Evolution in Healthcare & the Role of the Social Worker: Past, - - PDF document

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Evolution in Healthcare & the Role

• f 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.

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Medical Ethics Historical Perspective

• The Code of Medical Ethics (Code) of the American Medical

Association (AMA) is rooted in an understanding of the goals

• f 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.

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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.

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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).

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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).

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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.

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National SW Conference, 1923

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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.”

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Ecological Perspective

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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

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Role of the Social Worker: Past

Public Policy Advocacy Medical Social Work Development Patient-Family Care October 1, 2019 CMSNE 30th Annual Conference 12

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Present Day Influences

• Shift from fee-for-service to value-based healthcare

reimbursement models.

• Places patient outcomes as priority and links reimbursement to
• utcome measures, including penalties for hospitals and

physicians.

• HMOs evolved, MCOs and ACOs emerged - so confusing!!
• Who is making decisions and ensuring ethical practice?

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HMOs MCOs ACOs Made up of insurance companies designed to keep patients in network to control costs and manage risks. Group of medical providers and facilities that provide care to its members at a reduced cost, linking health insurance with care for a defined population. Made up of clinicians, practice groups, and/or hospitals—that agree to be responsible for the cost and quality outcomes of a patient population. No measurable standards required to account for efficient, quality control and care. No measurable standards required to account for efficient, quality control and care. Financial incentives and payment structures focused around quality performance and shared risk. Provide customers with quality health care services within a network of practitioners or health care providers at a lower cost. Deliver high quality health care when it is medically necessary and to render the services by the most appropriate health care professional. Achieve the triple aim of: (1) improving the population’s health, (2) improving the patient and family care experience, and (3) reducing the costs of care.

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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
• utcome measures and incentives and penalties for care of

Medicare and Medicaid recipients.

• Compliance oversight and quality measures

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Oh, the internet…

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How have you seen your patient population change?

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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

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Social Work Values

• These values, as defined by the National Association of Social Workers

(NASW) guides ethical practices within the NASW Code of Ethics:

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Ethics in the Acute Care Setting Today

Social Workers

October 1, 2019 CMSNE 30th Annual Conference 21 Autonomy Beneficence Non- Maleficence Justice Veracity Fidelity

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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
• ften respect autonomy, but are these informed decisions?
• Palliative care and hospice services can be a solution to the

conundrum.

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Role of the Social Worker: Present

October 1, 2019 CMSNE 30th Annual Conference 23 Public Policy Advocacy Medical Social Work Practice Patient-Family Care

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.

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Treating Beyond Futility

• With advances in medicine and more options becoming

available, will we see an increase in treating beyond futility?

• OR
• With the population growth, struggles for supply to meet

demand with healthcare professionals, and increasing costs will futile treatments decrease?

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Population Changes

• In 2011, the Baby Boomers began turning 65 and all of them

will be age 65+ by 2029.

• Increase aging population needing more health services
• Advances in medicine turn terminal illnesses into chronic illnesses,

leading to longer but sometimes sicker life spans

• Baby Boomers pose unique cultural needs in medical care
• The nation’s population will rise to 438 million in 2050, from

296 million in 2005, and fully 82% of the growth during this period will be due to immigrants arriving from 2005 to 2050 and their descendants.

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Ethnic Mix Changes Lead to Cultural Changes in Healthcare

• By 2050, the nation’s racial and ethnic mix will look quite

different than it does now.

• Non-Hispanic whites, who made up 67% of the population in

2005, will be 47% in 2050.

• Hispanics will rise from 14% of the population in 2005 to 29%

in 2050.

• Blacks were 13% of the population in 2005 and will be roughly

the same proportion in 2050.

• Asians, who were 5% of the population in 2005, will be 9% in

2050.

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Healthcare Costs will Continue to Rise

• Healthcare spending increased by $933.5 billion between

1996 and 2013.

• Increases in US population size were associated with a 23.1% or a

$269.5 billion spending increase;

• Aging of the population was connected to an 11.6% or a $135.7

billion spending increase;

• Changes in disease prevalence or incidence were related to

spending reductions of 2.4% or a $28.2 billion decrease;

• Changes in service price and intensity were associated with a 50%
• r a $583.5 billion spending increase.

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Healthcare Workers Will Change

• Women comprise 46 percent of all physicians in training and nearly half of all

medical students.

• Based on these statistics, we can assume more women may enter the medical

profession in the coming years.

• African-American women are more likely to become doctors than their male

counterparts.

• While African-Americans comprise only four percent of the physician

workforce, 55 percent of the African American physician workforce is female.

• This shift in demographics to include more women in healthcare supports

diversity in the industry and represents overall population diversity.

• Workforce expectations will change as younger generations embrace work-life

balance, equity in pay, and employment satisfaction.

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Increase Utilization of Support Services

• As the nursing profession struggles to keep up with the

demands in filling open positions, medical providers will likely rely more heavily on ancillary support services.

• More utilization of Nurse Practitioners, Physicians’

Assistants, and Social Workers.

• EMS workers are likely to have expanded training and

responsibilities.

• IT professionals will increasingly be in demand.

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Role of the Social Worker: Future

October 1, 2019 CMSNE 30th Annual Conference 32 Public Policy Advocacy Medical Social Work Practice Patient-Family Care

Social Workers Will Balance Values, Ethics, and Evolutionary Changes

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References

• Jecker, N.S. (2016). Medical
• Futility. https://depts.washington.edu/bioethx/topics/futil.html retrieved 06.09.19
• Jonsen, A.R., et al. (2010). Clinical Ethics. 7th ed. McGraw-Hill.
• National Council of State Boards of Nursing (2014). A Nurse’s Guide to Professional
• Boundaries. Chicago, IL www.ncsbn.org
• Ramirez, A.G., et al. (2016). SaludToday: Curating Latino health information for a

new generation. Journal of Communication in Healthcare, 9(1), 60-69.

• Talley, J. (2016). Moving from the margins: the role of narrative and metaphor in

health literacy. Journal of Communication in Healthcare, 9(2), 109-19.

• Van Dongen, J.J., et al (2016). Successful participation of patients in interprofessional team

meetings: A qualitative study.

• Vaughn, L. (2016). Bioethics: Principles, Issues, and Cases. 3r Ed. Oxford University
• Press. Health Expectations, Oct. 17 ahead of print.
• Welfel, E. (2015). Ethics in Counseling & Psychotherapy, 6th Ed. Cengage Learning.

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Questions?

Want to email me a question? I can be reached at: rhilliard@seasons.org

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