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N A S W S t a n d a r d s f o r

Social Work Practice

i n H e a l t h C a r e S e t t i n g s

N A T I O N A L A S S O C I A T I O N O F S O C I A L W O R K E R S

N A S W S t a n d a r d s f o r

Social Work Practice

i n H e a l t h C a r e S e t t i n g s

National Association of Social Workers

Darrell P. Wheeler, PhD, ACSW, MPH

President

Angelo McClain, PhD, LICSW

Chief Executive Officer

Health Care Standards Expert Panel

Lisa E. Cox, PhD, LCSW, MSW

Terrie Fritz, LCSW

Virna Little, PsyD, LCSW-R

Shirley Otis-Green, MSW, ACSW, LCSW

Anthony Yamamoto, LCSW

NASW Staff

Stacy Collins, MSW

©2016 National Association of Social Workers. All Rights Reserved.

Contents

5 Introduction

9 Goals

10 Definitions

14 Guiding Principles

16 Standard 1. Ethics and Values

17 Standard 2. Qualifications

18 Standard 3. Knowledge

22 Standard 4. Cultural and Linguistic Competence

24 Standard 5. Screening and Assessment

27 Standard 6. Care Planning and Intervention

29 Standard 7. Advocacy

31 Standard 8. Interdisciplinary and Interorganizational

Collaboration

33 Standard 9. Practice Evaluation and Quality

Improvement

34 Standard 10. Record Keeping and Confidentiality

37 Standard 11. Workload Sustainability

39 Standard 12. Professional Development

40 Standard 13. Supervision and Leadership

42 References

45 Acknowledgments

5

Introduction

Since the early 20th century, social work has been an integral component of the U.S. health care system, and the profession continues to play a leadership role in the psychosocial aspects of health care. Today, social workers are present in settings across the health care continuum, including prevention and public health, primary and acute care, specialty care, rehabilitation, home health, long-term care, and hospice. Professional social workers provide services to individuals and families throughout the life span, addressing the full range of biopsychosocial–spiritual and environmental issues that affect well-being. Social work’s strengths-based, person-in- environment perspective provides the contextual focus necessary for client- and family-centered care and is unique among the health professions.

A hallmark of social work’s commitment to health and well-being is the profession’s continued focus on the issue of health care inequality in the United States. People living in poverty and communities of color continue to experience disproportionately higher rates of acute and chronic illness, due to unequal access to health care services, lack of health insurance coverage, poverty, discrimination, and other social determinants of health. Social workers recognize that reducing health disparities can only be accomplished by addressing the biopsychosocial–spiritual needs of individuals and families, as well as the systemic issues that contribute to poor health outcomes.

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The Evolving U.S. Health Care System

The U.S. health care system is in an era of unprecedented change. In recent years, the nation has witnessed continuing high rates of uninsurance (13 percent of the U.S. population, or 42 million people, were uninsured in 2013 [U.S. Census Bureau, 2014]), inadequate coverage, escalating health care costs, erosion of employer-based health insurance, and increasing demand for health care services as the baby boom generation enters retirement. The Patient Protection and Affordable Care Act (ACA) (2010) was designed to address these issues. The goal of the ACA is to expand access to affordable and comprehensive health coverage, improve patient outcomes, and increase the efficiency and cost-effectiveness of the health care delivery system. The ACA invests heavily in care delivery models that promote coordination of acute and postacute care and greater integration of primary and behavioral health services.

Challenges for the Profession

Their long-standing role in the health system notwithstanding, social workers practicing in health care settings today face significant challenges. Ongoing changes in the financing and delivery of health care and a shortage of social work effectiveness data have contributed to the reduction of social work services in certain health care settings. Increasingly, health care social workers are supervised by individuals without social work degrees, and tasks previously performed by social workers are often assigned to other personnel, including nurses, paraprofessionals, and volunteers, in an effort to reduce costs.

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Opportunities for Social Work in the ACA Era

Despite these challenges, health care social work is poised to experience a resurgence in the ACA era. With its emphasis on the “triple aim”—improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care (Institute for Healthcare Improvement, 2014)—the ACA strengthens social work’s traditional role in health care and offers new opportunities for the profession.

