Academic journal article Health and Social Work

Utilization Review: A Powerful Social Work Role in Health Care Settings

Academic journal article Health and Social Work

Utilization Review: A Powerful Social Work Role in Health Care Settings

Article excerpt

During the past decade, social work in health care has undergone major changes. The growth of managed care and the "corporatization" of health care have had major implications for hospitals, nursing homes, and home care agencies. Hospitals are downsizing as lengths of stay decrease and pressures to maximize health care dollars increase. Because hospital-based social work typically has not been income generating, social work departments have been vulnerable to downsizing and elimination. Some departments have responded creatively, developing critical roles in their facilities. Many have not. Social workers have much to learn from studying departments that have achieved continued integration and growth within hospital organizations despite threats to their survival. By looking at successful models and identifying factors that foster continued integration, these models can be extended to community-based health care agencies such as primary care settings and managed care organizations. The integration of social work practice into these settings is essential to the survival of health care social work because medical care is increasingly provided in these environments.

Kenney (1990) suggested that a shift from "hospital social work" to "social work in health care" was necessary for continued integration in health care settings. To remain essential to their agencies, she stated, medical social workers needed to develop power. Kenney (1990) described three types of power that social workers can attain in organizations:

1. resource power, which is gained by having control over a critical resource that is essential to the functioning of the organization, is in short supply, or cannot be substituted--for example, providing utilization review for third-party payer reimbursement.

2. expert power, which is gained by possessing special skills and knowledge important to agency function--for example, the knowledge of community resources and continuum of insurance-covered services available to a client necessary to develop a discharge plan, which in turn would decrease patient length of stay.

3. referent power, which is the ability to inspire others to emulate one's attitudes, beliefs, and values--for example, the ability to facilitate team decision making that takes into account all aspects of the bio-psycho-social model, which would result in decreased long-term medical costs.

One of the ways medical social workers can gain access to these forms of power is to embrace utilization review (UR) as a professional task within a case management practice model.

This article considers UR as an essential component of case management, a practice model that has its roots in early social work and recently has been identified as the most appropriate model to use in the fragmented U.S. health care system. The article describes the successful implementation of one such case management model by a social work department in a hospital setting. In addition, we discuss the effect that the addition of the UR task to this practice model has had on professional task definition, patient care, department growth, fiscal solvency of the organization, and identification of additional roles for health care social workers.


In a 104-bed freestanding physical rehabilitation hospital in upstate New York, social workers have been critical members of the treatment team since the inception of the hospital 65 years ago. Because of his or her clinical skills, a social worker is assigned the teams of professionals treating each patient admitted to the facility. When lengths of stay were longer and resources were considered plentiful, the main task of the social worker was to provide counseling for the patient, family, and treatment team.

When increased health care costs began to challenge health care facilities to limit length of stay as a way of preserving resources, the formal role of the social worker in this facility began to change. …

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