Transcript Social Workers as Translators

The Conceptual Underpinnings
of Health Social Work
S30 5453-01
August 31, 2011
Sarah Gehlert, PhD
E. Desmond Lee Professor of Racial & Ethnic Disparities
Washington University in St. Louis
Ida Cannon wrote (1923):
“basically, social work, wherever and
whenever practiced at its best, is a constantly
changing activity, gradually building up
guiding principles from accumulated
knowledge yet changing in techniques.
Attitudes change, too, in response to shifting
social philosophies” (p. 9).
Question For Today
How, if at all, have the guiding
principles of social work in health
care changed over the last
century?
Parallel Paths of Health Social Work
The Brown School, Washington University
1925
Children’s Memorial Hospital (Chicago) Social Work Department
1911
St. Louis Children’s Hospital Social Work Department
1910
First hospital social worker Massachusetts General Hospital
1905
Progression in Focus
Hospital Social Work
(1905)
Medical Social Work
Health Social Work
(1990s)
Health Social Work Origins



the demographics of the US population
during the 19th and early 20th
centuries
attitudes about how (and where) the
sick should be treated
attitudes toward the role of social and
psychological factors in health
19th & Early 20th Century
Demographic Changes
35,000,000 to 40,000,000
Europeans immigrated to the US
between 1820 and 1924
European Immigration
Germany
 5.5 mi. persons between 1816 and 1914 (for
political & economic reasons)
Ireland
 2 mi. persons during the 1840s alone
Italy
 5 mi. persons between 1820 and 1990
Struggling to Adapt
Ellis Island Immigration Station
• opened in 1892
• by 1907, processed 1
1 mi. persons/year
Ellis Island
Ellis Island
By 1865:
Over 650,00 persons resided in the
southern half of Manhattan Island in
NYC alone
 most lived in tenements
 accidents common, sanitation poor,
food supplies in poor condition
 1 in 5 infants died in their first year
Immigrant Life
Late 1880s
Adding to the situation….
wide range of health beliefs
 most did not speak English
 the vast majority lived in
poverty

Attitudes About How (and Where) the Sick
Should be Treated





Late 1600s and early 1700s the sick were
cared for at home
As the population grew, almshouses were
constructed in cities for those without means
1713 -- Philadelphia (Quakers only)
1736 -- New York (now Bellevue Hospital)
1737-- New Orleans
Late 1700s
Sick treated in…
…separate parts of almshouse  public
hospitals
New York
Hospital
Hospitals for the poor 
Hospitals for patients with means
First Public Hospitals
Pennsylvania Hospital
Pennsylvania Hospital 1751


funds from Benjamin Franklin
subscriptions from Provincial General Assembly
of Philadelphia
New York Hospital 1791
New York Hospital
Massachusetts General Hospital 1821
Massachusetts General Hospital
Dispensaries



Appeared in the late 1700s
Originally to dispense medications to
ambulatory patients
Physicians hired to visit patients
Philadelphia 1786 (Quakers only)
New York 1795
Boston 1796
19th Century Reform
Led by women physicians…..
Dr. Elizabeth Blackwell in NYC
1853 - dispensary with home visits
1857 - hospital beds
•
NY Infirmary for Women & Children
Sloan Maternity Hospital
Dr. Rebecca Cole
1st “sanitary visitor”
discussed education & employment
Elizabeth Blackwell
(1821 – 1910)
• first woman to receive an MD
from Geneva Medical College in 1849
• established the New York Infirmary in
1857
Rebecca J. Cole
(1846 – 1922)
• the second African-American
woman to receive an MD
• 1867, Woman's Medical
College of Pennsylvania
19th Century Reforms
1890
Dr. Annie Daniels at NY Infirmary for Women
and Children kept records of family size,
income, etc. in the manner of social workers
Dr. Henry Dwight Chapin established a program
for home visitors to check on conditions
- led to 1st foster care home for ill and convalescing
children
Hospital Almoners in London



1st hired by the Royal Free Hospital in 1895
to screen patients to see if qualified for free care
(only 36% were)
sat by the entrance and reviewed applications
for admission
training became formalized by 1905
10 Years Later in the U.S. (1905)
Garnet Pelton was hired to work at
Massachusetts General Hospital (MGH)

originally trained as a nurse

worked at a settlement house

hired and paid out-of-pocket by Dr.
Richard Cabot

developed tuberculosis after 6 months
at MGH and was no longer able to work
Pelton Hired to:



