Social Work Fills in the Gaps for All Kinds of Patients

Health care just isn’t simple. There is a whole world of factors that affect it besides treating and managing disease and injury. Items like safe housing, income, access to nutritious foods, discrimination and even literacy can all impact whether a person can recover. These factors, known as social determinants of health (SDHs), account for 30-55% of health outcomes according to studies.

It’s logical that encouraging people to eat healthy won’t be effective if a person doesn’t have access to a grocery store where healthy food is available. That’s one example of how socioeconomic situations are related and can contribute to an increased risk for developing heart disease, diabetes or obesity – or block recovery from it. Some time ago, hospitals and clinicians began to focus on SDHs and realized social workers were essential to addressing these concerns.

There isn’t just one kind of social worker, though. For just about every group, illness or concern, there are trained social workers making calls, getting funding, finding resources and comforting parents so every patient has the same opportunity to get well. 

“Social workers are not counselors, we’re middlemen. We’re behind the scenes getting things done, filling in gaps,” says licensed social worker Kimberly Johnson, with Lehigh Valley Reilly Children’s Hospital.

She explains common scenarios, such as if a child has asthma and misses school. They’ll help parents get medical forms signed by the child’s doctor. For a family that cannot afford their electric bill but have a child on a feeding tube, they’ll work with the utility company to get the electric reinstated. Or if parents don’t have transportation or bus fare to get to an appointment, they’ll reach out to LVHN Philanthropy to assist in ordering an Uber.

Social workers like Johnson consult with parents and report back to the doctor. “All social workers are different, but we have the same goal of making sure everyone’s needs are met,” Johnson says. “We have a close internal network. If we learn of a homeless person who needs a coat in the middle of winter, we all jump in to help.”

Primary care clinicians also collaborate with, and rely on, social workers. They are part of the Patient Partnership Model, a “hub” of health care specialists ready to assist at primary care offices within an assigned region.

If, during a visit, a clinician learns a patient is food insecure, has had their insurance dropped, is in a violent situation or has some other social issue, the clinician will recommend a phone call with, or place a referral for, a social worker like Sloane Radcliffe with LVPG Primary Care Regional Support. She lets the patient know the clinician placed a referral and helps them connect to resources.  

“That might include food stamps, local food pantries, soup kitchens and programs that can offset the cost of groceries,” Radcliffe says. “If they are older, I’ll tell them about the senior farmers market voucher program offered through the Pennsylvania Department of Aging. Those are just a few options.”

To Radcliffe, who works with family and internal medicine patients including children and seniors, the glass is always refillable. “People don’t know about this stuff and if they don’t know, they’ll just continue doing what they’re doing,” she says. “We’re able to bridge that gap and say, ‘Here are the connections that can make the day-to-day a little bit easier, so you can feel more hopeful.’”  

It can be very distressing if you have a baby coming and are without basic necessities. When a clinician in an obstetrician’s office encounters such a patient, they contact a social worker. The family might need transportation, housing, food, or many times, they cannot afford a car seat or crib. “We help families during pregnancy and in the postpartum period,” Tiffany Adams, a social worker with LVHN Payor-Based Care Coordination, says.

Adams says she spent the first year of her job reaching out to community agencies and others to line up the resources she could offer to expectant moms and their families. Now, she has an extensive list. “I work a lot with health bureaus, schools, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and even Medicaid, which offers assistance,” she says. “I also familiarize families with the services LVHN provides, such as classes in birthing, breastfeeding and preparing for labor. We help with sign-ups and tours, whatever is needed.”

Other resources include programs within LVPG obstetrics and gynecology offices, such as counseling for mental health in the event a patient screens positive for anxiety. One program, Women Adjusting to Various Emotional States (WAVES), can help pregnant women with prescription medication and other behavioral health needs.   

From pediatrics to primary care and beyond, LVHN social workers are there, working with clinicians to help patients regardless of their condition or life event. They bring compassion and resourcefulness in the most difficult times. “We find a way to steer people in the right direction,” says Johnson. “Our philosophy is that everything is ‘figure-outable.’”