Social Work in Health Care Family Practice Social Work

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Family Practice Social Work a

Gilbert J. Greene PhD ACSW , Katherine A. Kruse MSW, a

ACSW & Ruth J. Arthurs MSW

a

a

Affiliated with School of Soclal Work. University of Iowa. lowd City. Iowa 52242 Published online: 26 Oct 2008.

To cite this article: Gilbert J. Greene PhD ACSW , Katherine A. Kruse MSW, ACSW & Ruth J. Arthurs MSW (1985) Family Practice Social Work, Social Work in Health Care, 10:3, 53-73 To link to this article: http://dx.doi.org/10.1300/J010v10n03_04

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Family Practice Social Work:

A New Area of Specialization

Downloaded by [Ohio State University Libraries] at 14:39 22 September 2014

G i l b e r t G r e e n e , PhD, A C S W K a t h e r i n e A . Kruse, MSW, ACSW R u t h J. A r t h u r s , MSW

ABSTRACT. Many physical problems presented to family physi-

cians by their paticnts often involve psychosocial variables with stress being a major one. Though family rncdicine advocates a biopsychosocial focus, one that is compatible with social work, the psychosocial aspects of health are often ignored. Thc involvement of social workers in the private practices of family physicians to deal with such problems is discussed in this paper as a new area of specialization. Issues such as the medicine-social work gap and the financing of social work services in private family medical practice are also addressed. It is concluded that this should be considered a new area of specialization. However, social workers must take thc initiative in its development.

Social work has been involved in the health care field since its beginnings in 1905 at Boston's Massachusetts General Dispensary. Although medical social work initially developed in primary health care settings, its predominate arena of practice has been within the hospital. With the move toward reducing health care costs in the United States in recent years, preventive and primary care providing comprehensive services has been receiving greater emphasis (Coulton, 1978). Concurrent with this development has been the development of family medicine as a new specialty in medical care (Conn, Rakel, and Johnson, 1973). T h e comprehensive treatment orientation of family medicine is compatible with social work's long held emphasis on the biopsychosocial needs of people. Social work and family medicine recognize the interconnectedness of the physical and psychosocial aspects of human well-being. This interconnectedness suggests that Gilbert Greene and Kathcrinc A. Krusc arc w ~ l hthe School of Soclal Work. University of Iowa. lowd City. Iowa 52242. Social Work in Hcnlth Carc. VoI. lO(3). Spring 1985 0 1985 by Thc Haworth Prcss. Inc. All rights reserved.


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family medicine could be at the confluence of health and mental health with social work as an active partner. People who have problems coping with stressful changes in their lives frequently develop somatic and psychosomatic complaints and consequently seek the attention of family physicians (Tessler, Mechanic and Dimond, 1976). There is evidence that 30 to 36 percent of all patients treated by family physicians have psychosocial problems that should receive attention; however, referrals or counseling sessions by the physician to deal with such problems are minimal (Cassata and Kirkman-Liff, 1981). Cassata and Kirkman-Liff indicate that the ignoring of psychosocial factors in family practice may be due to a lack of time andlor training of physicians to deal with such problems. Social workers, on the other hand, put primary emphasis on the biopsychosocial well-being of people and, thus have the necessary orientation, time and training. Usc of social workers in private practice family medicine is supported by Compton (1983). She states that health care today focuses primarily on illnesses related to individuals' life-styles and the consequent need of such people to comply with medical regimens which may interfere with their usual habits of living. The problems of infections and communicable disease and accidents are no longer the only major focus in health care. Patients who are having problems related to transitions in life-style are more likely to receive the bulk of their treatment in primary health carc settings rather than in a hospital. Compton believes that social workers can offer much to such people. This suggests that social workers working with family physicians in their private medical practices is a possible area of specialization. There are instances in which social workers have been and still arc affiliated with private medical practices (Barkan, 1973; Baumann and Browder. 1983; Forman, 1976; McGreehan, 1977; Blanchard and Kurtz, 1978; Burbridge, Spasoff and Steel, 1982). According to Gordon (1983), "Specializations in social work may continue to form wherever thcre are enough social workers with common concerns who wish to get together and exchange views (renal social workers, perinatal workers, hospital social service administrators, and so on)." Gordon states further, in referring to a report on specialization in social work (National Association of Social Workers and Council on Social Work Education, 1978), that the criteria for specialization include: (1) "a critical number . . . of people in a dysfunctional relationship to some part of their environment"; (2) the existence of a "body of knowledge applicable to successful intervcntion to relieve the dysfunctional relationships and the complexity of the dysfunction"; and (3)

