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CME-MOC

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Time Stamps

• 03:54 What are the various roles within a multidisciplinary teams?
• 10:48 Understanding limitations of social workers and case managers
• 15:55 The “behind the scenes” paperwork 
• 18:42 Insurance and medications
• 22:17 Insurance and disposition options
• 25:15 The importance of creating a safe space for better communication

Show Notes

Part 1: Setting the stage

• The demands to our healthcare system – increased volume of patients, new metrics to which we are held, documentation requirements – have compressed the pace of our day-to-day work on the wards and in the clinics.
• This compressed pace impacts all members of the interprofessional team – including social workers (SWs) and case managers (CMs).

Part 2: 5 Ways to Improve Collaboration and Understanding

#1: Role Confusion

• “Role confusion” is defined as a lack of knowledge around the precise scope of practice of SWs or CMs (or how these two roles differ from one another). This is thought to contribute to workplace tension on interprofessional teams.
• The codes of ethics for each role emphasizes empowering patient autonomy and facilitating patient decision-making.
  • Training: 
    • SW: Bachelor’s or a Master’s degree in social work (BSW or MSW) as a minimum requirement. Those with additional training in providing mental health services and counseling are called Licensed Clinical Social Workers (LCSW).
    • CM: Less standardized, varies by state. Usually hold a bachelor’s degree, but can sometimes be nurses or SWs by training. About 4% of CMs are SWs.
  • Team care roles:
    • Both: experts in facilitating and coordinating transitions of care and accessing community resources 
    • As above, LCSWs can provide counseling to address social and/or mental health needs
    • CMs have emphasis on addressing barriers to care. They often follow patients longitudinally and act as an advocate in:
      •  Accessing resources such as housing, medications, transportation, equipment, medical appointments.
      • Facilitating cost-effective care. 
  • In practice, these roles are defined differently at every institution. Ask your SW/CM colleagues early and often what their individual scope of practice is (and remember – social workers often ask each other!)

#2: Understanding limitations of SW and CM

• Because we aren’t always 100% clear on what’s in the purview of our interprofessional colleagues, our referrals to SW or CM often lack specificity or a clear “ask”.
• We may be making things worse by over-promising solutions that are not feasible. SWs and CMs often have their hands tied by insurance, time, and other limitations.
• Be realistic of the limited resources our case manager and social work colleagues have in their toolboxes.

#3: The “Behind the Scenes” paperwork and documentation 

• IPT members are often sensitive about approaching clinicians to sign off on documentation (e.g. peer-to-peer reviews, wheelchair scripts, letters of medical necessity for hospital bed).
• Takeaways:
  • Although seemingly mundane in the scheme of sick patients, these requests are important.
  • Moreover, IPT members may have already spent hours on the phone interfacing with insurance companies before they come to you – meaning that the “last minute form” may represent a significant amount of work and coordination on their part.

#4: Insurance and medications

• Harness your EMR’s ability to make insurance status front and center. 
• Become familiar with “big-ticket” medications that may receive approval by insurance (see below for examples). When you see these on your med list, give a heads up to the CM so she/he can run a test claim:
  • DOACs
  • Certain insulins
  • Newer diabetic regimens
  • Oral chemotherapeutic agents
  • Newer antiplatelets (e.g. ticagrelor). 

#5: Disposition planning

• Insurance status can impact where a patient can go after hospitalization (more on that in the next episode). 
• If you have a medically stable patient waiting for authorization or making a choice for disposition options, consider speaking to the patient regarding their expectations, fears, goals. That extra “nudge” from the clinician may very well be exactly what they need to make a decision!

Part 3: Improving Teamwork

• In organizations such as healthcare, we often don’t prioritize intentional training around teamwork: 

 “It is naïve to bring together a highly diverse group of people and expect that by calling them a team, they will, in fact, behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the 2 hours on Sunday afternoon when their work really counts. Teams in organizations, though, seldom spend 2 hours per year practicing when their ability to function as a team counts 40 hours a week.” 