The ACA promotes care delivery models, such as the patient-centered medical home (PCMH) and accountable care organization (ACO), which are designed to improve health outcomes and control health care costs. To succeed, these models will rely on social workers skilled and competent in health care navigation, behavioral and mental health integration, chronic care management, and care coordination, among other skills. The aging of the population will necessitate a need for social workers skilled in transitioning patients between different settings and levels of care and managing complex discharges.

The anticipated influx of patients into the health care system resulting from the ACA insurance coverage expansion will increase the need for social workers who are educated and trained in working with diverse populations and with clients who have challenging physical, behavioral, and mental health needs. Greater emphasis on community-based care will require social workers skilled in reducing nonmedical barriers to health care access. As important, expanded social work involvement

8

in these roles and settings presents an opportunity to advance the evidence base for the profession.

Prevention and public health, traditional social work roles, have gained renewed importance under the ACA. With its ecological viewpoint, the social work profession is well-positioned to take a leadership role in new ACA prevention initiatives, including workplace wellness, home visiting, and smoking cessation programs. Social workers are also well positioned to participate in macro-level prevention efforts, such as policy change to reduce obesity, which can improve population outcomes more efficiently than individual-actions at the clinical care level. Furthermore, new research fields, particularly patient-centered outcomes research and community-based participatory research, offer an opportunity for social workers to contribute to the prevention and public health research base.

Purpose of the Standards for Social Work Practice in Health Care Settings

These standards articulate the necessary knowledge and skills health care social workers should possess to deliver competent and ethical services in today’s health care environment; provide benchmarks for quality social work practice for use by health care employers; and assist policymakers, other health professionals, and the public in understanding the role of professional social workers in health care settings. These standards are intended to guide social work practice and may be applied differently, as appropriate, to different health care settings.

9

Goals

The specific goals of the standards are to

� Ensure that social work practice in health care settings is guided by the NASW Code of Ethics (NASW, 2008)

� Enhance the quality of social work services provided to clients and families in health care settings

� Advocate for clients’ rights to self- determination, confidentiality, access to supportive services and resources, and appropriate inclusion in decision making that affects their health and well-being

� Encourage social work participation in the development, refinement, and integration of best practices in health care and health care social work

� Promote social work participation in systemwide quality improvement and research efforts within health care organizations

� Provide a basis for the development of continuing education materials and programs related to social work in health care settings

� Promote social work participation in the development and refinement of public policy at the local, state, federal, and tribal levels to support the well-being of clients, families, and communities served by the rapidly evolving U.S. health care system

� Inform policymakers, employers, and the public about the essential role of social workers across the health care continuum.

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Definitions

Social Worker

Within the United States, a social worker is an individual who possesses a baccalaureate or master’s degree in social work from a school or program accredited by the Council on Social Work Education. Although all 50 states and the District of Columbia license or certify social workers, licensure and certification laws vary by state. Each social worker should be licensed or certified, as applicable and required, at the level appropriate to her or his scope of practice in the practitioner’s jurisdiction(s).

Client

Client refers to the “individual, group, family, or community that seeks or is provided with professional services” (Barker, 2013, p. 73). For purposes of these standards, the term “client” refers to an individual. The term “patient” is more commonly used by social workers employed in health care settings.

Biopsychosocial–Spiritual Perspective

A biopsychosocial–spiritual perspective recognizes the importance of whole person care and takes into account a client’s physical or medical condition; emotional or psychological state; socioeconomic, sociocultural, and sociopolitical status; and spiritual needs and concerns.

Bioethics

Bioethics is “the analysis and study of legal, moral, social, and ethical considerations involving the biological and medical sciences” (Barker, 2013, p. 41).

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Case Management

Case management is a collaborative process to plan, seek, advocate for, and monitor services, resources, and supports on behalf of a client. Case management enables a health care social worker to serve clients who may require the services of various health care providers and facilities, community-based organizations, social services agencies, and other programs. Case management limits problems arising from fragmentation of services, staff turnover, and inadequate coordination among providers. “Care coordination,” “care management,” and “patient navigation” are sometimes used interchangeably with “case management” (Barker, 2013).