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"knowledge of the intervention must be sufficiently great to require a mastery that calls for specialized training over and above the basic knowledge to practice social work in general" (p. 979). The purpose of this paper is to discuss the involvement of social workers in the private medical practices of family physicians. The criteria for a specialization in social work will serve as a backdrop for the discussion. A rationale for such involvement will first be presented followed by a discussion of the social work orientation and skills unique to this setting. Last will be a discussion of some key issues facing social workers in this area of specialization.

SOCIAL WORK IN FAMILY MEDICINE: A RATIONALE Diseases associated with stress, such as heart attacks and strokes, are the leading causes of death in the United States. Stress can also contribute to the abuse of substances such as alcohol, illegal and prescription drugs, and tobacco which have consequent medical problems. In addition, stress is related to other major medical problems such as hypertension, headaches, back pain, peptic and duodenal ulcers, colitis, asthma, and mental and emotional problems. In fact, it has been estimated that 50-85 percent of all illnesses are stress-aided or stress-induced (Danskin and Crow, 1981). People with such problems will often initially go to the family physician even when there is no organic involvement requiring the highly technical skills of a physician. For instance, it has been found that 60 percent of all visits to physicians' offices involve psychosomatic or functional problems (Noble, 1976). Such a finding is compatible with the position of Tessler, Mechanic, and Dimond who state that "persons who are distressed, or who otherwise face life problems with which they have difficulty in coping, deal with such situations in part by seeking medical care" (1976, p. 354). Thus, medical practitioners are serving as latent social service providers though they do not have the time or training to deal with many of these problems. Since the goals and policies of family practice organizations emphasize comprehensive care and evaluation of the total health needs of the entire family regardless of sex, age, or type of problem, i.e., biological, behavioral, or social, the family practitioner will tend to have long term contacts with family members at all life stages (Conn, Rafel and Johnson, 1973; Rakel, 1977). Although American society is quite transient, family physicians may be the one "constant" and thus have a special opportunity to prevent,


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recognize and treat mental health and psychosocial problems (Huntington, 1981a, p. 205). Psychosocial problcms may accompany disease or thcy may be the primary problem, frequently expressed directly through vague or generalized complaints of i l l health or lack of physical well being (Mechanic, 1980). Somatization, which is the articulation of emotional problems and psychosocia1 stress by means of physical symptomatology, may be thc only legitimate and culturally sanctioned means of seeking and receiving "care" from the medical system and the family and social networks. Consequently, a shift from a biomedical model, which focuses on identifying and treating a disease process, to a biopsychosocial model where psychosocial and cultural dimensions of sickness are viewed as legitimate hcalth care problems has been advocated (Rosen, Kleinrnan and Katon, 1982; Smilkstein, 1982; Engel, 1983). This position is further supported by research that has found illness onset to bc frequently associated with the occurrence of stressful events which occur during the life stagcs of all families (Rahe and Arthur. 1978; Holmes and Rahe, 1967; Rabkin and Strueng, 1976; Tessler, Mechanic and Dirnond, 1976). Family physicians today are often overloaded with expectations and responsibilities. They are expected to keep abreast of new medical and technological developments, to be technically proficient and humanely responsive, to be familiar with a wide variety of areas such as alcoholism, human sexuality, psychosocial problems, child and adolescent development, management of chronic diseases, and the appropriate handling of death and dying. Physicians are also expected to participate in peer review, informed consent. patient education with consideration of cultural differences, and pursue a cost-effective practice while maintaining a broad perspective of the wholc person within a family and social contact (Mechanic, 1980). Such expectations are enormous and time consuming. In spite of the goals and intentions of family physicians, in actual practice the individual, not thc family, is the primary focus (Fosson, Elam, and Broaddus, 1982) and physical problems the primary interest. Although physicians are consulted for a wide rangc of psychosocial problems and may have some training in behavioral medicine, they do very few psychosocial assessmcnts or interventions and make few referrals despite the high lcvel of need or availability of social service agencies in their community (Harwin, Cooper, Eastwood, and Goldberg, 1970; Corney and Bowen, 1980; Cassata and Kirkman-Liff, 1981; Fosson, Elam, and Broaddus, 1982). In one study, for cxample, the involvement in mental health activities of 199 family physicians in private practice was


