteemUnemployment and self esteem Impact of potential job lossImpact of potential job loss

Employment and Working Employment and Working ConditionsConditions

Double edged swordDouble edged sword Toxic working conditionsToxic working conditions Unsafe working conditionsUnsafe working conditions Work stressWork stress Unpaid workUnpaid work

Early Childhood Early Childhood DevelopmentDevelopment

Prenatal healthPrenatal health Emotional attachmentEmotional attachment Birth weight and incomeBirth weight and income Day care and early learning Day care and early learning

programsprograms

Child Poverty in Wealthy Child Poverty in Wealthy NationsNations

Figure 7.1. Child Poverty in Wealthy Nations, Mid-2000s

3

4

4

5

6

8

89

9

10

10

10

10

11

12

12

12

13

14

15

15

1616

16

17

17

21

22

2225

0 5 10 15 20 25 30

DenmarkFinland

SwedenNorwayAustriaIcelandFrance

SwitzerlandHungary

KoreaCzech R.

BelgiumUK

Slovak R.Australia

LuxembourgNetherlands

GreeceJapan

CanadaNew Zealand

GermanyIreland

ItalySpain

PortugalUSA

MexicoPolandTurkey

Percentage of Children Living in Relative Poverty Defined as Households with <50% of the National Median Household Income

13.4

8.6 8.1 8.3

5.1

0

2

4

6

8

10

12

14

<20,000 20,000-39,999 40,000-59,999 60,000-79,999 >80,000

Average Family Income and Average Family Income and Percentage of Children with Poor Percentage of Children with Poor

HealthHealth

Raphael: SDOH, The Canadian Facts

Food SecurityFood Security

One in eight families have One in eight families have inadequate access to regular healthy inadequate access to regular healthy mealsmeals

1.1 million children living in a home 1.1 million children living in a home with food insecuritywith food insecurity

Link to development of chronic Link to development of chronic diseasesdiseases

Increased use of food banksIncreased use of food banks

Figure 5. Number of Canadians Assisted by Food Banks: 1989-2010 (March of Each Year)

0200,000400,000600,000800,000

1,000,000

89 97 98 99 00 01 02 03 04 05 06 07 08 09 10

Year

Numb

er A

ssiste

d

HousingHousing

Lack of a housing framework Lack of a housing framework although promised since 2005although promised since 2005

Successful Mental Health Successful Mental Health Commission Initiative - Housing Commission Initiative - Housing First (Chez Soi)First (Chez Soi)

Costs of homelessnessCosts of homelessness Rental costsRental costs Unsafe housingUnsafe housing

Source: United Way of Greater Toronto. (2004). Poverty by Postal Code: The Geography of Neighbourhood Poverty, 1981-2001. Toronto: United Way of Greater Toronto.

Social ExclusionSocial Exclusion

Importance of family supportImportance of family support Value of community Value of community

connections/supportconnections/support Link between social connections and Link between social connections and

lower premature death rateslower premature death rates Impact of volunteering and Impact of volunteering and

community programmingcommunity programming

Social Safety NetSocial Safety Net

Social Assistance funding decreases Social Assistance funding decreases as cost of living increasesas cost of living increases

Deterioration of the traditional Deterioration of the traditional social safety net social safety net

Impact of aging populationImpact of aging population

Figure 3.5: Total Average Income by Income Quintile, All Family Units, Canada, 1995-2008

15,00013,100

55,10047,500

169,000

128,400

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2205

2006

2007

2008

Lowest Quintile Second Quintile Middle Quintile

Fourth Quintile Highest Quintile

Welfare Assistance Situation for persons in Ontario, 2008Welfare Assistance Situation for persons in Ontario, 2008 Single Single

PersonPerson Considered Considered

EmployableEmployable

Single PersonSingle Personwith a with a DisabilityDisability

Lone Parent Lone Parent with Child with Child Aged TwoAged Two

Couple with Couple with Two Two

Children Children Aged 10 & Aged 10 &

1515

Total IncomeTotal Income $7,352$7,352 $12,647$12,647 $16,683$16,683 $21,215$21,215

