10/1/19 Evolution in Healthcare & the Role of the Social Worker: Past, Present, and Future Russell Hilliard, PhD, LCSW, LCAT, MT-BC, CCHRC, CHC, CCTP Senior VP of Key Initiatives Seasons Hospice & Palliative Care Objectives • Identify core ethical principles that remain consistent from past to future within healthcare practice within a multi- cultural context. • Recognize barriers in the present time within the healthcare system that pose threats to patient autonomy and beneficence. • State practical ways to balance ethical principles and healthcare delivery to ensure quality patient care for the future. CMSNE 30 th Annual Conference October 1, 2019 2 Medical Ethics Historical Perspective • The Code of Medical Ethics ( Code ) of the American Medical Association (AMA) is rooted in an understanding of the goals of medicine as a profession, which dates back to the 5th century BCE and the Greek physician Hippocrates, to relieve suffering and promote well-being in a relationship of fidelity with the patient. • The Code is a living document that has evolved as medicine and society have changed over time. CMSNE 30 th Annual Conference October 1, 2019 3 1
10/1/19 Evolution of Medical Ethics • In the 1930s, medicine was a paternalistic profession. • Doctors gave advice, and patients were expected to follow along. Patients did not have many rights. They could even be enrolled in experiments without their knowledge, which was widely condoned. • During WWII, German doctors inflicted horrors on concentration camp victims. • Efforts to right these wrongs, enshrined in the Nuremberg Code, signaled the beginning of modern medical ethics. • In 1972, word of the Tuskegee syphilis experiment in Alabama appeared in the media. • Since 1946, researchers in an observational study of the disease at the US Public Health Service had been enrolling African Americans infected with syphilis under the guise of offering them free healthcare, but they received placebos instead of the standard treatment of penicillin and many died as a result. CMSNE 30 th Annual Conference October 1, 2019 4 Autonomy and Transparency Emerge • It wasn’t until the 1980s that researchers were held to a strict code protecting human subjects in medical research. • Focus on transparency, non-maleficence, justice, and beneficence • 1960s social revolution led to a questioning of authority that spilled over into medical care. • 1969 Kubler-Ross published On Death and Dying calling physicians to task to tell patients of their terminal illness (fidelity) and honor their wishes for end of life care (autonomy). CMSNE 30 th Annual Conference October 1, 2019 5 Concept of Futility Emerges • Also in the 1960s and 1970s, hospitals began to routinely use ventilators, feeding tubes, and other technology to keep patients alive. All this life support, however, rarely helped dying patients to recover and eventually had to be removed. • Deciding what is futile care and when life support should be removed can pit doctors against families, and family members against each other. These battles have been played out in several high-profile legal cases involving patients in permanent comas, memorably Karen Ann Quinlan (1976), Nancy Cruzan (1990), and Terri Schiavo (2005). CMSNE 30 th Annual Conference October 1, 2019 6 2
10/1/19 Role of the Social Worker: Past • Hospital social work pioneer Ida Cannon and visionary physician Richard Cabot faced significant resistance from doctors and nurses in their first efforts at Massachusetts General Hospital. • However, once the positive impact of assisting patients with the consequences of illness became clearer, hospital social work grew rapidly. • Because few of the rampant diseases, such as tuberculosis and syphilis, were curable, social work offered valuable and pragmatic psychosocial assistance. CMSNE 30 th Annual Conference October 1, 2019 7 National SW Conference, 1923 CMSNE 30 th Annual Conference October 1, 2019 8 Medical Social Work Department Purpose Statement, 1910 “Sickness is rarely an isolated fact, but is related to condi- tions under which people live. Thus the aim of the department is to find out the social causes of the trouble, to cooperate with the hospital in remedying the case, to prevent its recurrence and by doing so, safeguard the community, as well as aid the individual. By rendering social aid, for which the hospital itself has no time, the hospital is saved much expense and the individual and community are greatly benefited.” CMSNE 30 th Annual Conference October 1, 2019 9 3