Cultural Competence

Cultural competence is “the process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors [including, but not limited to, sexual orientation; gender, gender expression, and gender identity; and family status] in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each” (NASW, 2007, pp. 12–13).

Health Disparities

Health disparities are preventable differences in the incidence, prevalence, mortality, and disease burden that are closely linked with social, economic, and environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their race or ethnicity; religion;

12

socioeconomic status; sexual orientation; gender, gender expression, and gender identity; age; mental health; cognitive, sensory, or physical disability; geographic location; or other characteristics historically linked to discrimination or exclusion (Centers for Disease Control and Prevention, n.d.).

Social Determinants of Health

The social determinants of health are factors that affect a wide range of health and quality- of-life outcomes and are responsible for most health disparities. These factors include income, housing, education, employment, and access to health services, among others. Social determinants of health are shaped by the distribution of money, power, and resources (Centers for Disease Control and Prevention, n.d.).

National Standards for Culturally and

Linguistically Appropriate Services in Health

Care (CLAS Standards)

The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the CLAS Standards), developed by the U.S. Department of Health and Human Services (HHS), are intended to advance health equity, improve quality, and help eliminate health care disparities by providing guidance to health care organizations for implementing culturally and linguistically appropriate services (HHS, Office of Minority Health, 2013).

Patient Protection and Affordable Care Act

(ACA) (2010)

The ACA is a broad-based federal law that seeks to reform the U.S. health care delivery system by expanding health insurance

13

coverage, enhancing quality of care, improving health outcomes, regulating the health insurance industry, and reducing health care spending.

Patient-Centered Medical Home (PCMH)

The PCMH is a health care delivery model accountable for meeting the large majority of a person’s physical and mental health care needs, including primary, acute, and chronic care. Within a PCMH, an individual has an ongoing relationship with a primary care provider who directs and coordinates his or her care across all elements of the broader health care system, including physician specialty services, hospitals, home health care, and community services and supports (Agency for Healthcare Research and Quality, n.d.-a).

Integrated Care

Integrated care is a health care delivery approach in which primary care, mental health, and behavioral health care services are systematically coordinated and available in one location (Substance Abuse and Mental Health Services Administration & HHS, Health Resources and Services Administration, Center for Integrated Health Solutions, n.d.).

Chronic Care Model

The chronic care model is a widely used approach to chronic illness management that adapts the acute care delivery system to more appropriately meet the needs of individuals with chronic illness (Agency for Healthcare Research and Quality, n.d.-b).

Accountable Care Organization (ACO)

An ACO is a group of physicians, hospitals, and other health care providers who share

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responsibility for providing coordinated care to patients. Within an ACO, providers are financially incentivized for meeting specific quality and utilization benchmarks for a defined patient population (Centers for Medicare & Medicaid Services, n.d.).

Evidence-Informed Practice

Evidence-informed practice is practice based on the best available research, practice expertise, and available resources.

Guiding Principles

The NASW Standards for Social Work Practice in Health Care Settings reflect the following guiding principles of the social work profession:

� Self-determination: Social workers respect and promote the right of clients to self- determination and assist clients in their efforts to identify and clarify their goals.

� Cultural competency and affirmation of the dignity and worth of all people: Social workers treat each person in a caring and respectful fashion. With skills in cultural awareness and cultural competence, social workers affirm the worth and dignity of people of all cultures.

� Person-in-environment framework: Social workers understand that each individual experiences a mutually influential relationship with her or his physical and social environment and cannot be understood outside of that context. This ecological perspective recognizes that systemic injustice and oppression underlie many challenges faced by clients.

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� Strengths perspective: Rather than focus on pathology, social workers elicit, support, and build on the resilience and potential for growth and development inherent in each individual.

� Primacy of the client–social worker relationship: The therapeutic relationship between the social worker and the client is integral to helping the client achieve her or his goals.

� Social justice: At all levels, from local to global, social workers promote and advocate for social, economic, political, and cultural values and institutions that are compatible with the realization of social justice.

� Importance of social work research: Social workers promote the value of research as a means of improving the well-being of individuals, families, and society; strengthening the current workforce; and maintaining the social work profession’s role in health care settings.

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Standards

Standard 1. Ethics and Values

Social workers practicing in health care settings shall adhere to and promote the ethics and values of the social work profession, using the NASW Code of Ethics as a guide to ethical decision making (NASW, 2015a).

