How Many Social Workers Are Needed in Primary Care? A Patient-Based Needs Assessment Example
McGuire, James, Bikson, Karra, Blue-Howells, Jessica, Health and Social Work
Beginning in the 1980s, social workers and other health professionals identified psychosocial services as an important element in the treatment matrix for patients in medical care clinics (Clare & Corney, 1982). Since then, authors have described primary care services social workers can provide and types of populations (for example, by age or diagnosis) who might receive those services (Claiborne & Vandenburgh, 2001; Netting & Williams, 2000; Wodarski, 2000). Recent U.S. government reports have underscored the role of social sciences research in providing effective health services interventions in medical settings (National Advisory Mental Health Council, 1998; Office of Behavioral and Social Sciences Research, 2001; Pellmar & Eisenberg, 2000; Singer & Ryff, 2001).
Research on psychosocial need began with a focus on psychiatric problems. Several studies conducted during the 1980s and 1990s have established the prevalence of psychological conditions among primary care patients. The Epidemiologic Catchment Area Study of 20,291 residents of five selected geographical regions conducted in the 1980s found an annual prevalence rate of 28 percent of the U.S. population for mental and addictive disorders. The study found that more Americans with mental and addictive disorders were seen in outpatient medical settings than in specialty mental health services settings (Regier et al., 1993). Subsequent studies that used self-report or physician screening tools found at least one of five or six major psychiatric diagnoses in 28 percent to 36 percent of primary care populations (Hahn, Kroenke, Williams, & Spitzer, 2000; Spitzer, Kroenke, &Williams, 1999).
Compared with the study of psychiatric problems, there has been much less examination of social problems in primary care. Several studies have identified one or several social problems, such as unemployment, job distress, economic pressure, need for child care, housing distress, or social isolation in primary care settings (for example, Stefannson and Svensson, 1994) or have recommended social functioning screening using a standardized tool like the SF-36 (Berkman et al., 1999). Only the study by Cook and colleagues (1996) measured a broad range and levels of social need commonly encountered among veterans seen in primary care. These researchers studied 132 primary care patients at the Indianapolis VA Medical Center. The most frequent high severity problems were housing (36 percent), loneliness (30 percent), employment or career (28 percent), transportation (26 percent), personal stress (25 percent), and need for supportive laundry or housecleaning services (25 percent). Thirty-one percent of patients in the study indicated a need to see a social worker about these problems.
Review of the literature on social work staffing in primary care yields no prior studies that can help guide how social work resources can be allocated to meet these service needs. To date, the relationship between identified social need and social service resources available has been addressed in some primary care settings by adopting the panel model used for medical staffing. A panel is the ratio of the number of patients active during a 12-month period divided by the number of full-time medical providers. Each full-time equivalent medical provider is usually expected to manage more than 1,000 patients in a panel. A primary care team consisting of a generalist physician and advanced-practice nurses may be joined by other specialist physicians and other health care professionals, depending on the needs of the patients in the panel, and the team is expected to have a patient panel equal to its total full-time equivalent staff (Systems Flow Incorporated, 1999).
Social work primary care staffing in the VA began with a model that assigned one social worker to a primary care team, assuming the team panel as his or her caseload. For example, a 1994 Department of Veterans Affairs guide for social work administrators in the field suggested:
Although no current model for social work staffing ratios in primary care exists, it appears that a commitment to primary care will require approximately one social worker per 1,500 to 3,000 patients depending on patient mix, functions and level of services provided. …