Social Workers Attack the Nonmedical Determinants of Health

Sometimes the best prescription for healing has nothing to do with healthcare.

Social workers are embedded in healthcare facilities to work shoulder-to-shoulder with clinicians, usually to address nonmedical needs. Hospital readmissions often are a result of nonmedical reasons: not enough to eat, an inability to pay utility bills, or living in unsafe housing. Health-policy analysts call these the “social determinants of health.”

Parkland Hospital has 43 licensed social workers who work with registered-nurse caseworkers. The nurses focus on post-acute care while the social workers focus on financial and psychosocial resources.

Nearly half of Parkland’s patients are uninsured. Of those, nearly all need help with non-medical needs, according to Marilyn Calles, Parkland vice president of case management and post-acute services.

“We help them apply for housing, food stamps and charity medications,” she said. “I don’t think there is an agency that we haven’t tapped into. Patients have so many different needs and resources are so limited. We look under every stone and at every angle.”

Calles’ department is beginning to tap into a data analytics project called Parkland Intelligent e-Coordination and Evaluation System—a software application developed by physician Ruben Amarasingham that identifies patients at high risk for hospital readmissions.

“We are in the infancy stage of implementing that program. It is going to be a huge benefit to us,” Calles said.

Jennie Reed, Baylor corporate director of social work and care coordination, said the system has one social worker for every 40 hospital beds. She said the greatest needs are for assistance with buying medications, meals and transportation.

“So many can’t get from place to place,” she said. “It’s a real barrier to seeking continued care. People don’t know assistance exists for these things, or they are too proud or shy to ask.”

Reed added that the clinicians appreciate the social workers’ efforts: “They could do without a lot of things, but not their social workers.”

Brandy Gray, a social worker at the Golden Cross Clinic in Dallas, said there is a shortage of health resources that are free or can be paid for on a sliding scale. Many patients do not qualify for assistance, she said, because they live in ZIP codes that are not flagged as being impoverished.

“There is a strong push to treat the whole person,” she said. “Medical issues are exacerbated by social conditions. The need for social workers (in healthcare) is pretty great.”

But help may be on the way. Health Leads, a Boston-based program with sites in six cities, focuses on the root causes of health problems. It relies on college students to help patients with such challenges with getting basic services.

Health Leads, which was founded in 1996 by Rebecca Onie, then a 19-year-old Harvard sophomore, has launched a four-year, $11 million effort to show it can improve outcomes and perhaps reduce healthcare costs.

Steve Jacob is editor at large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at 

Posted in Hospitals, News.