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assessed. These physicians estimated 30-36 percent of their patients had behavioral or psychosocial problems, yet referrals or counseling sessions occurred in only two to four percent of the cases despite the widespread availability of mental health services (Cassata and Kirkman-Liff, 1981). Since physicians focus on physical problems, often patients with psychosocial problems continually seek help by presenting physical problems to their family physician. For instance, it has been found that patients with mental illnesses utilized twice as much nonpsychiatric medical care as patients with only physical illnesses (Hankin and Oktay, 1979). In addition, in one family practice, patients with emotional and psychosomatic illnesses required 28 percent of the physician's services and 48 percent of the physician's time (Collyer, 1979). This finding is similar to the findings of a prospective one year study in which it was found that the distress level of patients at the beginning of the year was a statistically significant predictor of physician utilization in the following twelve months (Tessler, Mechanic, and Dimond, 1976). Many patients who express their distress through physical complaints are often resistant to the explicit psychosocial diagnosis and resist referrals to mental health agencies. Physicians are also reluctant to refer patients, perhaps because they do not want to risk alienating or losing their patients. Given this situation, one logical and responsible option would be to provide psychosocial services within the family health setting by someone other than the overworked physician; such a person could be a social worker (Mechanic, 1980). Inclusion of a social worker in the family practice setting is one way of offering comprehensive care, involving the whole patient and family in a community context, without the physician's attempting to meet all the needs. The need for the development of family practice social work is further supported by the findings of Cassata and Kirkman-Liff (1981) that the six most common psychosocial problems encountered by family physicians are: depression, anxiety, obesity, marital discord, alcohol abuse, and sexual problems. These are problems that clearly come within the realm of social work expertise since they are commonly presented to, and treated by, social workers in other practice settings. It is suggested by Corney (1980) that a wider section of the community will be served with the inclusion of a social worker in a family health setting compared to clients who are served by social service agencies. This contention is supported by a study of referrals to hospital social workers in which it was found that patients are more likely to accept an in-house referral to a social worker on the health team because there is no overt stigma of social welfare


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agencies and because the social services are easily accessible in the familiar medical environment (Goldberg and Neill, 1972). In a survey of patients referred to the social worker within the general practice setting, 50 percent would not have gone to a social worker outside the general practice setting to a social service agency. One reason for this is that there is less stigma attached to receiving social work services in such a setting as compared to that which is usually associated with more typical welfare settings (Huntington, 1981b). The inclusion of a social worker in this type of health care setting has been shown to improve the psychosocial functioning of patients. A study in England evaluated outcomes of chronic neurotic patients in general medical practice settings. Comparisons were made on certain psychiatric and social functioning dimensions between one group of patients seen at a medical clinic with a social worker attached to it and patients seen at other medical clinics without a social worker. The results showed that all patients, regardless of where they were treated, significantly improved in psychiatric functioning while only those patients treated at the clinic with the social worker working collaboratively with the physicians also significantly improved in social functioning (Cooper, Harwin, Depla, and Shepard, 1975). That social workers can effectively help clients deal with stress has been noted by one physician to be a significant time saver for the physician as well as a needed service for patients (Williams, 1979). Personal and clinical support to the physician is another benefit of a social worker's inclusion on the family health team. In discussing the reluctance of other physicians to discuss his work and his resulting isolation, one physician found the support and feedback of the social worker to be the most valuable aspect of their collaboration (Wilson, 1976). The social worker can complement the physical assessment with a psychosocial assessment and collaborate with the physician in a more comprehensive treatment plan thus offering more continuity of care to the patients. This demonstrates to the patients a comprehensive interest in them and strengthens the doctor-patient relationship (Watson, 1972). Other possible benefits of including a social worker on the family health center team are: (1) more frequent and easier interchanges between the family physician and social service agencies in the community (Goldberg and Neill, 1972); (2) enhancement of public relations and marketing for the health care facility through services the social worker provides such as preventative education, public speaking on stress, and consumer satisfaction due to direct services (Bauman and Browder, 1983); and (3) an additional revenue generating service.