Benefits Benefits Decline Decline

from from 19921992

$4,048$4,04836%36%

$3,069$3,06920%20%

$5,761$5,76112%$12%$

$8,674$8,67429%29%

Source: National Council of Welfare (NCW) (2010). Welfare Incomes, Nos. 1-4. Source: National Council of Welfare (NCW) (2010). Welfare Incomes, Nos. 1-4. Ottawa: NCWOttawa: NCW

Health Care ServicesHealth Care Services

Services not covered by Canada Services not covered by Canada Health ActHealth Act

Lack of family doctorsLack of family doctors Long wait lists for tests and Long wait lists for tests and

proceduresprocedures Budget for health care ballooning Budget for health care ballooning

with aging population, cost of drugs, with aging population, cost of drugs, new proceduresnew procedures

Aboriginal StatusAboriginal Status

Prevalence of all major chronic Prevalence of all major chronic disease higher in Aboriginal disease higher in Aboriginal communitiescommunities

Higher rates of infectionHigher rates of infection High mental health, addiction and High mental health, addiction and

suicide ratessuicide rates Life expectancies are 5-14 years less Life expectancies are 5-14 years less

than those of total populationthan those of total population

GenderGender

Longer life expectancy for femalesLonger life expectancy for females Higher incidence of depression, Higher incidence of depression,

stress overload and chronic stress overload and chronic conditions in femalesconditions in females

High risk for injuries and death from High risk for injuries and death from family violencefamily violence

Female households more likely to be Female households more likely to be poorpoor

The psychosocial aspects The psychosocial aspects of healthof health

Thoughts, feelings and moods Thoughts, feelings and moods significantly effect:significantly effect:

a)a) Onset on diseaseOnset on diseaseb)b) Course of the diseaseCourse of the diseasec)c) Management of the diseaseManagement of the diseaseEmpowering patients and addressing Empowering patients and addressing

their psychosocial needs can be their psychosocial needs can be health and cost effectivehealth and cost effective

Relationship between perceived Relationship between perceived health and future healthhealth and future health

Impact of self-determination and Impact of self-determination and sense of control on illnesssense of control on illness

Need to reorganize the health Need to reorganize the health care hierarchycare hierarchy

Equity and InequityEquity and Inequity

This year, the richest one per cent of This year, the richest one per cent of Canadians are each taking home Canadians are each taking home $180,000 more annually today than $180,000 more annually today than they did in 1982. But the bottom 90 they did in 1982. But the bottom 90 per cent of Canadians saw income per cent of Canadians saw income gains of just $1,700 a year, 10.6 per gains of just $1,700 a year, 10.6 per cent of the increase enjoyed by their cent of the increase enjoyed by their wealthiest fellow citizens. wealthiest fellow citizens.

Improving HealthImproving Health

Guaranteed annual incomeGuaranteed annual income Living wageLiving wage National food security programNational food security program Affordable housingAffordable housing Accessible housing, transportationAccessible housing, transportation PharmacarePharmacare

Where are our Allies?Where are our Allies? What makes Canadians sick? Poverty, says a What makes Canadians sick? Poverty, says a

report from the Canadian Medical Association report from the Canadian Medical Association (Ottawa Citizen, July 2013)(Ottawa Citizen, July 2013)

  Public Health Agency of Canada’s 2011 Public Health Agency of Canada’s 2011 report concluded “public health policy needs report concluded “public health policy needs to be broadened to explore interventions that to be broadened to explore interventions that address socioeconomic determinants”address socioeconomic determinants”

Canadian Institute for Health Information Canadian Institute for Health Information 2008 report “people in lower socioeconomic 2008 report “people in lower socioeconomic groups were far more likely to be hospitalized groups were far more likely to be hospitalized for mental illness and childhood asthma” for mental illness and childhood asthma” 

What Can We Do About What Can We Do About It?It?