Act as a critic and help to socialize medicine
“…criticism from the inside, which I think is
the most valuable kind” (Cabot, 1912)
Act as translator between the physician and
patient and family
Provide information on social and mental
factors
Ida Cannon
(1877-1960)
Hired to replace Pelton
Ida Cannon
first trained as a nurse
heard Jane Addams and became
interested in social work
trained at Simmons College of SW
hired by Dr. Richard Cabot
worked at MGH from 1906 to 1945
Simmons College of Social Work
Richard C. Cabot, MD
(1868-1939)
Physician &
Medical Educator
Richard C. Cabot, MD
(1868-1939)
Richard Cabot



active from the 1890s to the 1930s
completed medical school in 1892 (Harvard)
accepted an appointment to work in the dispensary
at MGH
• no medical treatment available
• patients mostly immigrant
• “running off the clinic”

saw that social and mental problems underlay
physical ones ~ purely physical problems were rare
Cabot Influenced by His Family
Paternal grandfather (1784-1863)
 made fortune in shipping
 favored commerce over culture
Parents studied philosophy with Kant
 father 1821 to 1903
 as transcendentalists questioned the
commercialism of their parents
and traditional beliefs
Cabot Born at End of Civil War (1868)






nation demoralized
shift from idealism to realism
conservatism and materialism reemerged
the Origin of Species fostered Social
Darwinism
growing concern about number of immigrants
charity seen as naïve and harmful
Mother Elizabeth Cabot
“It seems to me that very few of us (women)
have enough mental occupation. We ought to
have some intellectual life apart from the
problems of education and housekeeping or
even the interests of society”
Elizabeth Cabot, 1869, p. 45
Cabot Shaped Social Work
in His Own Image
Radical centrism
 took two opposing views and help to find a middle
ground
 greater truth would emerge through a dialogue
 saw himself as a translator
Believed in acting versus observing
 influenced by John Dewey and Jane Addams
 knowledge gained through problem solving ~
important to learn from failure
Hull House
Est. 1889
Jane Addams
(1860-1935)
..influenced hospital
social work
Cabot Fashioned Hospital Social
Work in His Own Image
Saw the social work role in health care
as:
 translator and communicator between two
sides with differing perspectives
 problem solver to find a solution and learn
from errors
Social Workers as Translators
…..of medical information to patients and
families in a way they could understand
“There is no one else who explains; there
is not other person in the hospital whose
chief business is to explain things”
Cabot, 1912
Social Workers vs. Nurses
Cabot thought that social work could best
fulfill this role because nurses had
“lost their claim to be a profession by
allowing themselves to become mere
implementers of doctor’s orders”
Cabot, 1911
Cabot and Cannon Saw Social Workers as
Translators……
…..of medical information about patients
and families to physicians
“ So the hospital social worker sees the patient not
merely as an isolated, unfortunate person
occupying a hospital bed, but as a member
belonging to a family or community group that is
altered because of his ill health”
Cannon, 1923, pp. 14-15
Cabot and Cannon Saw Social Workers as
Problem Solvers…..
Cabot (1923) said that physicians and social
workers were natural allies and could learn
from one another
 physicians could learn about the non-somatic
aspects of health
 social workers could learn to be more
scientific and systematic (being on the moral
high ground was not sufficient)
Cabot Paid Social Work Salaries (<13
workers) Out of Pocket Until 1919….
MGH Superintendent did not support
hiring Pelton
 Cabot demonstrated cost effectiveness
($120/mo. for a baby with GI problems
in 4 times because no money for
prescribed treatment)
 did not want to recreate British almoners

Success at Massachusetts General
Hospital






Drew the attention of the AMA and AHA
1911 ~ 44 social service departments in 14
cities (17 in NYC alone)
1912 ~ 1st NY Conference on Hospital Social
Work
1912 ~ first training course
1913 ~ 200 US hospitals had social workers
1918 ~ Amer. Assoc. of Hospital Social
Workers
Ida Cannon’s Role Became Established





named chief of social work at MGH in 1914
hired Harriet Bartlett as first education
director
philosophy to accommodate hospital
mechanisms and not be critics or reformers
worked with Cabot until he left MGH (1919)
Social Service Department made permanent
in 1919
Abraham Flexner Said Social
Work Not a Profession



address to National Conference of
Charities and Corrections in 1915
social work lacked
a written body of knowledge
educationally communicable techniques
individual responsibility for its members
impetus for more formal training
A. Flexner
1866-1959
10 Schools of Social Work Offered Formal
Coursework in Medical Social Work in 1929










Washington University
The University of Chicago
The New York School of Social Work
Tulane University
Indiana University
The University of Missouri
Simmons College
Western Reserve University
The Pennsylvania School of Social and Health Work
The National Catholic School of Social Work
The American Association of Medical Social
Workers (Est. 1918)