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SOCIAL WORK PRACTICE IN FAMILY MEDICINE: ORIENTATION AND SKILLS

A s previously noted, social work practice in health care is not n e w - e i t h e r in hospitals o r in community based settings. What is new is a medical specialty-family medicine-that is philosophically congruent with family oriented social work practice. Most of the functions of a hospital social worker would also be performed by a family practice social worker such as: patient assessment, psychosocial counseling, liaison with family and community, advocacy, resource finding, and aftercare planning. All of these functions in the hospital are usually directed specifically at the medical problem which necessitated the hospitalization. Although importance is assigned to physical symptoms and diagnosis, the difference lies in the family oriented focus of both family physician and social worker in developing and implementing a plan for biopsychosocial intervention. A s a result, responsibility is more clearly equally shared by social worker and physician. The opportunity provided for the direct involvement of the social worker in preventive and remedial treatment is much greater in the primary health care setting. Consequently the social worker in family practice will have to develop an orientation to intervention skills and techniques that are different from hospital social work and, in many ways, from other areas of social work. Family Systems Medicine

In formulating and implementing an interdisciplinary approach to comprehensive treatment in primary health care, Miller (1983) states that general systems theory should be the foundation. This orientation is compatible with the emerging field of family systems medicine which integrates family therapy, systems theory, and modern medicine (Bloch, 1983). In turn, this orientation to health care is compatible with the biopsychosocial philosophy and practice of some family physicians and educators (Smilkstein, 1982; Rosen, Kleinman, and Katon, 1983; Engel, 1983). Such an orientation to health care puts major emphasis on the role of individuals' social environments in determining etiology of and treatment strategies for most health problems. Instead of searching for causes and cures of health problems from a strictly deterministic perspective, family systems medicine focuses o n the interactive aspects of an individual's health problems with hisfher environment from a nonlinear perspective. Family practice social work should, therefore, be grounded in a


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systemic perspcctive. Such a perspective is not new to social work, but for it to be truly cffcctivc, social workers need to become well grounded in the sophisticated systemic orientation of Watzlawick, Bea-vin, and Jackson (1967), Watzlawick, Weakland, and Fisch (1974), Fisch, Weakland, and Segal (1982), Haley (1963, 1976), Madanes (1981), Hoffman (1981), Selvini-Palazzoli, Cecchin, Prata, and Boscolo (1978), Minuchin, Rosman and Baker (1978), dcShazer (1982), and Papp (1983). It should be noted that social workers have already been involved in furthering the sophistication of systemic practice since Segal, Hoffman, deshazer, and Papp are social workers. With the systemic perspective as the framework for family practice social work, other proven strategies and techniques can be integrated within thc practice approach in the family practice setting. Thcsc strategies and techniques can be included under the rubric of "behavioral medicine." Though they are not necessarily germane to thc systcmic perspective, they are potential complements to a systems oriented practice. Behavioral Medicine

The use of behavior modification principles and techniques in dealing with human problems is no longer considered a novelty by most human service professionals. The successful application of behavior modification to health related problems has lead to the development of the field of behavioral medicine. Though many writers restrict behavioral medicine to the use of behavior therapy with medical problems, other writers on the subject (Schartz and Weiss, 1978; Yale Conference on Behavioral Medicine, 1977) broaden the definition to include behavioral science knowledge in general. A broader definition, therefore, allows for the use of stratcgics and techniques from other therapeutic models that have also been found effective in dealing with hcalth rclated problems. Cognitive therapy (Halroyd, Andrasik, and Westbrook, 1977; Johnson and Leventhal, 1974; Mcichcnbaum and Turk) and transactional analysis (Pinkster and Russel, 1978; Marx, Barnes, Somes, and Garrity, 1978; Fetsch and Sprinkle, 1982; Horwitz, 1982) are two such models. Relaxation training, biofeedback, and hypnosis are other interventive methods that have proven effectiveness with health problems. Though these three techniques have much in common, relaxation training and biofeedback are more germane to behavioral medicine while the use of hypnosis has been encouraged by both bchaviorists (Kroger and Fozler, 1976) and systemic practitioners