The World Health Organization suggests The World Health Organization suggests all nations establish policies and programs all nations establish policies and programs to:to:

1.1. Improve the conditions of daily lifeImprove the conditions of daily life2.2. Tackle the inequitable distribution of Tackle the inequitable distribution of

power, money and resourcespower, money and resources3.3. Measure the problem, evaluate action, Measure the problem, evaluate action,

expand the knowledge base, DEVELOP A expand the knowledge base, DEVELOP A WORKFORCE TRAINED IN THE SDOHWORKFORCE TRAINED IN THE SDOH

4.4. Raise public awareness about the SDOH Raise public awareness about the SDOH (WHO, 2008, p.6)(WHO, 2008, p.6)

Implications for Social Implications for Social Work InterventionsWork Interventions

Every intervention should be tied to Every intervention should be tied to a social determinanta social determinant

The outcomes should be identifiedThe outcomes should be identified The healthcare team should see how The healthcare team should see how

the intervention has the potential to the intervention has the potential to improve health / quality of life improve health / quality of life and/or reduce the number of and/or reduce the number of interfaces with the health care interfaces with the health care systemsystem

EvaluationEvaluation 1. Which social determinants were 1. Which social determinants were

influenced by the social work intervention?influenced by the social work intervention? 2. What was the outcome?2. What was the outcome? Reduced visits to the ER?Reduced visits to the ER? Reduced visits to family physician?Reduced visits to family physician? Reduced admissions to hospital?Reduced admissions to hospital? Improved self reported QOL?Improved self reported QOL? Decreased stress levels or symptom Decreased stress levels or symptom

levels?levels? (ESAS scores)(ESAS scores)

Making the ConnectionMaking the Connection Attention to concrete needs and ecological Attention to concrete needs and ecological

risks often is undervalued, but it is part of risks often is undervalued, but it is part of social work’s “uncelebrated strength” (social work’s “uncelebrated strength” (Johnson, Johnson, 1999)1999)

Attention can lead to improved quality of life, Attention can lead to improved quality of life, reduced psychological stress and IMPROVED reduced psychological stress and IMPROVED PHYSICAL HEALTHPHYSICAL HEALTH

Identifying potential resources and services, Identifying potential resources and services, discussing them with the client and facilitating discussing them with the client and facilitating referrals are important functions for social referrals are important functions for social work and fulfill one of social worker’s key role: work and fulfill one of social worker’s key role: linking people to resources (linking people to resources (Hepworth et al., Hepworth et al., 2002)2002)

Hamilton Spectator Letter Hamilton Spectator Letter to Editorto Editor

Aug 23, 2013  Social workers key to health careSocial workers key to health careHealth care challengesHealth care challengesDr. Anna Reid, president of the Canadian Medical Association, was Dr. Anna Reid, president of the Canadian Medical Association, was

quoted this week as saying "an estimated one in every five dollars quoted this week as saying "an estimated one in every five dollars spent on health is directly attributable to the social determinants spent on health is directly attributable to the social determinants of health."of health."

Given this fact, it is imperative that social workers be part of the Given this fact, it is imperative that social workers be part of the solution to this health care challenge. Social workers bring solution to this health care challenge. Social workers bring expertise and training in the social determinants of health which expertise and training in the social determinants of health which will impact the quality of people's lives and their health care will impact the quality of people's lives and their health care outcomes. They work directly with patients, advocating on their outcomes. They work directly with patients, advocating on their behalf to find housing, access financial supports and connect with behalf to find housing, access financial supports and connect with family and community agencies.family and community agencies.

Through their activities, social workers are able to reduce pressures Through their activities, social workers are able to reduce pressures on the health care system by preventing readmission to hospital on the health care system by preventing readmission to hospital and assisting people to remain in the community.and assisting people to remain in the community.

Joan MacKenzie Davies, Executive Director, Ontario Association Joan MacKenzie Davies, Executive Director, Ontario Association of Social Workersof Social Workers

Public Perception of Public Perception of Social WorkSocial Work

Physicians, nurses and social workers view Physicians, nurses and social workers view and frame patient problems and their and frame patient problems and their solutions to those problems through solutions to those problems through separate lenses.separate lenses.