10/1/19 Ecological Perspective CMSNE 30 th Annual Conference October 1, 2019 10 Medical Social Work Evolution • Advocacy (macro level): social workers pioneered public health policies leading to improved access to medical care and raising awareness of vulnerable populations. • Federal Children’s Bureau halved infant mortality rate • 1921 Federal Maternity Act led to Title V of the Social Security Act • 1930s-60s- social workers shaped federal policy in public health • 1960s-70s – social revolutions led to social workers engaged in civil rights, community planning, and urban support • 1980s – shift to managed care healthcare moved social workers from counseling in hospitals to discharge planning CMSNE 30 th Annual Conference October 1, 2019 11 Role of the Social Worker: Past Public Policy Advocacy Medical Social Work Development Patient-Family Care CMSNE 30 th Annual Conference October 1, 2019 12 4
10/1/19 Present Day Influences • Shift from fee-for-service to value-based healthcare reimbursement models. • Places patient outcomes as priority and links reimbursement to outcome measures, including penalties for hospitals and physicians. • HMOs evolved, MCOs and ACOs emerged - so confusing!! • Who is making decisions and ensuring ethical practice? CMSNE 30 th Annual Conference October 1, 2019 13 HMOs MCOs ACOs Made up of insurance Group of medical providers Made up of clinicians, practice companies designed to keep and facilities that provide care groups, and/or hospitals—that patients in network to control to its members at a reduced agree to be responsible for the costs and manage risks. cost, linking health insurance cost and quality outcomes of a with care for a defined patient population. population. No measurable standards No measurable standards Financial incentives and required to account for required to account for payment structures focused efficient, quality control and efficient, quality control and around quality performance care. care. and shared risk. Provide customers with Deliver high quality health Achieve the triple aim of: (1) quality health care services care when it is medically improving the population’s within a network of necessary and to render the health, (2) improving the practitioners or health care services by the most patient and family care providers at a lower cost. appropriate health care experience, and (3) reducing professional. the costs of care. October 1, 2019 CMSNE 30 th Annual Conference 14 Affordable Care Act and Others… • ACA increased access to health insurance for millions of Americans. • Healthcare exchange • Medicaid expansion • ACA and other government regulations created quality outcome measures and incentives and penalties for care of Medicare and Medicaid recipients. • Compliance oversight and quality measures CMSNE 30 th Annual Conference October 1, 2019 15 5
10/1/19 Oh, the internet… CMSNE 30 th Annual Conference October 1, 2019 16 How have you seen your patient population change? CMSNE 30 th Annual Conference October 1, 2019 17 CMSNE 30 th Annual Conference October 1, 2019 18 6
10/1/19 Social Work Policy Issues • Social workers continue to influence public policy in a variety of ways with top 5 areas of current focus being: Public Assistance Programs Social Isolation Food Deserts Student Loan Forgiveness Health Insurance Gap CMSNE 30 th Annual Conference October 1, 2019 19 Social Work Values • These values, as defined by the National Association of Social Workers (NASW) guides ethical practices within the NASW Code of Ethics: CMSNE 30 th Annual Conference October 1, 2019 20 Ethics in the Acute Care Setting Today Autonomy Fidelity Beneficence Social Workers Non- Veracity Maleficence Justice CMSNE 30 th Annual Conference October 1, 2019 21 7
10/1/19 Treating Beyond Futility • According to the Critical Nurses’ Association, moral distress is the leading cause of nurses leaving the profession and of nursing turnover in hospitals. • The leading cause of moral distress for nurses is treating beyond futility. • Futile treatments violate non-maleficence and beneficence but often respect autonomy, but are these informed decisions? • Palliative care and hospice services can be a solution to the conundrum. CMSNE 30 th Annual Conference October 1, 2019 22 Role of the Social Worker: Present Public Policy Advocacy Medical Social Work Practice Patient-Family Care CMSNE 30 th Annual Conference October 1, 2019 23 Healthcare Evolution: Where are we going? • Technological advances will continue to shape healthcare delivery, options of care, and present new ethical challenges. • Earlier detection of diseases (e.g. Alzheimer’s Disease and cancer). • Advancement of treatment and possible curing of disease. • Sharing of information will become more fluid. • Place of care will shift to include increased utilization of telehealth and telemedicine, increasing access to care. CMSNE 30 th Annual Conference October 1, 2019 24 8
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