The Conceptual Underpinnings of Health Social Work

S30 5453-01

August 31, 2011 Sarah Gehlert, PhD

E. Desmond Lee Professor of Racial & Ethnic DisparitiesWashington University in St. Louis

Ida Cannon wrote (1923):

“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” (p. 9).

Question For Today

How, if at all, have the guiding principles of social work in health care changed over the last century?

Parallel Paths of Health Social Work

First hospital social worker Massachusetts General Hospital1905

St. Louis Children’s Hospital Social Work Department1910

Children’s Memorial Hospital (Chicago) Social Work Department1911

The Brown School, Washington University1925

Progression in Focus

Hospital Social Work Medical Social Work Health Social Work

(1905)

(1990s)

Health Social Work Origins

the demographics of the US population during the 19th and early 20th

centuries attitudes about how (and where) the

sick should be treated attitudes toward the role of social and

psychological factors in health

19th & Early 20th Century Demographic Changes

35,000,000 to 40,000,000 Europeans immigrated to the US between 1820 and 1924

European Immigration

Germany 5.5 mi. persons between 1816 and 1914 (for

political & economic reasons)Ireland 2 mi. persons during the 1840s aloneItaly 5 mi. persons between 1820 and 1990

Struggling to Adapt

Ellis Island Immigration Station• opened in 1892• by 1907, processed 1 1 mi. persons/year

Ellis Island

Ellis Island

By 1865:

Over 650,00 persons resided in the southern half of Manhattan Island in NYC alone

most lived in tenements accidents common, sanitation poor,

food supplies in poor condition 1 in 5 infants died in their first year

Immigrant LifeLate 1880s

Adding to the situation….

wide range of health beliefs most did not speak English the vast majority lived in poverty

Attitudes About How (and Where) the Sick Should be Treated

Late 1600s and early 1700s the sick were cared for at home

As the population grew, almshouses were constructed in cities for those without means

1713 -- Philadelphia (Quakers only) 1736 -- New York (now Bellevue Hospital) 1737-- New Orleans

Late 1700s

Sick treated in… …separate parts of almshouse public

hospitals

Hospitals for the poor Hospitals for patients with means

New York Hospital

First Public Hospitals

Pennsylvania Hospital 1751 funds from Benjamin Franklin subscriptions from Provincial General Assembly of Philadelphia

New York Hospital 1791

Massachusetts General Hospital 1821

Pennsylvania Hospital

New York Hospital

Massachusetts General Hospital

Dispensaries

Appeared in the late 1700s Originally to dispense medications to

ambulatory patients Physicians hired to visit patients Philadelphia 1786 (Quakers only) New York 1795 Boston 1796

19th Century Reform

Led by women physicians…..Dr. Elizabeth Blackwell in NYC

1853 - dispensary with home visits 1857 - hospital beds

Dr. Rebecca Cole • 1st “sanitary visitor”

discussed education & employment

NY Infirmary for Women & Children

Sloan Maternity Hospital

Rebecca J. Cole

(1846 – 1922)• the second African-American woman to receive an MD • 1867, Woman's Medical College of Pennsylvania

Elizabeth Blackwell(1821 – 1910)

• first woman to receive an MD from Geneva Medical College in 1849• established the New York Infirmary in 1857

19th Century Reforms

1890Dr. Annie Daniels at NY Infirmary for Women and Children kept records of family size,

income, etc. in the manner of social workers Dr. Henry Dwight Chapin established a program for home visitors to check on conditions - led to 1st foster care home for ill and convalescing children

Hospital Almoners in London

1st hired by the Royal Free Hospital in 1895 to screen patients to see if qualified for free care (only 36% were) sat by the entrance and reviewed applications for admission training became formalized by 1905

10 Years Later in the U.S. (1905)

Garnet Pelton was hired to work atMassachusetts General Hospital (MGH) originally trained as a nurse worked at a settlement house hired and paid out-of-pocket by Dr. Richard Cabot developed tuberculosis after 6 months at MGH and was no longer able to work

Pelton Hired to:

Act as a critic and help to socialize medicine “…criticism from the inside, which I think is the most valuable kind” (Cabot, 1912) Act as translator between the physician and

patient and family Provide information on social and mental

factors

Ida Cannon (1877-1960)

