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Short Summary

Literature review of the role of social workers in primary health care with a focus on community health centers.

Intro

Primary care has been playing an integral role in the health care system serving many communities, as the first point of contact, providing integrated, accessible, and comprehensive healthcare services by the interdisciplinary healthcare teams (AAFP, n.d.). Recognizing its effectiveness, Primary Care Networks (PCNs) and Community Health Centres (CHC) in which part of PCNs have emerged. In the United States, CHCs first emerged in the 1960’s as a response to the demand for equitable and accessible health care, and the model has expanded to serve 28 million people, playing a vital role as the social safety net (NASCHC, 2019 as cited in Longhurst, 2019). In BC, following the footsteps of the US and other providences such as Ontario, PCNs and CHC are expanding with the launch of primary care strategy in 2018 and the implementation plan to serve 41 communities (BC gov., 2019). With the expansion, the demand for social workers to join the integrated primary care teams is increasing but newly joined social workers struggle with the association of a medical model environment, assertation of their roles, and organizational barriers (Ashcroft et al., 2018). Indeed, the challenges associated with social workers in the predominant biomedical field to bring own values and navigate the interdisciplinary team dynamic while negotiating to establish their own scope of practice and identity as a health professional are well noted (Tucker & Webber, 2021; Morriss, 2017; O’Brien & Calderwood, 2010). The paper aims to provide an analytical review of research papers on the features and impact of overall primary care services, with an emphasis on CHC model and the role of social workers in primary care. As well, writer's commentary on application to social work practice is offered.

Primary care models

In light of the increasing demand for comprehensive community health care services, primary care has been adopting different models to serve various marginalized populations such as the Integrated Health Hub model (Malachowski et al., 2018), Community Health Centre Model (Bhuiya, 2020), Model of Health and Well-being (Rayner et al., 2018) and Integrated Care model (Davis et al., 2015), Integrated Behavioral Health (Taylor et al, 2010). The IHH, as the first point of access for mental health services, provides various health care services such as case management, community wellness service, specialized psychiatric care, supportive housing and outreach (Malachowski et al., 2018). Recognizing the multiple barriers and complex care needs that people with mental health illnesses, the model evolved to meet the needs and provide wrap-around support by bridging the current gaps in health care and mental health care services. As well, Integrated Health Hub model refers to a primary care model that focuses on promoting the highest quality health and well-being for people and communities, health equity and social justice and community belonging, which has been gaining much attention in Ontario for its delivery of integrated and equitable primary care (Rayner et al., 2018). While these models adopted primary care clinics, under different names and focus of population or geographic area, operate, they share many fundamental guiding principles with CHCs which are the commitment to serve marginalized communities, to provide integrated and comprehensive care and to reduce barriers in accessing equitable health care.

Community Health Centres model

In BC, primary care services are being reformed with many openings of the Primary Care Network, Urgent and Primary Care Centers and Community Health Centers with the endorsement of the Ministry of Health (BC Gov., 2019). In the Greater Vancouver area, there are REACH, RISE, Mid-Main and Atira Women’s resource society adopted the CHC model and opened their doors to serve their communities, and there are many underways (BCACHC, n.d.). According to the BC Association of CHC, CHCs are multi-sector health agencies that commit to delivering integrated, person-centred and culturally sensitive care (n.d.). The guiding principles of the model include: providing team-based care, integrated health and social care services, community-governed, social determinants of health focus and commitment to health equity and social justice (Bhuiya, 2020).

The CHC primary care clinics typically consist of a multidisciplinary team such as physicians, nurse practitioners, registered nurses, physiotherapists, registered counsellors, dietitians, social workers, community health workers and other administrative staff. The team-based model allows collaborative and fluid care for complex health needs clients and creates a supportive and equal relationship within the team and better health outcomes for clients such as shorter stay in hospitals, reduced visits to emergency departments and chronic disease management (Goldman et al., 2010; Jacobson, 2012; Katon et al., 2011 as cited in Rayner et al., 2018). The second principle, the integration of health and social care services refers to a diverse array of care such as medical care, mental health, harm reduction care such as Opioid Agonist Therapy, health promotion and outreach support. This approach allows for a one-stop-shop and holistic model of care (Chien, Walters & Chin, 2007; Rayner et al., 2020 as cited in Bhuiya, 2020; RISE, n.d.). Through the partnership with the health authority and community agencies, they strive for seamless and efficient care, thus reducing timeless efforts required by clients who struggle to navigate complicated systems.