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(Haley, 1976; deshazer, 1975, 1979). Though these methods have not been discussed to any extent in the social work literature, social workers are using them in various practice settings and periodically discuss them in books and other literature. (For example, see Lankton and Lankton, 1982.) Though family systems medicine and behavioral medicine have different theoretical foundations, they are not incompatible. Their commonalities have been pointed out by Knudson, Gurman, and Kniskern (1980), Foster and Hoier (1982), and Birchler and Spinks (1980) and integrated and applied in treatment by Ascher and Efran (1978), and Alexander, Barton, Schiavo, and Parsons (1976). Several major points on which systems theory and behavioral theory concur are: the effects of environment on behavior; focus on observable behaviors only; deemphasis on the usefulness of catharsis; no need to recall past traumatic experiences but rather focus on present behaviors. PRIMARY ROLES OF THE SOCIAL WORK PRACTITIONER IN FAMILY MEDICINE Keeping in mind the backdrop of family systems medicine and behavioral medicine, the family practice social worker must perform several primary roles in day-to-day practice. More specifically, these roles are: clinical social worker, consultant, and educator. Regardless of which role the social worker is performing at any one time, s/he should also be ready to draw from the vast reservoir of knowledge and skills provided by family systems mcdicine and behavioral medicine. Clinical Social Worker A major part of the family practice social worker's time would be spent providing a variety of direct practice treatment services in dealing with a range of problems. As a therapist, a social worker functions on a continuum from giving simple information to crisis intervention to long term casework (Goldberg and Neill, 1972, p. 173). The social worker's goal is to strengthen people by expanding their understanding, adaptability, options, skills and behaviors. The social worker helps families adapt to illness, reduce family conflicts, helps with behavior modification, helps to build social relationships and self-help groups, provides supportive interviews (Fielden, 1979), expands problem solving and coping abilities, facilitates communication between an individual and others in his or


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her environment (Coulton, 1981), and manages crisis interventions with problems such as serious accidents, bereavement, terminal illness, self-poisoning, anorexia nervosa, strokes, and emotional breakdowns (Twersky and Deisher, 1981). Social workers in the family practicc setting will have to be skilled in several treatment methods and techniques in order to deal with the range of problems mentioned above. Since stress is such a prevalent ingredient in many of the problems presented to the family practice social worker, slhe should be proficient in methods for dealing with it. As noted earlier, family physicians tend to focus primarily on the physical complaints of the individual patient. A unique contribution of the family practice social worker is the inclusion of the patient's significant others in the treatment process. This is incumbent on family practice social workers if they are using a family systemslbehavioral medicine approach. This is true even when the individually oriented techniques of relaxation training, biofeedback, and hypnosis are being used. These techniques should be only a part of a larger treatment package that includes dealing with the patient's social context.

A social worker has a variety of concepts and skills to offer physicians as they collaborate in the Pamily health setting. A social worker can contribute to a more comprehensive diagnosis with knowledge of the psychosocial aspects of the patient's functioning, hislher relationships, and the social systems in which the patient lives (Goldberg and Neill, 1972). A social worker's assessment contributes most when slhe is an early participant (Regensburg, 1974) and early referrals are seen as "preventative measures" (Fielden, 1979, p. 268). The social worker helps sensitize the physician to important individual and family dynamics that may affect etiology and treatment of health problems (Rosen, Kleinman, and Katon, 1982) such as secondary gains of symptom as a means of power and control, crossgenerational triangles, and scapegoating. The social worker can also emphasize the transitions and life stages of a family, encouraging appropriate timing of referrals to give the most benefit to the patient (Huntington, 1981a). Physicians who are open and interested can gain additional perspectives through the feedback of a social worker whether about their work style, interviewing or intervention skills. The social worker can help physicians improve hislher interviewing skills and ability to deal straight with paticnts either through modeling, co-


