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Forging Solutions Out of Challenges: Why Social Workers Are an Essential Part of Effective Home Care

The outstanding and irreplaceable support they provide -- not only to patients, but also to the nurses, therapists and home health aides that they're collaborating with -- underscores the reality that effective home care is truly team endeavor.
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In addition to being the month in which we turn ahead the clocks, welcome spring, and celebrate St. Patrick's Day, March is also National Social Work Month. This year's theme, "Forging Solutions Out of Challenges," brilliantly summarizes the impact that social workers are having on people's lives every day, across our nation. While many Americans may associate the social work profession with efforts to support struggling families, or with the thousands of practitioners who have earned social work degrees on the way to becoming psychotherapists, it's important to note that social workers also play a critical role in home health care organizations like the Visiting Nurse Service of New York, where I work.

In fact, social workers are integrated into virtually every aspect of our operations, including the interdisciplinary care teams who treat patients in their homes following surgery or acute illnesses. When a patient's coordinating nurse determines there's a need for social work support, that patient will get referred to a social worker like Kenia Alcantara, who works out of VNSNY Home Care's Bronx regional office.

A fluent Spanish speaker, Kenia relishes the chance to help each new client. She recalls arriving at the home of a newly assigned patient recently, only to find the elderly woman waiting for her outside the front door. "We stood talking for 15 minutes before she finally invited me in," says Kenia. "When she did, I could barely walk in the door. It turns out she's a hoarder, and was keeping nine cats in her apartment."

Unable to find a clean chair to sit on, Kenia conducted her assessment standing up. She educated the patient about available services and then pulled out her phone to begin making referrals -- New York City Adult Protective Services, to assist with the hoarding situation, and VNSNY's Community Mental Health Services to assess the patient's mental health needs and link her to counseling. She also touched base with her interdisciplinary care team to confirm that the woman would be getting physical therapy visits in addition to home nursing care for her hypertension and diabetes.

Through it all, Kenia was careful to keep her patient informed about each step. "I tell everyone I work with, we're not here to change you but to help you take good care of yourself, so you can stay safe at home," she notes. For Kenia, seeing her clients in their home environment is a key to resolving their issues. "You see the whole person that way," she says. "You begin to understand why they're not taking their insulin, or realize that the reason their adult child isn't coming around is because the parent is shutting them out. Every patient has a different dynamic and different challenges. When I'm with a frail elderly woman who speaks no English and is overwhelmed by paperwork, and I can break everything down for her and make it manageable and obtainable so that she lights up with understanding, it's a great feeling."

Marilyn Dos Santos, a social worker with VNSNY Hospice and Palliative Care, uses the same sense of empathy and commitment to help patients and their families handle the challenges that arise at the end of life. Dealing with tricky family dynamics is commonplace in Marilyn's work. "The role of social workers in hospice is to help families negotiate uncharted territory," she says. "I always tell patients that in hospice we work as a team. The nurses help them with the stress inside their bodies, and I help them and their family members cope with the stress outside their bodies. I help them adjust to what's going on and give them a sense of control."

To encourage families to open up, Marilyn often uses humor. "I'll ask patients and family members to pinkie swear about something. Nine times out of ten they'll laugh, and then they'll shake pinkies with me!" she chuckles. While she doesn't try to fix everything -- "If a family had trouble getting along before, they're not all going to suddenly get along now" -- she does try to get families to share their feelings and work through them. "My goal is to help everyone come together so their loved one can feel more peaceful during his or her last days."

Marilyn's work may also involve arranging for home health aides and making sure advance directives are in place and understood. If everything is going smoothly, she'll typically check in with a client every couple of weeks. "When it gets closer to the end, though, I visit more often, because that's when I'm really needed," she notes. "Patients need help acknowledging what's happening, and families need help with their feelings of helplessness and uncertainty."

Ultimately, says Marilyn, a big piece of what she does involves providing reassurance and the strength to deal with often unwelcome changes. "I have one elderly patient who is dying from Alzheimer's," she says. "She lives with her daughter, who looks after her every minute of the day. The daughter was the baby of the family, and she's having a lot of difficulty acknowledging that her mother doesn't have much time left. My goal is to help the daughter reach that point where she's ready to let go -- to help her accept that she's done a wonderful job taking care of her mom, and that now it's time to let nature take its course."

Social workers also play an essential role at VNSNY CHOICE Health Plans, which includes comprehensive managed long term care plans, helping members deal with everything from mental health issues -- administering depression screens and linking members to mental health services as needed -- to helping plan members and their family caregivers navigate Medicare and Medicaid and arranging for services like food stamps or housing assistance. "Sometimes I'm just giving support, listening to their concerns and encouraging them to do something they enjoy," says CHOICE social worker Grace Owen. "I work closely with our plans' coordinators of care, keeping them informed of what my interventions are and tracking what's happening in terms of medical follow-up."

We also have a wonderful group of psychiatric social workers who spearhead our community mental health teams, as well as social workers in our business development and private pay divisions who work through other avenues to address the mental, behavioral, emotional, and other social work needs of our patients and members.

Social workers are filling these same vital roles at every home health care organization across the country. The outstanding and irreplaceable support they provide -- not only to patients, but also to the nurses, therapists and home health aides that they're collaborating with -- underscores the reality that effective home care is truly team endeavor.

In these final days of March, I hope you'll join me in taking this opportunity to recognize and thank America's social workers for their vital contributions to the well-being of our nation. The empathy, skill, emotional support, and problem-solving expertise they bring to their work is making us a healthier, better, and stronger nation -- for which we should all be immensely grateful.