Interpretation

The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs, with special attention to the needs of people and communities who are vulnerable, oppressed, or living in poverty. Social workers have an ethical obligation to address the health care needs of these groups and advocate for change to ensure access to quality care.

The profession’s mission is rooted in core values that have been embraced by social workers throughout the profession’s history and highlight social work’s distinct purpose and perspective. These values—service, social justice, dignity and worth of the person, importance of human relationships, compassion, integrity and competence—constitute the foundation of social work and underlie the practice of social work in health care settings.

The NASW Code of Ethics establishes the ethical responsibilities of all social workers with respect to their own practice, clients, colleagues, employees and employing organizations, the social work profession, and society. Acceptance of these responsibilities— which include upholding a client’s right to privacy and confidentiality and promoting

17

client self-determination—fosters competent social work practice in health care settings.

In a health care system characterized by technological advancement and rapid change in care delivery and financing of health care services, ethical dilemmas among and between clients, families, health care professionals, and organizations are potentially numerous and complex. The NASW Code of Ethics and prevailing clinical bioethics provide a foundation for social workers to manage such dilemmas. Health care social workers have the responsibility to know and comply with local, state, federal, and tribal legislation, regulations, and policies, addressing topics such as guardianship; parental rights; advance directives; and reporting requirements for abuse, neglect, exploitation, suicide, and threat of harm to others.

When an ethical dilemma or conflict occurs, the health care social worker is expected to employ available mechanisms, including social work supervision, peer review, institutional ethics committees, and external consultation, to resolve the dilemma.

Standard 2. Qualifications

Social workers practicing in health care settings shall possess a baccalaureate or master’s degree in social work from a school or program accredited by the Council on Social Work Education, shall comply with the licensing and certification requirements of the state(s) or jurisdiction(s) in which she or he practices, and shall possess the skills and professional experience necessary to practice social work in health care settings.

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Interpretation

Social work degree programs provide the fundamental education and training required for all social work practice specialties. As an area of specialization within the social work profession, health care social work requires a distinct skill set and knowledge base, as outlined in these standards. Ideally, prospective health care social workers should have prior health care–related educational or employment experience. At a minimum, it is a health care social worker’s responsibility to

� Acquire and maintain social work licensure or certification, as available, for the social worker’s educational level and professional experience

� Abide by a defined scope of practice, as required by state law or regulation

� Adhere to supervision requirements � Pursue ongoing professional development

activities, to acquire the competence necessary to perform job responsibilities.

A health care social worker whose responsibilities include the diagnosis of mental and behavioral health conditions and/or the provision of psychotherapy must have a master’s degree in social work and should either be licensed at the clinical level or, if the licensing jurisdiction allows, perform clinical tasks under supervision.

Standard 3. Knowledge

Social workers practicing in health care settings shall acquire and maintain a working knowledge of current theory and evidence- informed practice, and shall use such information to ensure the quality of social work practice.

19

Interpretation

As health care professionals, social workers require specialized knowledge and skills. This knowledge and skill base can be obtained through multiple approaches, including coursework and field practice in a social work degree program, specialty practice credentials earned after graduation, health care–related employment experience, and ongoing continuing education. Developing a knowledge and skill base is a cumulative process that requires a commitment to career-long learning.

Given the growing complexity of services delivery systems and client needs, even experienced health care social workers may encounter situations requiring knowledge and skills beyond the scope of their usual practice setting. In such situations, the health care social worker seeks supervision, consultation, and continuing professional development, as described elsewhere in these standards, to ensure she or he has both the requisite knowledge of health care delivery systems and the skills to serve clients effectively. In addition, the social worker may need to collaborate with health care and other services providers on behalf of a client, or refer a client to other social workers whose expertise is more suitable to the client’s needs and circumstances.

