A healthcare organization’s care team model provides complex patients with holistic care, helping them stay out of the hospital and ED.

The care team includes master’s-level social workers who fulfill a care management role for the team. They collaborate with other team members and with providers in the community and hospital, says Mo’sha Myles, MSW, LSW, a social work program manager at Oak Street Health in Indianapolis.

The following is a sample case study that demonstrates how the care team interacts with patients and collaborates to provide the best treatment and care coordination:

“Let’s say we have a 50-year-old homeless female with a history of being a victim of domestic violence. She’s been in and out of rehab for substance abuse and has uncontrolled high blood pressure and uncontrolled diabetes,” Myles says.

The care team discusses the woman’s case at a weekly meeting. The social worker might say, “I met with her yesterday, and there are cognitive issues displayed. She has not had cognitive screening or testing done yet,” Myles says.

When the woman visited the clinic the previous week, her blood pressure was high. The care team provided education about her health issues, but the information was not connecting with her. She was unable to grasp her diagnoses or the importance of taking her insulin.

The care team’s physician might speak up and ask the scribe, “Can you check that chart and say what her blood pressure was the last two times she was here?”

Then the social worker talks about run-ins the woman has had with a home health company.

The nurse practitioner says she is less concerned about the woman’s blood pressure than she is about her insulin levels. So the social worker says, “I talked with her about that, and she told me she can’t afford her insulin.”

The goal of the care team meetings is to dig into the patient’s problems to come up with pragmatic solutions. So the team begins to discuss whether the woman’s nonadherence to taking her insulin is due to cognitive issues or something else. Maybe she doesn’t understand the importance of taking the medication. Taking insulin may not be a priority because she is homeless and spends more time worrying about finding a place to sleep.

The social worker might mention how the patient said she couldn’t afford her insulin, and the team then discusses how to eliminate the barrier.

“They’ll describe her next appointment on Monday and say, ‘When she comes in next Monday, this is what everyone is going to do,’” Myles says. “The nurse will take her blood pressure and glucose and provide her with diabetes information and see if the patient is connected to a diabetes resource.”

The social worker will do some research to see whether the woman can be connected to adequate housing.

“We talk with the patient collaboratively,” she explains. “The doctor may go in the room and say, ‘I was talking about you to the team, and we’re very concerned about you. Do you mind if the social worker comes in and talks to you about housing resources? We’re concerned about your glucose level. Do you mind if I bring in my nurse to talk with you about these important issues?’”

At that visit or another one, the nurse might bring up the woman’s history of domestic violence: “My understanding is that you were a victim of domestic violence. Have you been hit in the head recently?”

Then the social worker can help the patient find local resources, including a shelter where she can be out of harm’s way if she currently is being abused.

Through the meeting’s discussion and follow-up, the care team resolves the patient’s pressing problems and eliminates care access barriers.