Hired to replace Pelton

Ida Cannon

first trained as a nurse heard Jane Addams and became interested in social work

trained at Simmons College of SW

hired by Dr. Richard Cabot

worked at MGH from 1906 to 1945

Simmons College of Social WorkSimmons College of Social Work

Richard C. Cabot, MD(1868-1939)

Physician & Medical Educator

Richard C. Cabot, MD(1868-1939)

Richard Cabot

active from the 1890s to the 1930s completed medical school in 1892 (Harvard) accepted an appointment to work in the dispensary

at MGH

saw that social and mental problems underlay physical ones ~ purely physical problems were rare

• no medical treatment available • patients mostly immigrant• “running off the clinic”

Cabot Influenced by His Family

Paternal grandfather (1784-1863) made fortune in shipping favored commerce over culture

Parents studied philosophy with Kant father 1821 to 1903 as transcendentalists questioned the

commercialism of their parents and traditional beliefs

Cabot Born at End of Civil War (1868)

nation demoralized shift from idealism to realism conservatism and materialism reemerged the Origin of Species fostered Social

Darwinism growing concern about number of immigrants charity seen as naïve and harmful

Mother Elizabeth Cabot

“It seems to me that very few of us (women) have enough mental occupation. We ought to have some intellectual life apart from the problems of education and housekeeping or even the interests of society”

Elizabeth Cabot, 1869, p. 45

Cabot Shaped Social Work in His Own Image

Radical centrism took two opposing views and help to find a middle

ground greater truth would emerge through a dialogue saw himself as a translatorBelieved in acting versus observing influenced by John Dewey and Jane Addams knowledge gained through problem solving ~

important to learn from failure

Jane Addams (1860-1935)

Hull HouseEst. 1889

..influenced hospitalsocial work

Cabot Fashioned Hospital Social Work in His Own Image

Saw the social work role in health careas: translator and communicator between two

sides with differing perspectives problem solver to find a solution and learn

from errors

Social Workers as Translators

……...of medical information to patients and families in a way they could understand

“There is no one else who explains; there

is not other person in the hospital whose chief business is to explain things”

Cabot, 1912

Social Workers vs. Nurses

Cabot thought that social work could best fulfill this role because nurses had

“lost their claim to be a profession by allowing themselves to become mere implementers of doctor’s orders”

Cabot, 1911

Cabot and Cannon Saw Social Workers as Translators……

…..of medical information about patients and families to physicians

“ So the hospital social worker sees the patient not merely as an isolated, unfortunate person occupying a hospital bed, but as a member belonging to a family or community group that is altered because of his ill health”

Cannon, 1923, pp. 14-15

Cabot and Cannon Saw Social Workers as Problem Solvers…..

Cabot (1923) said that physicians and social workers were natural allies and could learn from one another

physicians could learn about the non-somatic aspects of health

social workers could learn to be more scientific and systematic (being on the moral high ground was not sufficient)

Cabot Paid Social Work Salaries (<13 workers) Out of Pocket Until 1919….

MGH Superintendent did not support hiring Pelton

Cabot demonstrated cost effectiveness ($120/mo. for a baby with GI problems

in 4 times because no money for prescribed treatment) did not want to recreate British almoners

Success at Massachusetts General Hospital

Drew the attention of the AMA and AHA 1911 ~ 44 social service departments in 14

cities (17 in NYC alone) 1912 ~ 1st NY Conference on Hospital Social

Work 1912 ~ first training course 1913 ~ 200 US hospitals had social workers 1918 ~ Amer. Assoc. of Hospital Social

Workers

Ida Cannon’s Role Became Established

named chief of social work at MGH in 1914 hired Harriet Bartlett as first education

director philosophy to accommodate hospital

mechanisms and not be critics or reformers worked with Cabot until he left MGH (1919) Social Service Department made permanent

in 1919

Abraham Flexner Said Social Work Not a Profession

address to National Conference of Charities and Corrections in 1915 social work lacked a written body of knowledge educationally communicable techniques individual responsibility for its members impetus for more formal training

1866-1959A. Flexner

10 Schools of Social Work Offered Formal Coursework in Medical Social Work in 1929

Washington University The University of Chicago The New York School of Social Work Tulane University Indiana University The University of Missouri Simmons College Western Reserve University The Pennsylvania School of Social and Health Work The National Catholic School of Social Work

The American Association of Medical Social Workers (Est. 1918)

Largest of all social work specialty organizations

2,500 persons attended annual meeting in 1954

Larger than current major specialty organization, the Society for Social Work Leadership in Health Care (1,300 members in 2009)