Knowledge and skills that are essential to social work practice in health care settings include, but are not limited to, the following areas:

Physical and mental/behavioral health

� The interplay between the physiological elements of acute, chronic, and life-limiting illness and biopsychosocial–spiritual health and well-being

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� Concepts and theories associated with life- span development, neurobiology, and behavioral change

� Grief, loss, and bereavement � Depression, anxiety, and other mental

health conditions � Addiction and other behavioral health

conditions � Sexual health � Concerns related to sexual orientation, gender

identity and expression, and gender roles � Basic medical terminology � Knowledge of common health conditions � Counseling and behavioral change

intervention

Health care delivery system issues

� The health care continuum � The unique needs of marginalized,

oppressed, and diverse populations � Health disparities and the social

determinants of health � Evidence-informed approaches to health

care, including the PCMH, integrated primary and behavioral health care, ACOs, and the chronic care model

� New health care policies and delivery system changes resulting from the ACA

� Basics of health insurance coverage, including Medicare, Medicaid, the Children’s Health Insurance Program, and commercial insurance plans

� Health care system trends, including ongoing health care infrastructure changes

� Accreditation and regulatory standards governing health care settings

� Thorough knowledge of community resources � Micro-, mezzo-, and macro-level preventive

health care

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Roles and responsibilities of social workers in

health care settings

� Understanding of common ethical and legal issues in social work practice in health care settings

� Biopsychosocial–spiritual assessment � Use of the strengths perspective � Client and family engagement in all aspects

of social work intervention � Case management/care management/care

coordination/health care navigation � Discharge and transition planning � Client concordance with and adherence to

the plan of care � Advance care planning � Palliative care, including pain and symptom

management � Hospice and end-of-life care � Identification of child/elder/vulnerable adult

abuse, trauma, neglect, and exploitation � Crisis intervention � Facilitation of benefits and resource

acquisition to assist clients and families, including an understanding of related policies, eligibility requirements, and financial and legal issues

� Advocacy with other members of the interdisciplinary team and within the health care institution to promote clients’ and families’ decision making and quality of life

� Client, family, interdisciplinary, and community education

� Family systems issues, including the impact of health care concerns, illness, and disease on family relationships; life cycles; and caregiving roles and support needs

Research and evaluation

� Research and evaluation methodology

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� Social work outcome/practice evaluation approaches

� Opportunities for social work participation in institutional quality improvement programs and research projects

� Client and family education regarding opportunities for clinical trial participation

� Ability to analyze research results and incorporate findings into practice, organizational quality improvement initiatives, and advancement of the social work profession

Standard 4. Cultural and Linguistic Competence

Social workers practicing in health care settings shall provide and facilitate access to culturally and linguistically appropriate services, consistent with the NASW Standards and Indicators for Cultural Competence in Social Work Practice (NASW, 2015b).

Interpretation

The increasing racial, ethnic, and linguistic diversity of the United States requires health care social workers to strive continuously for cultural competence. Recognition and affirmation of cultural and linguistic diversity are critical to both therapeutic alliances with clients and cooperative working relationships with colleagues. Given the many facets of culture, every interaction between a health care social worker and a client is potentially a cross-cultural exchange, as two individuals are unlikely to be identical in every aspect of cultural identity.

The practice of health care social work requires an understanding of the broad scope of diversity in the United States. Client diversity

23

is expressed in many ways, including race, ethnicity, socioeconomic class, sexual orientation; gender, gender expression, and gender identity; religion, age, health and family status; cognitive, physical, or psychiatric ability; and sensory differences, preferred language, immigration status, degree of acculturation, level of formal education, and literacy, among others. Health care social workers must also recognize that cultural self- awareness is an integral component of cultural competence. Such awareness entails understanding how one’s own cultural values, beliefs, biases, experiences, and perceptions affect interactions with clients and colleagues.

Health care social workers must acquire a cross-cultural knowledge base to provide effective, culturally competent practice. In particular, social workers must develop and maintain an understanding of the history, traditions, rituals, values, family systems, and communication patterns of major client groups served, as well as an understanding of the influence of culture on help-seeking behaviors and perceptions of health, illness, health care treatments, disability, caregiving roles, and death and dying among client/patient groups served. Social workers should also recognize how societal oppression and privilege related to cultural and linguistic diversity (such as racism, sexism, homophobia, ageism, or xenophobia) affect clients’ biopsychosocial– spiritual well-being, access to and use of supports and services, and health outcomes.

Health care social workers should advocate for organizational practices and policies that promote and support …

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