CHCs stand out with their focus on addressing the social determinants of the health of their clients. The social determinants of health (SDH) are considered social factors influencing the health outcome consisting of income security, employment, education, housing, food security, gender identity and expression, and social network (Craig, Bejan & Muskat, 2013) as well as immigration status and language barriers. With the recognition of the (in)direct impact on the quality of life and physiological health of clients and communities, CHCs commit to identify and address SDH by allied health professionals such as social workers and community health workers. Through the intake process, frontline workers typically engage with clients to discuss their social factors and attempt to bridge the gaps. This is sometimes called social prescribing which involves empowerment, motivation, community connection and referral and health care system navigation for complex needs clients (Frostick and Bertotti, 2021).

CHCs’ community-oriented approach can be evident in their development. For instance, RISE CHC was established as a response to the Collingwood-Renfrew neighbours’ lowest rate of Family Practitioners per person and the community’s ongoing advocacy work (RISE, n.d.). As well, the community governed model also refers to that they elect community members of the board of directors or committees and have their saying in the delivery and overall structure of care to promote community engagement and a sense of ownership (Muldoon et al., 2010). They often either have a close partnership with local community agencies or are part of a non-profit agency. In Vancouver, the Collingwood neighbourhood house for RISE and Atria are examples of a non-profit agency operating CHC.

Lastly, CHC’s commitment to health equity and social justice is a crucial element of the guiding principles. This principle is demonstrated through their population of focus who experience marginalization and oppression due to their social identities such as gender identity, socio-economic status, ethnicity, and disability status (Glazier, Rayner & Kopp, 2015; Hudson, Boudreau & Graham as cited in Bhuiya, 2020). For instance, RISE has a population of focus that consists of Indigenous, isolated seniors, newcomers, LGBTQ2S, sex workers, those with inadequate housing, people experiencing racism, mental health conditions and problematic substance use, and to receive their primary care service clients are required to share their barriers to health care services (RISE, n.d.). Those who experience discrimination due to their gender identity may be reluctant to seek or receive health care services, leading to poor health outcomes (Giblon & Bauer, 2017), thus by providing gender-affirming and competent care CHCs actively aim to promote health equity amongst the affected population. As well, many CHCs recognize multiple barriers for complex needs clients in accessing care and thus incorporate home visits and mobile clinics for accessible and equitable care. Clients with mobility needs or mental health conditions are usually the targets of outreach offered by CHCs.

The role of social workers in primary care setting

While the values and roles of social workers in the primary care setting are researched and recognized (Feryn, Corte & Rudi, 2022; Rehner, Brazeal & Doty, 2017; Tadic et al., 2020), there are also some barriers to social workers in primary care often face. There is a lack of awareness of the scope of social workers’ practice and reluctance in accepting social workers as part of the medical team from primary care providers (Keefe, Geron & Enguidanos, 2009). This view stems from the perception that social workers are secondary support rather than health professionals who can equally contribute to the care coordination plan. As well, the overlapping responsibilities with other allied professionals such as community health workers, line workers, mental health workers and triaging nurses is an added barrier that social workers often must navigate (Berrett-Abebe et al., 2020). Indeed, the work that social workers are involved in can be viewed as everyone’s scope of practice and therefore not valued (O’Brien & Calderwood, 2010). Thus, it’s crucial for social workers in the field to be able to articulate and demonstrate their role in order to be valued and appreciated as an equally contributing member of the interdisciplinary team, who can offer a unique social work value-driven approach and a concrete set of practice.

