Social work CMs help ­members connect

They work as adjunct to case management

The publicly insured members covered by Horizon-Mercy often have psychological and social needs along with their medical conditions. To better serve these needs, the Trenton, NJ, health plan for the publicly insured started a social work program in May 1997.

The program is staffed by certified and licensed social workers and a social work outreach staff that assist with follow-up such as reminding members to go to appointments and helping connect the members to services.

Staff have received extensive training and alert the social workers if it appears that the member needs more assistance.

"The Medicaid population has needs that are so different from those of people covered by ­commercial health plans. They are close to the poverty line and have extensive psychosocial needs in addition to their need for medical care," says Irma Alicea, LCSW, manager of the social case management department.

The social case managers are assigned by region and by county, so they are experts on all the resources and programs in the areas they cover. They work closely with the nurse case managers who cover the same areas.

The nurse case managers and social work case managers get together frequently and discuss the members who have complex needs and care plans. A medical director is always present.

The social workers advocate for the members and make sure they are tied in with the community and other state and federal programs that are available to them. The social workers help remove barriers that may hinder medical adherence.

For instance, if a Horizon-Mercy member is homeless, the social worker directs him or her to a housing assistance program and helps the member connect with community organizations that can provide food and clothing and/or help with transportation needs.

"We work with the members on problem-solving skills and empowerment. We want them to be aware of all the resources available to them and to educate them on how to access the services so they are not dependent on the social workers," Alicea says.

Social workers are called in when there is a crisis in the family, such as a seriously ill family member who might have social needs.

"We are working with families living on the edge of poverty as well as other dynamics related to poverty," says Rita Brown, LCSW, senior social case manager. "We understand the effect a serious disease can have on a family, whether it’s an older couple or a family with young children. We use our clinical skills in this kind of crisis situation to assist the member in getting involved with community services, therapy, or a support group, as well as helping them with needs such as food and shelter and helping them become the owner of their care plan."

The health plan has contracted with taxi companies to drive members from one point to another at a fixed rate for medical appointments. In cases of medical necessity, an ambulance transports members.

When new members join the plan, the intake coordinator does an initial assessment and alerts social work if the family needs its services.

The social workers have an active caseload of between 80 and 100 clients at any given time, reports Mizuki Ogawa-Peterson, LSW, social case manager.

Working with members

Most of the social work clients also are being followed by a Horizon-Mercy case manager in another department who helps with their medical needs. The social work case managers are called in only when there is a psychosocial issue.

"When the client’s basic psychosocial needs are met, we close the case but make sure they know that we are always available. I’ve closed and reopened some case many times," Ogawa-Peterson adds.

One member, who lost her private health insurance when she was laid off from a Wall Street firm, developed a severe heart problem. When she didn’t go to her doctor’s appointment, her social worker found out that she didn’t have money for transportation.

The social worker arranged for the hospital to pick her up in a van. The member participated in a clinical trial. A few months later, the woman called to say she was well enough to drive herself to the physician.

The social work team is alerted any time a member needs psychosocial services. The call may come from a provider, a community organization, a Horizon-Mercy nurse case manager, or the members themselves.

For instance, a provider called Brown about a newborn member with a rare disorder.

"The family was very proud and resistant to any help from social agencies. They had a child with a serious medical condition and were living on the kindness of relatives," Brown says.

She persuaded the mother to apply for Social Security Supplemental Security Income (SSI) benefits for the child and helped the mother find a nearby food pantry.

"It’s a win-win situation. The child is getting the care he needs. The SSI income gives the family a stable amount of income," Brown says.

Some of the members are from working families and have another form of insurance but family members qualify for Medicaid because of special needs, such as a child with cerebral palsy or mental retardation, reports Sherri McPherson, CSW, senior social case manager.

"These are truly medically ill members. We become the secondary insurer, but we still monitor them and provide social work case management to assist them in identifying resources that are available for them," she says.

Many members move around frequently, and the social workers sometimes have to track down their whereabouts, particularly in case of a medical crisis.

"A social worker is sometimes a bit of an investigator as well. When we really need to get hold of other members, we use the state Medicaid system as a resource but also call people who may have a connection with the member and track them that way," Brown says.

For instance, Alicea was contacted by the physician of a pregnant member whose tests showed a serious medical condition and who could not be contacted by telephone.

Alicea knew from talking to the woman that she was homeless and had been staying in shelters, so she started calling all the shelters until she found her.

A social worker visited the shelter early the next morning, arranged for care for the woman’s younger child, and got her back to the hospital.

The Horizon-Mercy social work team is very diverse, with more than half of the social workers and outreach staff speaking at least two languages.

Being bilingual and understanding other cultures is invaluable, says Ogawa-Peterson, who is Japanese and recently worked with a Japanese man with severe diabetes.

"He had been admitted to the hospital several times; but because of language barriers and cultural differences, he did not follow medical advice. He wasn’t able to care for himself and would not seek the help he and his family needed," she recalls.

The wife had not been able to get help from social agencies because of cultural and language barriers.

Ogawa-Peterson worked with the family, gradually building trust and rapport. She helped the family apply for welfare and got disability for the wife. The man began following his treatment plan.

"He still suffers from diabetes, but he is more medically stable, and the family is getting the services they need," she adds.

The health plan has social workers who visit members in the hospital and has started a pilot project that locates social workers in the emergency department of a large hospital.

"When they are in the hospital or emergency room, the social worker sees them face to face and can assess for their needs, educate them, and help them get the services they’ll need when they are discharged," Alicea says.

When the members are admitted into the hospital, the social worker assigned to that particular hospital is notified.

"We do outreach, education, and follow up with the primary care provider and send out letters to the members reminding them to go back to their physician," she says.