In the realm of healthcare, social workers play an indispensable role within the hospital setting, serving as vital advocates and pillars of support for patients and their families. Beyond the confines of medical diagnoses and treatments, these dedicated professionals navigate the complicated web of social, emotional and economic challenges that often accompany medical care. With a commitment to fostering holistic well-being, hospital social workers have evolved from workers in the social service department to integral parts of the case management team, either working directly as a case manager or serving in a more consultative clinical role. Their empathetic approach, coupled with a comprehensive understanding of community resources, equips them to navigate complex situations and collaborate on tailored care plans, providing patients with the essential tools to navigate the intersection of health and social dynamics.
The story of social workers in the hospital setting begins with Dr. Richard Cabot, a leading physician at Mass General who hired Ida Maude Cannon in 1906 to jointly organize the nation’s first hospital-based social work program. After treating his patients and seeing the difficulties they faced, Cabot believed that although patients were separated from their homes to be treated medically, patients were unable to separate themselves from their personal problems (History of Social Service, 2024). At the time, Cannon had been a home health nurse; however, she found that her nursing skills were unable to address the psychosocial needs of her homebound patients. Influenced by one of the social work originators, Jane Addams, who is responsible for founding the settlement house movement in the United States, Cannon decided to obtain her social work degree. She was named chief of social work in 1914 and organized the first social work department in a hospital setting. During the early years, social workers at Mass General focused their services on the outpatient clinics, helping to bridge the gap between medical care and community and social needs. Their most notable contribution at the time was their support for patients suffering from tuberculous, providing comprehensive assessments and care plans to the medical team for how to ensure compliance with treatment and potential prevention from spreading the disease. By the 1930s, social workers expanded into the acute care setting, an area that was already well established at John Hopkins, providing the social perspective at interdisciplinary rounds. Cannon was also a founding member of the American Association of Hospital Social Workers in 1918, which would later be rolled into the National Association of Social Workers (NASW) in 1955.
During the 1920s, medical social work underwent a notable division from psychiatric social work, spurred by the Freudian movement and the increasing trend of social workers gravitating toward specialized therapeutic roles. This led medical social work to concentrate more on casework services within hospital and healthcare settings. In 1934, the American Association of Hospital Social Workers rebranded itself as the American Association of Medical Social Workers, placing a renewed focus on social workers providing casework to address the interplay between disease and social maladjustment. As social workers gained traction within the medical sphere, their practice exhibited some regional variations across the country. Notably, during the New Deal era, social workers played crucial roles in shaping numerous present-day social welfare programs. Their impact continued to expand during and after World War II, as they integrated with rehabilitation and veteran services, broadening their reach and influence.
In the 1960s, Elizabeth Rice, a social worker and professor at Harvard School of Public Health, spearheaded the movement of social workers back into the outpatient setting to help with the prevention of health-related problems (Ruth, 2017). During this time, a large portion of social workers entered the public health arena, serving on the prevention and public policy side. Many social work programs adopted dual degrees for master’s in social work or social welfare and public health emphasizing the strong relationship between social workers as advocates in preventing and managing health-related conditions in an outpatient setting.
In the acute setting, social workers served in both a clinical and social service capacity at Mass General until 1985, when nurses were added to help address the growing constraints and payer requirements, creating the dyad model that would differentiate between nurse case managers for payer communication and discharge planning and social workers who would assume a more clinical function (History of Social Service, 2024). This movement was a common practice across the country. With the rise of escalating health costs, many hospital-based social worker departments were decentralized or eliminated. Their roles shifted into any negotiated position that would ensure preservation of the positions. “[F]rom counseling to discharge planning and case management, some traditional social work tasks moved to allied professionals. Medical social work entered a protracted phase of self-justification, contracting into a state of functional survival” (Ruth, 2017). However, during this time social workers continued to find their niche in different areas of the hospital, providing behavioral and mental health support, case management, palliative care and hospice services, and emergency room services. Social workers also played a vital role in hospital and healthcare policy around patient care rights, guardianship and surrogacy policies and abuse and neglect response policies. Despite the changing hospital landscape and role social workers play in the hospital setting, medical social work has maintained a strong presence in VA medical facilities, which are still the largest employer of social workers in the country, with about 17,300 master’s-level social workers on staff (VHA Social Work, 2024).