• Consider creative ways to create psychological safety among the interdisciplinary team.
  • Vocalize your appreciation for the work your IP colleagues do.
  • Not only does it feel great to share in the gratitude – it often fosters a culture of goodwill and cooperation at your workplace!

Transcript

Part 1: Setting the Stage 

Drew: I got into this to like be a part of a system that helps people and heals people and provides kindness. I don’t think we actually make them that much more healthy in the long term. We fixed an acute thing and we were like one of my fingers in this hole, but man… the next crack in the dam is about to burst. But I was here to fix this thing so I’m holding it in, you know, and that’s overwhelming, right? 

I don’t know how many, what your caseload is, but it’s so long and all you really want to do is… I just want to be off shifts so I can go home and be on call, but I won’t be here.

Susan: Everybody’s always under a tremendous amount of pressure to get people out of the hospital quickly. 

Shreya: Those aren’t the voices of tired residents or attendings, those are actually the voices of social workers and case managers, Susan Hedlund and Drew Grabham at OHSU.

Susan: It used to be in the old days, we had time, you know, we had time to plan for some of this. And I think that’s been one of the biggest changes in our current medical system is we rarely have much time.

Shreya: Truthfully, I never really thought about how the new demands of of our health system impact social workers and case managers. It’s so easy to feel bad for myself, four new admissions, 20 notes to write and billing to do. The more I spoke with our interprofessional colleagues, the more it became apparent that we all feel the strain. And Drew speaks to that tension he sees and has felt in the past: 

Drew: …you kind of just get caught in the machine and as you’re doing the 20 of those discharges, you kind of lose touch of the human side of things. And then you kind of get dehumanizing and it’s a lot easier to just kind of like churn people out. And then once you sort of realize that release for me, I would recognize like, “Oh that’s not who I was. That’s not how I got in this. But really just recognizing that oftentimes we’re the messengers, especially in hospitals of a broken system.”

Shreya: We do become messengers for the system. And unfortunately, that means most of the exchanges we have are just reflections of our to-do lists, “Did you fill out that shelter packet?” “When is transport coming?” “Is the patient medically cleared?” 

Drew: We have these multidisciplinary teams but we aren’t really talking. We don’t, we don’t get a chance to like kind of talk about that or, or even dialogue with our colleagues about the pressures we feel like when it’s happening and kind of commiserate. But when we can slow, slow down and step back, we often find like, yeah, none of us liked this, this discharge. 

Shreya: Without much pause in the day, it’s easy to fall into the trap of thinking it’s us against the SW and CM who want to get these patients out.  But we are all being held to these metrics, this volume, this pace. I have rarely got to think what’s it like to be in the shoes of a social worker and case manager nowadays.

And importantly, if we are all so busy with trying to get done our piece of the pie, when do we get a chance to learn from each other? 

That’s where the beauty of podcasts come in, let’s go places we don’t go and the perspectives of people that we don’t usually get to hear. Welcome to our 2nd interprofessional education series on Core IM. I am Dr. Shreya Trivedi, an internist at NYU. And today I am joined by:

Ryan: I’m Dr. Ryan Chippendale, a Geriatrician and the Geriatrics Fellowship Program Director at Boston University.  Thanks for having me on!

Gaby: I’m Gaby Mayer, a 4th year medical student at NYU. It’s been great to learn alongside you all. 

Shreya: I hope you will be curious with us and learn with us. 

Ryan: So today, we will start with hearing 5 ways for potentially improving collaboration and understanding with case managers and social workers. 

Shreya: I do have to give a heads up that the latter points are geared towards inpatient or nursing homes but Ryan did sprinkle in her outpatient geriatrics hat.  After those 5 points, we will end hopefully on an inspiring and creative note on how to better work together.