Largest of all social work specialty
organizations
2,500 persons attended annual meeting in
1954
Larger than current major specialty
organization, the Society for Social Work
Leadership in Health Care (1,300 members
in 2009)
The American Association of Medical Social
Workers (Est. 1918)
Seven organizations dissolved when NASW
was founded in 1955:
American Association of Medical Social Workers
National Association of School Social Workers
Association for the Study of Community Organization
American Association of Group Social Workers
American Association of Psychiatric Social Workers
Social Work Research Group
American Association of Social Workers
Beyond the Hospital



Social work grew after WWII/Social Security
Act
doubled between 1960 and 1970
new settings and arenas
new techniques and interventions
Social Security Act 1935
No medical benefits included
Amendments signed by President Johnson
on July 30, 1965:
Medicare (Title XVIII)
Medicaid (Title XIX)
Medicaid and Medicare
Costs of health care soared
 1967 utilization review measures
 1972 Peer Standards Review Act
 …neither was effective
New Attempts at Cost Containment


1973 Nixon’s Health Maintenance
Organization (HMO) Act
By 1993, 70% of Americans with insurance
enrolled in HMOs
“The social worker becomes an agent of managed care and agrees to
serve the public within the corporate guidelines and not necessarily
according to the assessed needs of the client”
Cornelius, 1994, p. 52
New Attempts at Cost Containment
DRGs* (1983)
 500 diagnostic-related groups
 each with own retrospective
reimbursement rate
 incentive to keep hospitals efficient
“Under DRGs, patients entered sicker and left sooner”
Dobrof, 1991
* Diagnostic and Regulatory Guidelines
Effect on Social Work





social work forces downsized/reconfigured
less time to spend with patients
HMOs ~ limited ability to act on own
assessment of needs
DRGs ~ forced emphasis on discharge
planning
hard to perform as outlined by founders
e.g.. Cannon’s “to remove those
obstacles…that interfere with successful
treatment” (Cannon, 1923, pp. 14-15)
Growth of Medical Social Work
Through Time
1905-1930 unprecedented growth almost
exclusively in hospitals
1930s
competition from psychologists &
social scientists
1935-1945 branched out from hospital base
1960-1970 doubled in size
1970 -2010 redefinition & continued branching
Social Work Response
New techniques based on time
limits
 task-centered casework
 adaptations of practice theories (e.g.,
stress inoculation)
New social work practice roles
 disease managers
Patient Protection and Affordable Care Act
(PPACA)




Enacted March 2010
Specifics of of reform unfolding
Role of SW as a profession virtually
absent from policy discussions
Expands Medicaid coverage to 133% of
poverty in 2014, but states are cutting
programs (i.e., more people, but fewer
services)
Patient Protection and Affordable Care Act
(PPACA)


Uninsured and underinsured need
assistance with transitioning to a
coverage model (i.e., to be assisted in
selecting and participating in traditional
insurance or Medicaid coverage and
steered toward mainstream providers and
services)
Emphasis on prevention and services in
the community
Patient Protection and Affordable Care Act
(PPACA)


The Congressional Budget Office
estimates that 21 million will be uninsured
in 2016
Undocumented immigrants will be
prohibited from purchasing insurance
through the new exchanges & ineligible
for Medicaid (~8 million persons, 1/3 of
uninsured by 2019)
How Do the Visions of Cannon and Cabot
Hold Today?
1. Social worker as translator
As salient in 2011 as in 1905
10% of residents born outside US ~ 2000
(up from 5% ~ 1990s)
15% born outside ~ 1890 – 1910
Social workers in best position to
ensure that each side is understood by
other
Lost in Translation
“ There are by now literally
hundreds of competent studies
and the overwhelming majority
have found that, overall, AfricanAmericans, Hispanic Americans,
and Native Americans receive less
care, and less intensive care, than
comparable white patients.”
Institute of Medicine, 2003
How Do the Visions of Cannon and Cabot
Hold Today?
2. Social work as scientific and systematic

advent of research late 1960s and early 1970s

demonstrate effectiveness (e.g. evidence-based
practice)

new opportunities for impacting health
research leaders (e.g. directors at NIH)
health care administrators
health policy makers and analysts
How Do the Visions of Cannon and
Cabot Hold Today?
3. Patient as “…a member belonging to a family
or community group that is altered because of
his ill health” (Cannon, 1923)

written before chemotherapy, antibiotics, etc.

more salient today ~ chronic health conditions

disease management
Ida Cannon’s 1923 Statement
Holds True Today!
“basically, social work, wherever and
whenever practiced at its best, is a constantly
changing activity, gradually building up
guiding principles from accumulated
knowledge yet changing in techniques.
Attitudes change, too, in response to shifting
social philosophies” (p. 9).
Conclusion


Social work has been through a lot in 106 years
Weathered seemingly insurmountable challenges
with grace
Its guiding principals remain in force and are as
strong today as in 1905