First of all, social workers have a skill set and knowledge in addressing social determinants of health. The psychosocial assessment task is usually delegated to social workers, which enables the workers to access psycho-social and environmental barriers related to health concerns, spiritual or religious beliefs that can be part of the treatment plan, individual’s views on health care services, motivation, social network and strengths (Rowe et al., 2017). With the information gathered, social workers can engage in various case-management responsibilities. This includes, but is not limited to: facilitating communication among the team members, between team and patients and/or caregivers (Fraser et al., 2018); connecting clients to financial assistance, other government benefits, and community resources for food security, housing, employment, and legal support; implementing the effective problem-solving skills; collaboration with other healthcare/community professionals; and navigation of social service systems. Because of the heavy emphasis on community connecting job, social workers are sometimes called community engagement specialists (Fraser et al., 2018). This wide range of responsibilities performed by social workers is what makes them stand out, although sometimes viewed as a factor for the confusion and unclarity around the role of social workers. Another contribution social workers offer is their advocacy work. With the understanding of psycho-social and structural factors impacting individuals, which social workers call ‘person in environment’ or systemic approach, social workers can advocate to address the pitfall. For instance, for those in need of a medical certificate for their disability benefit or employment insurance, social workers can advocate and facilitate the provision by communicating the need and impact of the certificate to their primary care support. As filling out a form can sometimes be viewed as a time-consuming task, physicians may be reluctant to commit the time and effort to complete one but relaying the importance and offering assistance to the team can make a positive difference in individuals’ well-being. Another example of advocacy work is around support for those with precarious status. Facilitating social and medical support for those without legal status can be challenging but advocating for the support on the ground of human rights and equitable health care could initiate bending a rule or policy by other specialists, identifying a loophole in the system and making allies with other community/health care agencies. When observed by other team members, social workers can change their perception and ambivalence of social worker involvement to appreciating the social work practice. As well, a systemic review demonstrates that the social work intervention in the primary care setting is effective in improving the overall health outcome for clients such as self-management of long-term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance (McGregor, Mercer & Harris, 2018).

In addition to case management and psychosocial assessment tasks, social workers are being more recognized for their behavioural interventions work or psychotherapeutic practice in some CHCs. Maxxine Wright CHC (n.d.) in Surrey has employed clinical social workers in this capacity while other social workers in CHCs typically focus on the earlier stated roles. They typically focus on the assessment and treatment of mental health and substance use issues clients have, using standardized assessment/diagnostic tools and brief interventions such as dialectical behaviour therapy, cognitive behavioural therapy, and motivational interviewing (Ell et al., 2008; Roy-Bryne et al., 2010; Safren et al., 2013 as cited in Fraser et al., 2018) as well as providing psychoeducation around mental health illness and utilizing person-centred skills such as empathy and active listening (Rowe et al., 2017) and connecting to and liaising with other mental health services. The integration of the behavioural health program offered by social workers is found to be especially effective in meeting patient population’s particular needs (Rehner et al., 2017; Davis, 2015).

Application to practice: Anti-oppressive framework in CHC model

In addition to these roles primary care social workers take on, there are additional ones social workers can do for their marginalized clients. One of the guiding principles of CHCs, commitment to health equity and social justice can be expanded with the anti-oppressive approach (AOP). Limiting the population of focus to the marginalized clientele may not be socially just as it can reinforce the deficit view that the clientele is problematic and thus requires more comprehensive care and costly intervention. AOP is strongly grounded in the social justice and equity principle which emphasizes the impact of oppressive structures such as racism, sexism and ageism on people’s lives including health-related well-being (Thompson, 2016). Instead of situating a health issue in the context of the individual, AOP-driven social workers could pay attention to the bigger structural force and attempt to address it by employing self-awareness, power-sharing and education (Larson, 2008). This means starting from being aware of own professional privileges and social locations and understanding how own values and cultural factors influence the relationship with clients. As well, social workers should be aware of the dominant narrative of the top-down and Western value focus approach in health care and thus should actively challenge the bio-medical model. Instead of perpetuating the “power over” dynamic, social workers utilize the “power with” strategies such as listening and validating to their discriminatory experiences in engaging with their healthcare providers; helping them aware and naming their experience as the structural oppression to bring the community together; building relationship based on mutual respect and safe space. This power-sharing can be also employed in conversing with the team. When the care providers may be frustrated with the lack of involvement and commitment from clients, social workers can educate them on the impact of trauma and other structural factors and experience of discrimination that marginalized clients may have experienced. Instead of quickly discharging non-engaging clients, social workers can then rather bring different strategies to approach and encourage them. As well, CHC’s principle of community development can be enhanced with AOP-driven practice. By naming their experience as something universal and shared experience among the community, social workers can bring the community together and empower them to define their narrative and increase their capacity within them. This can mean creating a peer support group amongst new immigrants or the elderly to create a sense of belonging and social connection. What social workers can offer could allow them to take a lead in promoting community development and empowerment.

Conclusion

So far, the paper provided an overview of the CHC model and the role of social workers as well as discussed the further development opportunities social workers can take on. While this is not an exhaustive list of social work approaches, the discussion could offer some concrete scope of social work practice that fellow social workers can list and share with their co-workers. Though social workers in a primary care setting are more recognized for playing a vital role, advancing to leadership roles within the setting perhaps enhances the delivery of CHC that more aligns with social justice values and perhaps policy change as well.

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