Part 2: 5 Ways to Improve Collaboration and Understanding

Point 1

Gaby: I have a confession to make…

Shreya: Safe space!

Gaby: Before doing research for this episode, I wasn’t entirely clear on what SWs and CMs do and what the differences were between the two.

Ryan: I can say with certainty, Gaby, that you’re not alone. I’ve been working on interprofessional teams for 8 years now as a geriatrician and I’m still learning on the regular about the many areas of expertise that these folks offer our patients.

Gaby: Ok that makes me feel better, medicine is lifelong learning, this included. What’s interesting is that this lack of knowledge around what social workers and case managers do – what we’ll call “role confusion”-  is actually cited as a main factor contributing to tension between physicians and SWers. 

Drew: In our residency they’re not like, “Hey this is the medicine floor. This is your case manager. They do discharge planning, here’s the social worker. They do stuff and that’s what they told you. You’re like, okay you do stuff so I’ll just send you stuff.”

Gaby: Just as Drew describes…I can’t remember ever getting taught what social workers do during medical school or while rotating on the wards. So if we don’t have explicit training in this – who does teach us? Answer  often the social workers or case managers themselves:

Susan: I was really young and it was new in my career, but I remember there was an occupational therapist who, uh, didn’t think that social work did anything other than apply for Medicaid…And so those were early pain points for me of trying to figure out how do I try to show the value that I might bring to our patients, uh, while not alienating my colleagues, you know, and that, and that took, took some years to finesse, if that makes sense.

Gaby: What this shows is the way in which role confusion can impact a SW’s lived experience in the workplace. So let’s try to alleviate a little bit of this role confusion and define the jobs that so many are confused about.

Let’s start by talking about SWs. Social workers hold either a bachelor’s or master’s degree in social work (BSW or MSW). In addition, some social workers have additional training in mental health services and counseling. These SW will have the initials LCSW behind their names (standing for licensed clinical social worker).  

Susan: We also have skills in individual, family and group therapy. So this is a little known fact that the largest number of mental health providers in the United States are our clinical social workers.

Shreya: Quite an important skill and role that SWs play on a population level! What about case managers? What’s their training like?

Gaby: Case managers at the minimum only need to hold a bachelor’s degree, however many have a nursing background, and a few (cited as few as 4% or so) have a SW background.  Regardless of their degrees, the majority learn their roles from on-the-job.  

Shreya: Sounds like intern year. But how do these distinct trainings play out in practice?

Gaby: This is where it gets confusing. Despite different training and skills on paper, in practice the roles of social workers and case managers can overlap a fair amount. Both can be responsible for facilitating transitions of care and accessing community resources (e.g. housing, financial assistance, insurance applications). 

The one hard and fast that is worth highlighting. However – because social worker training has that extra emphasis on counseling, they can provide counseling services for i.e. those with substance use disorders, mental health diagnoses or other social needs. 

Ryan: To hammer that point home, if I think about all the different SWs I work with, their roles differ a ton based on the site of care we’re in. In the outpatient world, I consult them mostly for counseling and resources vs. the inpatient or nursing home settings, where they’re more involved in care coordination.

Susan: What confuses the issue is that in many health systems, social workers are the discharge planners. And so, um, and a lot of people will tell us that they, social workers feel frustrated that they’re not getting to practice at the top of their license using their clinical skills because instead they’re calling nursing homes and things like that

Ryan: I think we can all relate to that feeling of – “wait a minute, the responsibilities of the job that I’m currently doing are not exactly matching all that training I did.” And that certainly doesn’t feel good…

Shreya: Not at all. So if SWs have these counseling skills, what distinguishes CMs on the job? 

Gaby: They focus on getting to know the patient’s barriers to care. They’ll use this knowledge to advocate for the patient in terms of: psych care, meds or housing (how many stairs does this pt have to climb?). They also keep an eye on patient navigation (i.e. making sure patients don’t have conflicting appointments) and what’s going to be cost effective for that patient. 