The American Association of Medical Social Workers (Est. 1918)

American Association of Medical Social WorkersNational Association of School Social Workers

Association for the Study of Community OrganizationAmerican Association of Group Social Workers

American Association of Psychiatric Social WorkersSocial Work Research Group

American Association of Social Workers

Seven organizations dissolved when NASW was founded in 1955:

Beyond the Hospital

Social work grew after WWII/Social Security Act

doubled between 1960 and 1970 new settings and arenas new techniques and interventions

Social Security Act 1935

No medical benefits included

Amendments signed by President Johnson on July 30, 1965:

Medicare (Title XVIII)Medicaid (Title XIX)

Medicaid and Medicare

Costs of health care soared 1967 utilization review measures 1972 Peer Standards Review Act …neither was effective

New Attempts at Cost Containment

1973 Nixon’s Health Maintenance Organization (HMO) Act

By 1993, 70% of Americans with insurance enrolled in HMOs

“The social worker becomes an agent of managed care and agrees to serve the public within the corporate guidelines and not necessarily according to the assessed needs of the client” Cornelius, 1994, p. 52

New Attempts at Cost Containment

DRGs* (1983) 500 diagnostic-related groups each with own retrospective

reimbursement rate incentive to keep hospitals efficient

“Under DRGs, patients entered sicker and left sooner” Dobrof, 1991

* Diagnostic and Regulatory Guidelines

Effect on Social Work

social work forces downsized/reconfigured less time to spend with patients HMOs ~ limited ability to act on own

assessment of needs DRGs ~ forced emphasis on discharge

planning hard to perform as outlined by founders e.g.. Cannon’s “to remove those obstacles…

that interfere with successful treatment” (Cannon, 1923, pp. 14-15)

Growth of Medical Social Work Through Time

1905-1930 unprecedented growth almost exclusively in hospitals

1930s competition from psychologists & social scientists

1935-1945 branched out from hospital base

1960-1970 doubled in size

1970 -2010 redefinition & continued branching

Social Work Response

New techniques based on time limits task-centered casework adaptations of practice theories (e.g.,

stress inoculation)New social work practice roles disease managers

Patient Protection and Affordable Care Act (PPACA)

Enacted March 2010 Specifics of of reform unfolding Role of SW as a profession virtually

absent from policy discussions Expands Medicaid coverage to 133% of

poverty in 2014, but states are cutting programs (i.e., more people, but fewer services)

Patient Protection and Affordable Care Act (PPACA)

Uninsured and underinsured need assistance with transitioning to a coverage model (i.e., to be assisted in selecting and participating in traditional insurance or Medicaid coverage and steered toward mainstream providers and services)

Emphasis on prevention and services in the community

Patient Protection and Affordable Care Act (PPACA)

The Congressional Budget Office estimates that 21 million will be uninsured in 2016

Undocumented immigrants will be prohibited from purchasing insurance through the new exchanges & ineligible for Medicaid (~8 million persons, 1/3 of uninsured by 2019)

How Do the Visions of Cannon and Cabot Hold Today?

1. Social worker as translator As salient in 2011 as in 1905 10% of residents born outside US ~ 2000 (up from 5% ~ 1990s) 15% born outside ~ 1890 – 1910 Social workers in best position to ensure that each side is understood by other

Lost in Translation

“ There are by now literally

hundreds of competent studies and the overwhelming majority have found that, overall, African-Americans, Hispanic Americans, and Native Americans receive less care, and less intensive care, than comparable white patients.”

Institute of Medicine, 2003

How Do the Visions of Cannon and Cabot Hold Today?

2. Social work as scientific and systematic advent of research late 1960s and early 1970s demonstrate effectiveness (e.g. evidence-based

practice) new opportunities for impacting health research leaders (e.g. directors at NIH) health care administrators health policy makers and analysts

How Do the Visions of Cannon and Cabot Hold Today?

3. Patient as “…a member belonging to a family or community group that is altered because of his ill health” (Cannon, 1923)

written before chemotherapy, antibiotics, etc. more salient today ~ chronic health conditions disease management

Ida Cannon’s 1923 Statement Holds True Today!

“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” (p. 9).

Conclusion

Social work has been through a lot in 106 years Weathered seemingly insurmountable challenges with grace Its guiding principals remain in force and are as

strong today as in 1905