Social Work is a profession whose purpose, Social Work is a profession whose purpose, logic and underlying rational differ from logic and underlying rational differ from those of other professions. (those of other professions. (Rolland, 1994)Rolland, 1994)

““Physicians and nurses have a surplus of technical Physicians and nurses have a surplus of technical medical information. They can have trouble seeing the medical information. They can have trouble seeing the psychosocial forest thru the technological lens they need psychosocial forest thru the technological lens they need to use to help the patient medically. And if they can to use to help the patient medically. And if they can switch lenses, often they have trouble deciding which switch lenses, often they have trouble deciding which trees in the medical forest are psychosocially important”. trees in the medical forest are psychosocially important”. IbidIbid

CEO’s PerceptionsCEO’s Perceptions

Exclusive roles of social work:Exclusive roles of social work:

1.1. Teaching social work studentsTeaching social work students

2.2. Liaison with/referral to other Liaison with/referral to other servicesservices

3.3. Assisting patients to cope with Assisting patients to cope with social problems associated with ill social problems associated with ill healthhealth

(Levine and Herbert, 1997)(Levine and Herbert, 1997)

Inner City Health Inner City Health NetworkNetwork

A healthcare strategy addressing the A healthcare strategy addressing the social determinants of healthsocial determinants of health

Involves collaborationInvolves collaboration Cost effectiveCost effective Multi-disciplinaryMulti-disciplinary Patient CenteredPatient Centered

Putting the Social Putting the Social Determinants into ActionDeterminants into Action

Places of influence for social work:Places of influence for social work:1.1. Primary carePrimary care2.2. Family Health Teams Family Health Teams 3.3. Community Health CentresCommunity Health Centres4.4. Community Care AgenciesCommunity Care Agencies5.5. Retirement homes, Nursing HomesRetirement homes, Nursing Homes6.6. Social Planning AgenciesSocial Planning Agencies7.7. Community Mental HealthCommunity Mental Health8.8. Seniors CentresSeniors Centres9.9. Hospitals especially ERHospitals especially ER

““Social Work occupies a unique Social Work occupies a unique position in that it has its feet in position in that it has its feet in health and mental health, its hands health and mental health, its hands in the social sciences, its viscera in in the social sciences, its viscera in clinical intervention skills, and its clinical intervention skills, and its head and heart in a commitment to head and heart in a commitment to the issues of the quality of life the issues of the quality of life of….persons in society”. (of….persons in society”. (Romano, Romano, 1981)1981)

Screening for SDOHScreening for SDOH

Case Example:Case Example:A 41 year old woman with no documented A 41 year old woman with no documented

medical history or family history of disease medical history or family history of disease presents with occasional chest pains on presents with occasional chest pains on exertion. exertion.

Also is a smoker and high cholesterolAlso is a smoker and high cholesterolEarns less than $12,000 per year though part Earns less than $12,000 per year though part

time work and rents a $600/month bachelor time work and rents a $600/month bachelor apartmentapartment

Which of these factors will prove most Which of these factors will prove most important when addressing her health?important when addressing her health?

““Let’s Talk About Health Without Let’s Talk About Health Without Talking About Healthcare” – Talking About Healthcare” – Sudbury Public Health DepartmentSudbury Public Health Department

Development and Development and Use of Use of

Standardized Standardized Social Work Social Work

Documentation Documentation ToolsToolsThe Ottawa Hospital The Ottawa Hospital

ExperienceExperience

Healthcare Providers Healthcare Providers Against Poverty Against Poverty

““Just as screening is important for other conditions Just as screening is important for other conditions or risk factors, like smoking, high cholesterol or or risk factors, like smoking, high cholesterol or domestic violence, so too is screening for poverty”domestic violence, so too is screening for poverty”

“ “ The evidence shows that poverty is a major health The evidence shows that poverty is a major health condition and the biggest determinant of health”condition and the biggest determinant of health”

Ontario College of Family Physicians has produced a Ontario College of Family Physicians has produced a primary care intervention tool on poverty primary care intervention tool on poverty for use by for use by every Family Physician in Ontario and is lobbying to every Family Physician in Ontario and is lobbying to have screening for poverty as a risk factor for health have screening for poverty as a risk factor for health as standard practice.as standard practice.

