Social Work Competencies A. Demonstrates ability to work with patients and their units of care for plan of care POC development Utilizes a culturally sensitive, client-centered approach in identifying goals and interventions Knowledgeable about caregiver issues including caregiver burden Knowledgeable about high-risk and safety-related issues including acute concerns related to mental health, depression, anxiety and, suicide; homelessness or lack of care, abject poverty; and abuse or neglect Knowledgeable about community resources and strategies for addressing problems or requests for assistance Follows through with referrals and commitments Continually reassesses effectiveness of interventions, adjusts as needed G.
Social Determinants of Health for Health Care: The social determinants of health also determine access and quality of medical care—sometimes referred to as medical social determinants of health see Figure 1 for the County Health Rankings model of factors shaping health.
Future opportunities may exist in genetics and biological determinants; however, whether modifying these will be as feasible as modifying the social determinants of health is unknown. First, they realize that this is not their domain of expertise or current accountability. Second, some are worried that health care systems already have enough to address and should not play a role in efforts to mitigate or improve the SDoH.
Third, they express concern about the limited evidence of effectiveness of interventions by health care on the SDoH . There is a viewpoint, however, for health care to find its role in population health , and some providers believe there is enough science to support integration of SDoH into health care and are pursuing evidence-informed interventions with community partners [4,5].
As a determinant of health, medical care is insufficient for ensuring better health outcomes. Medical care is estimated to account for only percent of the modifiable contributors to healthy outcomes for a population . The other 80 to 90 percent are sometimes broadly called the SDoH: Although we as a country spend a higher percentage of our gross domestic product on medical care expenditures than other developed countries, it is more difficult to compare spending on the SDoH.
We do know that many developed countries proportionately spend more on social services than the United States . Although social services do not correspond directly to the SDoH, this comparison gives one view of proportional expenditures in our country.
Despite our significant spending, our outcomes are among the lowest for developed countries, including significant inequities . For health care, the hope is that addressing the more upstream social determinants will improve health outcomes, reduce inequities, and lower costs.
For example, tobacco is a leading determinant of many health outcomes e. Community partnerships that synergize medical interventions and PSE changes produce a more comprehensive approach to behavior change.
For example, walking prescriptions for patients can be complemented by community changes to increase availability of safe walking spaces. For example, measures of cardiac care are ideally outcome measures e.
However, process measures continue to be important for quality improvement and for some payment programs. New summary measures for population health and well-being for use by health plans and accountable care organizations have been proposed [11,12], and frameworks for rewarding health outcomes are being developed.
One framework includes community-driven and individual data for use in primary care, recognizing that there are still questions about the effect on outcomes . The framework, however, does not include how the data might be used with community partnerships to expand the effect of collecting the data.
Screening tools have been developed, e. Models are emerging for how to follow up screening data, e. The incentive, training, and privacy barriers for feasibility of incorporating SDoH into EHRs have been discussed . Interestingly, electronic screening produced higher rates of self-disclosure of some sensitive determinants violence and substance abuse than in-person screening .
Most recently, the feasibility, reliability, and validity of the IOM-recommended domains except for income were evaluated, and clinical trials were recommended [19, 20]. Integrating the SDoH into health care should not fall primarily on primary care clinicians. These leadership actions allow front-line clinicians to be natural champions for the SDoH within the organization and the community without being responsible for all the necessary components of a systems approach.
State innovation models are exploring connections among health care, social services, and some SDoH . ACOs are responding to nonmedical needs of patients such as transportation, housing, and food with the assumption that outcomes and cost will improve . With a robust evaluation plan, the five-year ACH model tests two tracks: These experiments will provide more evidence about effectiveness in achieving better outcomes, better experience, and lower costs.
How do we prioritize SDoH for individual patients and for communities? Prioritization requires an assessment of readiness to address proven or testable interventions, and return on investment.
Which patients are most ready for these interventions? Which interventions will decrease per capita spending?
From a community perspective, which SDoH are of most concern to community stakeholders, and which SDoH will have the greatest effect on total population health and well-being, health equity, and health care expenditures? How do we intervene without medicalizing SDoH?Social determinants of health (SDoH) is a relatively new term in health care.
As defined by the World Health Organization (WHO), SDoH are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global.
The approach of health and social care towards leadership and management, reflects the dynamic state of social and health care practice. Management has evolved from competing health and social care managerial activities in a hierarchical, bureaucratic organisation to complexity theory involving both health and social sciences.
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A. Demonstrates knowledge about Hospice and Palliative Care. Able to articulate the philosophy and services including the practice and roles of social work and the interdisciplinary team. It is widely accepted that the system for funding social care is in urgent need of reform. Faced with shrinking budgets, local authorities are struggling to meet the growing demand for care, linked to increasing complexity in need and an ageing population.