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therapy or discussions. The social worker can help the physician to: (1) recognize how psychosocial problems are masked by chronic physical complaints, (2) become more aware of the dynamics going on between himlherself and the patient, (3) respect the patient by focusing on the whole person in hislher environment, i.e., how illness affects the individual and family, (4) avoid focusing only on the disease (Edelson, 1965), and (5) recognize body language and other signals indicating when the patient is depressed or emotionally hurting. A social worker can also assist the physician in using community resources, incorporating their knowledge of the individual and resources available (Edelson, 1965). Cooperation of physician and social worker leads to earlier appropriate treatment and less reluctance on the patient's part to enter therapy. Collaborative treatment is shorter in duration and involves less life disruption, drug therapy, and hospitalization since it is a more comprehensive and preventative approach (Brown, 1982).

Educator The social work role of educator provides the context for developing preventive health education services. Such services would be provided in groups, with the social worker functioning as a resource person and facilitator, providing information about the development of stress related diseases, those having a large psychosocia1 component, as well as various coping behaviors or skills. Health education services could be provided to the community at large, providing a linkage to community health needs and an orientation to the community that is not presently found in family practice. Health related problems, such as obesity, substance abuse (including smoking), prolonged stress, child abuse, child sexual abuse, terminal illness and behaviors leading to high risk pregnancy, could be the focus of such group activities. Education enables people to become more knowledgeable about themselves and develop responsibility and control ovcr their lives, thus increasing the potential for preventing illness and promoting health in the future. It has been suggested that there is not a clear distinction between educational and therapeutic approaches to patient change (Guerney, 1977). Patient education and secondary level prevention activities may also be developed for groups of patients with a common diagnosis. With additional knowledge, patients will have an increased feeling of control and less anxiety about their illness (Coulton, 1981). A social worker can also teach social work perspectives to the

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medical and nursing staff (Goldberg and Neill, 1972; Twersky and Deisher, 1981). Social workers are currently being employed in family practice residency training programs to teach psycho-social assessment and interventions to family practice residents as well as providing direct service to clients (Tanner and Carmichael, 1970; Hove, Kruse, and Wilson, 1979; Twersky and Deishcr, 1981; Chernin, 1981; Chapin, 1981). For the most part, in the private family practice setting, the social worker will educate physicians and other medical staff informally as a consultant as the needs and interest of the medical staff arises. ISSUES RELATED TO FAMILY PRACTICE SOCIAL WORK Rural Health Needs

Though family medicine is practiced in both urban and rural areas of this country, it is particularly suited to the needs or the latter for both health and mental health services. The relative absence of mental health services in rural areas has been reported by several sources (Mosher, 1982; Palmer and Cunningham, 1982). In addition, "accepted concepts of human service dclivery are often in conflict with rural norms" (Bachrack, L.L., 1981, p. 36). People who need help with psychosocial problcms are viewed negatively. Mental illness is not well understood and thus is subject to stigmatizing. The person with emotional problcms is reluctant to discuss them since helshe is fearful of being labcled, at worst "crazy" and at best, weak and ineffective. However, it is legitimate to have a health or medical problcm. Consequently the family physician is consulted, ostensibly for the "medical" problem, when in reality the person is seeking mental health counseling. The relative lack of preparation of the physician to provide such services combined with a reluctance to take the time needed suggests that a referral to a mental health practitioner is needed. The availability of a family oriented social worker in a family practice office offers a viable resource to such people. This position is compatible with Kelley (1982) who advocates for family system theory as the orienting framework for rural social work practice. The Social Work-Medicine Gap

Although the ideology of family medicine is highly consistent with that of social work practice, there are significant gaps remaining in the education, history, and general characteristics of these