Opportunities for interventions that can increase Opportunities for interventions that can increase income while advocating for government policies that income while advocating for government policies that can improve income supports and reduce income can improve income supports and reduce income inequalityinequality

Assessing Psychosocial Assessing Psychosocial ConditionsConditions

Accurate assessment is at the heart of Accurate assessment is at the heart of effective social interventioneffective social intervention

Assessment involves “the thinking Assessment involves “the thinking process that seeks out the meaning of process that seeks out the meaning of case situations, puts the particulars of case situations, puts the particulars of the case in some order and leads to the case in some order and leads to appropriate interventions” appropriate interventions” (Meyer, 1993)(Meyer, 1993)

Social Workers as the “screener” for Social Workers as the “screener” for the SDOH on the part of the teamthe SDOH on the part of the team

Environmental ScanEnvironmental Scan

130 social workers in large tertiary setting 130 social workers in large tertiary setting providing inpatient and outpatient care providing inpatient and outpatient care including trauma, ICU, rehabilitation, including trauma, ICU, rehabilitation, Family Health Teams, mental health Family Health Teams, mental health services, cancer care, cardiac careservices, cancer care, cardiac care

Independence in style observed thru Chart Independence in style observed thru Chart AuditsAudits

Ontario College of Social Work and Social Ontario College of Social Work and Social Services Work guidelinesServices Work guidelines

Many and varied consumers of informationMany and varied consumers of information

Pain PointsPain Points

Lack of timeLack of time Lack of consistencyLack of consistency DisorganizationDisorganization Illegible handwritingIllegible handwriting Poor or non existent relationship Poor or non existent relationship

between assessment and between assessment and interventionsinterventions

Limited use by consumersLimited use by consumers

Intercampus Charting Intercampus Charting Initiative Action Team Initiative Action Team

(CIAT)(CIAT) Goals:Goals:1.1. Improve the clarity, efficiency, Improve the clarity, efficiency,

clinical reflection and communication clinical reflection and communication aspects of socila work assessmentsaspects of socila work assessments

2.2. Improve interprofessional Improve interprofessional communication and quality of care communication and quality of care planningplanning

3.3. Make documentation more widely Make documentation more widely accessible through use of technology accessible through use of technology (a secondary goal and benefit)(a secondary goal and benefit)

Steps:Steps:1.1. Literature search to find existing templatesLiterature search to find existing templates2.2. Assessment of environment and needsAssessment of environment and needs3.3. Peer review of psychosocial assessments Peer review of psychosocial assessments

from benchmark hospitalsfrom benchmark hospitals4.4. Extensive consultation with IS/IT Extensive consultation with IS/IT

departments to create user friendly departments to create user friendly templatetemplate

5.5. Change management training to encourage Change management training to encourage openness to new charting modelopenness to new charting model

ImplementationImplementation Mandatory educationMandatory education Clinical Practice Rounds to provide Clinical Practice Rounds to provide

examples and discuss challenges to changeexamples and discuss challenges to change Use of a Pre and Post Test to gather Use of a Pre and Post Test to gather

qualitative and quantitative feedback qualitative and quantitative feedback measuring:measuring:

1.1. EfficiencyEfficiency2.2. TimelinessTimeliness3.3. ClarityClarity4.4. Clinical reflectionClinical reflection5.5. Link to intervention/plan of care by Social Link to intervention/plan of care by Social

WorkWork

Electronic TemplatesElectronic Templates

1.1. AssessmentAssessment

2.2. Summary of InvolvementSummary of Involvement

3.3. Discharge SummaryDischarge Summary

Social Work Assessment Social Work Assessment ContentContent

DemographicsDemographics Relevant Health InformationRelevant Health Information Financial SituationFinancial Situation Living Situation/Functional statusLiving Situation/Functional status Family/Social/CommunityFamily/Social/Community Clinical ImpressionsClinical Impressions Interventions/Recommendations Interventions/Recommendations

