Targeting social needs with a social worker

Trend is a response to rise in patient problems

Adding a social worker to the mix of staff is one of the best things the TB clinic in Long Beach, CA, has ever done, says Barbara Taylor, RN, the public health nurse at the city’s TB control program. Cynthia Brayboy, MSW, helps patients solve problems that otherwise might interfere with compliance, often more quickly and easily than regular clinic staff can, says Taylor.

The idea of TB controllers hiring social workers isn’t exactly new. San Francisco and San Diego added master’s-prepared social workers to their staffs about six years ago. But the trend seems to have picked up steam over the past five years, says Rosa Lee Black, MSW, social worker for the state health department’s division of TB control. The reason is simple: Over the past five years, there’s been a marked increase in the number of TB patients with difficult social and psychological problems.

"There was a time when the typical TB patient was an American-born alcoholic," explains Tony Paz, MD, program manager for TB control in San Francisco. "But over the years, so many other issues have begun trickling in. Now we have patients who deal with homelessness, poverty, HIV infection, substance abuse, and mental health issues."

As the number of patient problems began to increase, Paz adds, health care workers in TB clinics responded as best they could. "Many of us began doing social work, but it was pseudo social work, really, given that our training is not in social work." Clinicians began devoting more and more time to this new aspect of their jobs, he notes. "We’d get someone a room after he’d been discharged from the hospital. We’d hand out sandwiches, since folks coming in for their meds need to have something on their tummy. We’d give out juice and bus tokens. We’d provide transportation. After awhile, we just got to feeling that we were out of our league — that what we needed was social services."

Long Beach TB controllers hired Brayboy on a contractual basis two years ago. As a rule, she sees patients referred by clinic staff, after they’ve spotted troubles that might impede compliance. She sees patients both inside and outside the clinic offices, sometimes heading out to meet someone about to be discharged from jail or the hospital. Other times, she makes home visits when an outreach worker picks up on a patient’s distress.

Initial sessions with patients are face-to-face encounters that can take anywhere from an hour to several sessions spread out over two to three days. Brayboy does a mental health evaluation and tries to establish whether there’s a history of incarceration, homelessness, or substance abuse. She asks about family and friends and checks for disabilities and eligibility for available services.

She also takes a medical history, even though that’s already been done by the time the client has reached her; sometimes, going over the same ground again nets a key fact the patient may have omitted the first time. "They’ll say, Oh, yes, I forgot to tell the nurse — a few years ago I had hepatitis.’" Names and phone numbers of emergency contacts Brayboy takes down also come in handy when a missing patient needs to be found.

Brayboy says she’s certain she saves the clinic staff time. "They’d all like to spend three or four hours with a client, but they just can’t do that," she points out. "Because I do, it frees them up to see more patients, and they can do their own jobs more effectively."

Along with helping patients fill obvious gaps in their lives — helping them fill out benefits forms, say, or referring them to a substance-abuse clinic — Brayboy believes she gives her clients something else as well. "Sometimes, people come in feeling so victimized that they feel they have no voice at all. The way I look at it, I can serve as their voice." That doesn’t mean doing everything for them, she adds. In fact, during the initial interview, she always asks patients to list their strengths. "Sometimes, they sit there for 20 minutes struggling to come up with some answers. It might be the first time anyone’s ever asked them that question."

Focusing on strengths can be a first step to getting patients to take responsibility for their recovery, she says. "Even though I want to give them a voice, I always stress that whatever we do has to be a partnership. They’ve got to at least make the effort to do their part."

Paz says having someone like Brayboy around pays long-term dividends, too. "We have patients here for a long time at the TB clinic, and relationships definitely get formed. But what if after treatment is over, the patient goes back to the same environment, the same set of problems? Are we really treating the whole patient?" Making sure TB patients have access to the kind of services Brayboy and other social workers can offer "is a national standard of care. If it’s not, it ought to be."