Psychosocial problems among patients in neighborhood health centers: perspectives from health care providers

The role of social workers in addressing nonmedical needs in primary health care

Nonmedical needs are intricately linked to health. Unaddressed nonmedical needs often result in poorer health and increased healthcare costs. Although social workers are well positioned to address nonmedical needs, their role in healthcare environments to address nonmedical needs is limited. The limited role relates to a lack of reimbursement streams, which stems from poor articulation about their unique contributions. An analysis of a case study in which a social worker using AIMS, a protocolized care coordination model, was undertaken to highlight specific activities performed by social workers. Implications for patient health outcomes and healthcare costs are discussed.

Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.

Perspectives on the roles and value of social work practice in neighborhood health centers and implications for the reimbursement of services

In recent years, increasing attention has been paid to the delivery of primary care services to underserved populations. This paper presents a subset of data from a larger exploratory study that examined how three professional groups (social workers, physicians, and administrators) in neighborhood health centers perceived the type and extent of psychosocial problems in their patient populations and the roles of their staff in addressing these problems. We examined the perceptions of physicians, administrators, and social workers as to who handles various psychosocial problems and whose responsibility it is to perform a range of psychosocial functions, with a focus on the function of social work. Social workers were highly praised and valued by administrators and physicians. While the respondents in neighborhood health centers confirmed the value of social work, public and private funders are reluctant to reimburse for social services beyond limited clinically diagnosed mental health services. Outcomes studies focused on the efficacy and efficiency of social work practice in neighborhood health centers are necessary to begin to overcome this barrier to social work services.