DemographicsDemographics

Age, gender, marital statusAge, gender, marital status Reason for admissionReason for admission Reason for referralReason for referral Presenting program/patient or Presenting program/patient or

family identified concernsfamily identified concerns Language/culture/religion/spiritual Language/culture/religion/spiritual

beliefsbeliefs Sexual OrientationSexual Orientation

Relevant Health Relevant Health InformationInformation

Past medical historyPast medical history Mental health historyMental health history Course in hospitalCourse in hospital Substance abuse historySubstance abuse history CognitionCognition Family medical historyFamily medical history Special dietSpecial diet Medication/treatment adherenceMedication/treatment adherence

Financial SituationFinancial Situation

Source of incomeSource of income Employment/professionEmployment/profession Household incomeHousehold income Extended health coverageExtended health coverage Expected time away from workExpected time away from work EducationEducation POA/PGT involvementPOA/PGT involvement

Living Situation/Functional Living Situation/Functional StatusStatus

Housing/type/adaptedHousing/type/adapted AD/IADLSAD/IADLS Mobility/ambulationMobility/ambulation Formal support (Community Care, Formal support (Community Care,

homemaking, etc.)homemaking, etc.) Subsidized housingSubsidized housing TranportationTranportation

Family/Social/CommunityFamily/Social/Community Family constellation/brief historyFamily constellation/brief history POA for decision makingPOA for decision making Dynamics from patient’s perspectiveDynamics from patient’s perspective Family violenceFamily violence Social network/supportSocial network/support Formal support (child welfare, mental health Formal support (child welfare, mental health

agency)agency) History of trauma/lossHistory of trauma/loss Legal historyLegal history Previous assessments (neuropsychological, Previous assessments (neuropsychological,

geriatric,etc.)geriatric,etc.)

Clinical ImpressionsClinical Impressions Patient/family strengthsPatient/family strengths Potential barriers to service deliveryPotential barriers to service delivery Mood/affectMood/affect Insight/judgmentInsight/judgment Risk factors/safety concerns (fall risk, cognition)Risk factors/safety concerns (fall risk, cognition) Coping/adjustment/problemsolving skillsCoping/adjustment/problemsolving skills Premorbid conditions/personality/moodPremorbid conditions/personality/mood Psychological/emotional response to illnessPsychological/emotional response to illness Observed dynamics (patient or family)Observed dynamics (patient or family) Caregiver stressCaregiver stress Patient unmet needs or concernsPatient unmet needs or concerns

Interventions/Interventions/RecommendationsRecommendations

Outcome of intervention thus farOutcome of intervention thus far Plan (what still needs to be done)Plan (what still needs to be done) Desired outcome/expectations: patient, Desired outcome/expectations: patient,

family, teamfamily, team Future planning ( advance directives, POA)Future planning ( advance directives, POA) Potential referralsPotential referrals Team collaboration needed to execute planTeam collaboration needed to execute plan Modality/action takenModality/action taken Recommendations for future careRecommendations for future care Plan to accomplish thesePlan to accomplish these

Summary of InvolvementSummary of Involvement

Used for brief interactions where patient may Used for brief interactions where patient may have been discharged before assessment have been discharged before assessment completedcompleted

If original assessment has been done by a If original assessment has been done by a previous workerprevious worker

Follow up contactsFollow up contacts ALL social work referrals must be ALL social work referrals must be

accompanied by some form of e-chartingaccompanied by some form of e-charting All social work interventions must be All social work interventions must be

proceeded by a Social Work Assessment onlineproceeded by a Social Work Assessment online

Discharge SummaryDischarge Summary

Saving the best for last! Saving the best for last! Educates the team as to the Educates the team as to the

value/importance of the social work role value/importance of the social work role in the casein the case

Ensures future admissions/care providers Ensures future admissions/care providers know what was done/recommended be know what was done/recommended be donedone

Can reduce readmissions if ER and Can reduce readmissions if ER and community workers can access and community workers can access and reaffirm plansreaffirm plans

OutcomeOutcome Increased staff engagement thru Increased staff engagement thru

involvement in processinvolvement in process Information in a consistent electronic Information in a consistent electronic

formatformat Frequent and regular use by teamFrequent and regular use by team Legible, accessible timely reports relevant Legible, accessible timely reports relevant

to achievable treatment and discharge to achievable treatment and discharge plansplans