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two professions. These gaps could hinder the development of social work practice in family medicine. Davidson (1980) states that there are significant gaps remaining in the training of family practice residents. Generally, medical education continues to place greater emphasis on the diagnosis and treatment of physical disorders, utilizing sophisticated capabilities which tend to be based in large, urban hospitals. Relatively little emphasis is placed on psychosocial factors which affect an individual's adaptation to disease. Although some family practice residency programs are beginning to prepare family practice physicians for a more wholistic practice which assigns equal importance to physical, psychological and social factors, the majority still have a hospital-based, illness orientation (Davidson, 1980). Consequently, before family physicians begin to appreciate the contributions of social workers to their practices on a broad scale, the psychosocial aspects of health care need to receive more emphasis in medical education. The University of California at Davis has developed a Family Practice Program (Davidson, 1980) which incorporates innovations in curriculum design and content. There are three developments of particular interest: (1) preparing the (family practice) resident for a delivery model for primary family oriented care by a health team; (2) preparing residents for a lifelong commitment to preventive care as an integral part of family practice; and (3) preparing residents to recognize, understand and treat psychosocial problems. In the last area, residents in their second and third years have course work on communication skills, group process, family, marital and sexual counseling, and specific therapeutic skills such as stress reduction exercises, hypnosis and biofeedback. The development of family practice social work can also be enhanced by some changes in social work education. If social work is to become more involved in existing family practice programs, social work practitioners must be prepared to provide psychosocial related services (preventive and therapeutic) which are responsive to the biologic/physiologic-based disease entities in order to: (1) meet the needs of patients and families being served; (2) relieve the family practice physician of those problems helshe is not prepared to handle, thus enabling himiher to see other patients and families who need hidher expertise; and (3) begin to "educate" the family practice physician to the need for a family oriented practice model which is more biopsychosocial with an emphasis on a "wellness" or health orientation. Familiarity with the biological/physiological aspects of health care is necessary for increasing practice effectiveness as well as establishing credibility with family physicians.


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Anothcr potcntial barricr to collaboration between social workers and family practice physicians is what Huntington (1981b) rcfers to as structural and cultural factors. Examples of structural factors are goals, knowledge, techniques, language, differences in age and stage of development as profess~ons,as well as size, class or origin, gender, worksetting, certification procedures, income size and income source. The lattcr points to still another issue that is beginning to receive attention and as such seems to represent the "bottom linen-money (Twersky and Cole, 1976; Nason and Delbanco, 1976; Hookey, 1979). Other issues seem more susceptible to resolution than thc matter of how social work services in family practice will be funded.

Financing Social Work Services in Family Medical Practice The three approaches to financing social work services in primary health care most frequently discussed are: (1) fee-for-services, which may be on a sliding fee scale; (2) as a part of the overall administrative costs of the clinic or office; and (3) third party payments, including private insurance, Medicaid and Medicare. All of these approaches have some limitations. The sliding fee scale requires a majority of higher income level patients if low income level patients are also to be served. Although the second approach has becn commonly used in hospitals, as part of the daily rate, it is more difficult to establish in an ambulatory setting. In addition, it suffers from being entirely subject to the physician's judgment since heishe provides the salary through hisiher fee. Third party payments are also subject to physician influence since heishe will be responsible for referral and supervision. This could be a major factor affecting the collaborative relationship between social worker and physician. Some insurance companies provide coverage for mental health treatment provided by a social worker only if it is conducted under the supervision of a physician who is physically present in the facility in which service is provided (Terrell, 1983). This means that for family practice social workers to receive third party reimbursement for services they provide to patients referred by a family physician, thcy must provide such services in the family physician's office/clinic rather than in their own offices where they conduct a private practice. One incentive for the development of family practice social work could possibly reside in the area of financcs. With the increased concern from many groups and organizations about the phenomenal increases in the cost of health care within the last five to seven years, cost containment measures of various kinds are being suggested.


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Mechanic (1980) discusses prospective budgeting based on a capitation allowance as one means of financing social work services in primary care and a means to containing costs. The health provider receives a fixed amount for each person seen regardless of the amount of service provided. Thus there would be the incentive to meet the needs of patients in the most effective and economical way. Hookey (1979) points out that social work in primary health care is cost-effective. H e identifies a "time effect" factor in an equation he developed to determine the net objective cost or benefit of a social work program. The "time effect" is the net change in total physician income resulting from the change in the physician's time allocation pattern during collaboration with a social worker. That is, when appropriate referrals of persons suffering from physical symptoms based on psychosocial stress are made to the social worker, the physician may allocate hislher time to those medical problems that require hislher medical expertise. (The assumption is, of course, the social workers' income expectations are much less than that of physicians!) Hardcastle (1983) also believes that mental health services provided by social workers should help to reduce health care costs. In referring to Fishman and Kasser (1976), he states that a significant amount of mental health services are provided by social workers and are generally less expensive than services provided by psychiatrists and psychologists. Social workers have not been accustomed to concerning themselves with funding of their services. Consequently, they find it difficult to develop and implement cost benefit studies of their services. That reluctance combines with the methodological problems of empirical evaluation of social services. Nevertheless, if social work in family practice is to develop fully, the issue of cost benefit must be addressed.