Today social workers are trained extensively on the biopsychosocial assessment and methodology of a strengths-based perspective in the care planning process. In 2016, NASW provided eight practice guidelines for medical social workers to ensure excellent patient care:
- Adherence to the social work code of ethics
- Advocacy for patient rights to self-determination, confidentiality, access to supportive services and resources and appropriate inclusion in decision making.
- Encouragement of social work participation in the development, refinement and integration of best practices in healthcare.
- Enhance the quality of social work services provided to clients and families in the healthcare setting.
- Promote social work participation in systemwide quality improvement and research efforts.
- Provide a basis for the development of continuing education materials and programs related to social workers in healthcare settings.
- Promote social work participation in the development and refinement of healthcare related public policy.
- Inform policymakers, employers and the public about the essential role of social workers across the healthcare continuum.
What typically draws social workers to the hospital setting is the fast-paced environment, which is different from clinical practice, where rapport is built over several sessions. The acute care social workers must build rapport and develop a care plan that is representative of the patient’s medical needs and social circumstances during one initial visit and one hospitalization, drawing upon their skills to creatively provide solutions for the care team while still advocating for the patient’s rights to self-determination. This practice extends across care units, whether working and supporting patients after a trauma or learning about a new, life-altering diagnosis. Different from the individualistic nature of a therapeutic setting, the medical social worker thrives on the interconnection between care team members in the hospital and the variety of patients across care levels the hospital provides.
From the pioneering efforts of individuals like Ida Maude Cannon to the contemporary practices outlined by NASW, the journey of hospital social workers is one of adaptation, resilience and unwavering commitment to patient well-being. As healthcare environments continue to evolve, the role of social workers remains indispensable. Today, armed with a strengths-based perspective and a commitment to ethical principles, social workers navigate the complicated intersection of health and social dynamics. While the landscape of hospital settings has undergone transformations over the years, social workers have persistently found innovative ways to contribute. Their ability to swiftly build rapport, develop tailored care plans and collaborate seamlessly with diverse care teams highlights their adaptability and effectiveness in the fast-paced, ever-changing healthcare environment.
In the current era, where the social determinants of health take center stage, the significance of social workers in healthcare is experiencing a resurgence. As healthcare systems recognize the interconnectedness of medical and social factors in overall well-being, social workers once again emerge as valuable contributors, advocates and architects of comprehensive care. The story of social workers in the hospital setting is not a mere historical narrative but an ongoing saga of dedication, evolution and resilience. Their presence continues to be vital, weaving a thread of empathy and support in a complex medical environment, ensuring that patients not only receive medical treatment but also experience compassionate care that addresses their unique social and emotional needs.
REFERENCES
History of Social Service, Massachusetts General Hospital, Social Service Retrieved on January 3, 2024 from https://www.massgeneral.org/social-service/about/history.
National Association of Social Workers, (2016) NASW Standards for Social Work Practice in Health Care Settings.
Ruth BJ, Marshall JW. A History of Social Work in Public Health. Am J Public Health. 2017 Dec;107(S3):S236-S242. doi: 10.2105/AJPH.2017.304005. PMID: 29236533; PMCID: PMC5731072.
VHA Social Work, VA Social Work, U.S. Department of Veterans Affairs, Retrieved on January 3, 2024 from https://www.socialwork.va.gov/.
, LMSW, CMAC, ACM, is CEO of Phoenix Medical Management, Inc., the case management company. Tiffany serves as an adjunct professor at Northern Arizona University, Department of Social Work and on the American College of Physician Advisors (ACPA) Observation Subcommittee. Tiffany is a regular contributor to RACmonitor, Case Management Monthly, serves on the editorial board for CMSA Today and is commentator for Finally Friday. She is a weekly correspondent on SDoH for the news podcast Monitor Monday. After practicing as a hospital social worker, she went on to serve as director of case management and quickly assumed responsibilities in system level leadership roles in health & care management, which include CM, UR, CDI, HIM and coding. She has held C-level responsibility for a large employed medical group, which included value-based arrangements, PCMH and outpatient care management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA. She is a licensed social worker, ACM and CMAC certified.
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