“Care for home-bound patients doesn’t end with just making sure they are taking their meds,” says Clarene Richards, Lead Social Worker with the Visiting Nurse Service of New York’s (VNSNY’s) CHOICE Managed Long-Term Care health plan. “It’s also keeping them psychologically grounded, monitoring their ability to function successfully and independently in their homes, and coming to the rescue with solutions when they can’t manage for themselves.”
Government officials and health care experts continue to assess the best strategy for an affordable health care “safety net” to protect the nation’s most vulnerable populations: the elderly, the chronically ill, and the impoverished. With this in mind as we celebrate national Social Work Month, it is especially important to acknowledge both the growing need for this “safety net,” and the essential but often unsung role that social workers play in keeping the net strong. As homecare gains more and more attention as a pathway to reducing risk factors and keeping individuals safe and independent in the communities where they live — minimizing costly hospital stays and emergency room visits at the same time — the tireless efforts of social workers play an enormous role in making home-based health care a viable, long-term alternative for our underserved populations.
Long-Term Care Based on Long-Time Patient Experience
Some of the most impactful long-term care support being provided today by social workers is taking place within Managed Long-Term Care (MLTC) insurance plans. Seen increasingly as an effective option in New York State, the MLTC insurance model brings coordinated care through home-focused delivery of medical and other services to individuals who are chronically ill or disabled and who wish to remain in their homes. Authorized by the New York State Department of Health (DOH), MLTC health plans provide a wide range of benefits for members who are well enough to remain at home with some assistance. Available to those eligible for Medicaid, or those with both Medicare and Medicaid, enrollment in MLTC plans can be mandatory or voluntary, based on age, geographic region, duration of care needed, financial resources and other factors.
From its beginnings in 1893 in a settlement house on Manhattan’s Lower East Side, VNSNY, the not-for-profit home- and community-based health care organization where I work, was an early home health care pioneer, and continues to be a leading innovator in and advocate for coordinated care in the home. The large, incredibly diverse population of vulnerable people in our New York service area has enabled us to shape and refine models of care that reflect the area’s widely diverse age, ethnic, income and cultural differences. Those successful models can then be replicated in other communities and geographic areas. In our VNSNY CHOICE MLTC health plans, social workers play an integral role in care coordination as they monitor and deliver care on a daily basis. When they link members with ongoing social services and community resources, that’s strengthening the “safety net” in a participatory way.
Listening, Learning and Linking
MLTC “safety net” plans are designed to serve people with complex chronic health issues, including medical, behavioral health and social service needs. Members are assigned to a care coordinator, typically a nurse, who oversees communications for a team of highly skilled healthcare professionals. Interdisciplinary care teams include the nurse and a social worker, as well as a mix of clinicians such as behavioral health, physical, occupational, and speech therapists, may also be called on to provide services in the home setting.
When emotional challenges, insurance coverage issues, or simply the overwhelming logistics of living alone arise, the care coordinator discusses them with the member and then refers the matter to the team’s social worker who provides links to social services, assistance managing benefits or entitlements, behavioral counseling, or other assistive services. The care coordinator or social worker maintains (at minimum) monthly regular telephone contact with the member, and sometimes is in touch multiple times per day. “With our phone-based approach, we build a relationship of trust and a real connection with our members,” says social worker Clarene Richards from CHOICE MLTC. “This, in turn, helps us to identify changes in their situation and risks that may emerge — and use preventive interventions to stop them before they become major issues.”
Social worker Belgica Rosario says that patient and active listening is one of the most important clinical skills she employs as a member of the interdisciplinary MLTC care coordination team. “Conferences with the nurse care coordinator and other specialists help me understand the kind of assistance a member might need — it’s important to listen carefully,” she says. “Loss of appetite and fatigue, for instance, can mean that a member is depressed. When these symptoms come up, I’ll gently ask questions to assess the situation and speak with the member (and their family if appropriate) to let them know that counseling services are available to them in the privacy of their home.” When another member dropped hints that her landlord was being abusive, Belgica was listening then too. “I worked with county social services to relocate her into other housing as soon as possible,” she said. “The key is developing a sense of trust and rapport with each person you care for and including them in decisions so they feel empowered and independent. Each member is a part of the care team too!”
Marian Unterman, a CHOICE MLTC Nurse Care Coordinator, observes that “lives are complex, and when health problems are compounded with other day-to-day challenges, it can become all-consuming. Our care is based on a holistic approach where the services of a social worker supplement clinical treatment and help maintain a stable home environment where the member can thrive. These services contribute to the member’s overall feeling of well-being, and to the belief that a small problem won’t break them.”
Marian currently speaks to as many as 25 to 50 members each day. She interacts with social workers for many of these cases, noting that “social workers are vitally important. I couldn’t do my work without them. The beauty of it is that nothing here is done in isolation — we meet continually to discuss issues pertaining to a member.” The social worker addresses each problem — from helping a member navigate the health care system, to coping with depression or anxiety, resolving family and housing issues, or reapplying for food stamps — and calls in clinical assistance or community resources, as appropriate.
During Super Storm Sandy, Marian referred social work services for an elderly member who suffered from severe asthma and whose Brooklyn home had been significantly damaged — exposing him to toxins that were dangerous for an asthmatic. “When his home insurer didn’t cover all the needed repairs,” Marian recalls that “the social worker linked him with community resources to subsidize special dehumidifiers and recommended home improvements to reduce asthma triggers. These supports helped improve his overall respiratory state, reduced the risk for ER visits, and went a long way to restoring his peace of mind. Social workers really are an integral part of our care coordination team.”
Stronger Safety Nets Depend on Active Participation
In a sense, MLTC plans are giving rise to a rare phenomenon — a health insurer that actually serves as a participant in the member’s life, and shares and supports their goal of staying healthy in the place where they are most comfortable. And, in many respects, the social worker serves as that special, familiar resource when times are especially difficult in someone’s life — a combination of confidant, health consultant, educator, and problem-solver who suggests solutions and provides a bridge when more specialized help is needed. As the health care sector demonstrates greater and greater evidence that long-term care plans are working, we have social workers to thank for many of the benefits that make that possible — and of course, for making the safety net ever-stronger.