Improvement in safety of transitions due to Improvement in safety of transitions due to ease of accessease of access

Ability to measure outcomesAbility to measure outcomes

ResultsResults Improvements:Improvements: EfficiencyEfficiency SimplicitySimplicity ClarityClarity Clinical ReflectionClinical Reflection Education showcasing the impact of SW Education showcasing the impact of SW

interventionintervention Social Workers’ perception that teams showed Social Workers’ perception that teams showed

more understanding of patients’ social situations more understanding of patients’ social situations Challenges:Challenges: Initially more time consuming due to learning curve Initially more time consuming due to learning curve Use of Dragon (voice dictation) to increase speedUse of Dragon (voice dictation) to increase speed

0 0

1711

65

56

18

33

0

10

20

30

40

50

60

70

% of respondents

Not at All Not Very Somewhat Very

Efficiency

Efficiency Ratings: Previous vs. New Format

Previous FormatNew Format

0 0

20

8

52

36

28

56

0

10

20

30

40

50

60

% of respondents

Not at All Not Very Somewhat Very

Simplicity

Simplicity Ratings: Previous vs. New Format

Previous FormatNew Format

1 0

15

5

42

13

42

82

0

10

20

3040

50

60

70

8090

% of respondents

Not at All Not Very Somewhat Very

Clarity

Clarity Ratings: Previous vs. New Format

Previous Format

New Format

1 0

22

7

4741

30

52

0

10

20

30

40

50

60

% of respondents

Not at AllUseful

Not VeryUseful

SomewhatUseful

VeryUseful

Usefulness re Clinical Reflection

Clinical Reflection Ratings: Previous vs. New Format

Previous Format

New Format

3 0

16

5

60

34

19

61

0

10

20

30

40

50

60

70

% of respondents

Not at AllUseful

Not VeryUseful

SomewhatUseful

VeryUseful

Showcasing Social Work

Showcasing Social Work Ratings:Previous vs. New Format

Previous FormatNew Format

Staff FeedbackStaff Feedback

““This helps convey to colleagues and underlines This helps convey to colleagues and underlines for ourselves the current situation patients for ourselves the current situation patients are in and the plan of action. It’s a roadmap”are in and the plan of action. It’s a roadmap”

““I like the structure and the fact that everyone I like the structure and the fact that everyone is following the same format. Previously there is following the same format. Previously there could be quite a variety of styles. Sometimes could be quite a variety of styles. Sometimes consults were not necessarily pertinent to the consults were not necessarily pertinent to the problems at hand”problems at hand”

I really like the clear headings, the flow and I really like the clear headings, the flow and especially that it allows us to share what will especially that it allows us to share what will really make a difference for this patient” really make a difference for this patient”

The Way Forward!The Way Forward! Social Workers must:Social Workers must:1.1. Identify ourselves as the profession knowledgeable Identify ourselves as the profession knowledgeable

about the SDOHabout the SDOH2.2. Identify ourselves as the profession who is trained to Identify ourselves as the profession who is trained to

intervene intervene to address the SDOHto address the SDOH3.3. Conduct research to show how our interventions Conduct research to show how our interventions

improve quality of life and produce savings for the improve quality of life and produce savings for the healthcare systemhealthcare system

4.4. Demonstrate through our recording how we have Demonstrate through our recording how we have identified and addressed the SDOH in our casesidentified and addressed the SDOH in our cases

5.5. Advocate individually and through our professional Advocate individually and through our professional organizations for policy changes to address poverty organizations for policy changes to address poverty and all other determinants influencing health and and all other determinants influencing health and health outcomeshealth outcomes

QuestionsQuestions

For more information:For more information:

Karen Nelson, MBA, MSW, RSWKaren Nelson, MBA, MSW, RSWThe Ottawa HospitalThe Ottawa HospitalEmail: knelson@toh.on.caEmail: knelson@toh.on.caLinkedin: Linkedin:

http://ca.linkedin.com/pub/karen-http://ca.linkedin.com/pub/karen-nelson/25/5aa/6a4/nelson/25/5aa/6a4/