Guidelines for Approaching Family Physicians Discussion in the literature on how to best approach physicians when initiating discussion about establishing a professional association is almost nonexistent. Baumann and Browder (1983) do offer some suggestions.

1. Look for a practice involving more than one physician. One physician may not be able to provide enough referrals to a social worker unless the social worker and the physician are looking for only a part-time arrangement.


68

SOCIAL WORK IN HEALTH CARE

2. If at all possible, the social worker should make a personal contact initially, perhaps by becoming a patient of the practice. An introduction to the physician(s) by a mutual friend or acquaintance is another possible route to take. Requesting time at a medical partnership business meeting may be necessary and having had some personal contact prior to that meeting would be helpful. 3. Asking people in a community what physician they see and why may be a source of clues about whom to approach. In so doing, ask about the physician's personal style, openness to innovations in health care, and awareness of the emotional needs of patients. 4. Additional information one may need before approaching physicians is: length of time slhe has been in the community; number of physicians in the practice as well as other professional staff such as nurses and physicians' assistants; spaciousness of the facility for accommodating another professional office. 5. Also, prior to approaching family physicians, a general and financial proposal should be written for presentation to the physician(s). The general proposal should include: "a concise rationale for the position; a discussion of the benefits the physicians might expect from your services; a discussion of the typc of problems appropriate for referral; possibly an example of another medical practice employing a social worker; a resume and two or three letters of reference (one of which would be preferably from a physician who knows your work). 6. The financial proposal is a budget in which expected income to the practice is specified as well as salary requirements of thc social worker. This includes fees charged to patients and/ or wages which can be on a per hour basis or other systems such as percentage of per hour fee paid. Within this proposal one should discuss social security and unemployment taxes, health insurance, continuing education, supervision, and vacation. Baumann and Browder state that a social worker seeking a professional association with a medical practice should be ready to ncgotiate about all facets of the arrangement. When physicians are reluctant to agree to such an association, the social worker can offer a "trial period" at part-time for several months at which time the arrangement can be evaluated. Since the determining factor for the existence of the social worker-family physician professional


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association will probably be cost-effectiveness, the social worker must do prior research concerning private insurance and Medicaid1 Medicare reimbursement. The financial success of this arrangement will certainly be part of the evaluation. Good preparation and a concise presentation are essential. Family physicians tend to work on tight schedules and this should be considered and respected. When negotiating in the initial stages the social worker should be flexible and nondefensive. T o take such an approach, the social worker should have a strong sense of professional identity and confidence in one's skills, points also made by Baumann and Browder. They state further that the social worker must possess self-motivation, organization, creativity, and assertiveness as well as a high level of clinical competence. Therefore, this type of professional arrangement is not for every social worker.

SUMMARYICONCLUSIONS The question "Is social work in family practice a new area of specialization?" was posed and addressed in this paper. The answer to this question must be affirmative in view of the criteria for a specialization in social work discussed by Gordon. It should be evident from the discussion in this paper that there are critical numbers of people visiting family physicians who could benefit from social work expertise. In addition, the knowledge and skills to be used in this new social work specialization-family systems medicine, behavioral medicine, hypnosis, biofeedback, relaxation training, and patient education-are applicable to successful intervention with such people and their mastery calls for specialized training beyond the basic knowledge required for social work practice in general. The knowledge and skills needed by the family practice social worker are compatible with family medicine in general and family medicine practiced in rural areas specifically. The opportunity for providing integrated health and mental health services in rural areas is particularly noted in this paper. Finally, some of the potential barriers to further development of social work practice in family medicine are identified and briefly discussed. The need for social work in this arena is well documented. Given the current economy and the stress arising from unernployment, the involuntary mobility of families and resultant family dysfunction, the need for such services is even greater. The reduction in funding for social services may mean that such families are


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