Ryan: And to add to that… what I distinctly see in my geriatrics practice is that case managers build really intimate relationships with pts and families long-term.. often over the span of years, but sometimes even decades.  

Gaby: So we’re starting to get a sense of how these roles occupy different niches. But like most things in medicine, we have to take these role descriptions with a grain of salt because in reality, the responsibilities for CM vs. SW can look very different across different hospitals, their prior training, and inpatient vs. outpatient, and everything in between.  

Drew: I’ve gotten much better at being like, Hey, what’s your title and can you tell me exactly what’s kind of in your scope or not in your scope?  I go to different hospitals and there’s different, you know, some hospital systems, he has a social worker here, all just discharge clinician, some they’re just therapists and all these things. So we just got to get better at understanding like what does it, you define your role as just to have an understanding. 

Gaby: So I’d say the biggest take away here is ask your SW or CM colleagues what their scope of practice is. There’s no shame in asking – even social workers have to ask each other.

Point 2

Ryan: Understanding the training and roles of our interprofessional colleagues is definitely the starting point. But once we’re there (which we hopefully are now!), we need to be mindful of the limitations that social workers and case managers face. 

Shreya: Just like how clinicians face the limits everyday of what we can do medically for tough conditions. Our second point gets at that: what is actually in the purview of our interprofessional colleagues? This point comes up more and more often for complex patients.  

Drew: Social work referral: “homeless”. And I’m like, “Okay, you want me to confirm that? Like what is it you want me to do with that?” And it’s very impersonal. So I think it feels overwhelming.I think it kinda starts with the physician because often they’re the first person with this very morally distressing case. And it’s not that they intentionally want to pass it on. But sometimes like, “Oh, and they’re homeless like, well, and I’m going to just do a social work referral.”

Ryan: Drew reminded me of so many times in my training when I was managing a complicated patient, that I truly had no clue what I was asking or who I was asking my question to, but just wanted to scream HELP!  Drew called this “passing along the moral distress.” The point being… that it’s not that these referrals to social work are wrong or inappropriate, but we have to acknowledge our SWs and CMs are also limited in what they can do.

Drew: I mean, I still think homelessness is an appropriate referral. Like I think if someone has addiction, mental health, um, lots of trauma, um, homelessness. But, but the, the reality is, we’re not going to solve those, but maybe we can just acknowledge them and then reflect on how those things might be at play during their hospital stay or during their engagement after the hospital system. 

Ryan: There’s no magic wand. But when we do loop in our team members, it’s important that we are as specific as possible with our “ask”. 

Drew: Let’s just get a little bit more specific and have a better communication style. “What is it you think I can do?” Cause again I get a referral. Homelessness, I don’t know what you want me to do. Confirm it? Acknowledge it? Fix it? I don’t know. Tell me a little bit more. You know, they think I’m going to house them then. And then they start to get mad and then they already have like a negative interaction towards this patient – some do, I should say, when they’re burned out. Of like, “Oh you know they want me to house them.” And if there’s not that clean dialogue and conversation and so it’s just, it gets back to the systems that we can do better.

Ryan: For example, in the clinic, I get really detailed with my consults to our social worker. Using the example Drew gave regarding homelessness, I instead may write something  along the lines of: “pt is facing eviction, please assist in connecting her to resources to help with an urgent housing application.” Or “please provide counseling over the stress of this pt losing her home.”

Shreya: You are a SW’s dream!

Ryan: Years of practice!

Gaby: So, this is kind of like how I have been taught to never place a cardiology consult that just states “chest pain”. And instead on my Sub-I, would rehearse my well-formulated, specific question before calling to make sure we got the most out of the consult.

Shreya: Exactly! It’s a best practice across the board regardless of who you are consulting. But you know what can be even worse? Overpromising things to our patients when we really have no idea what our colleagues are actually capable of offering either from an insurance angle, time or resource limitations.

Susan: For example, the um, palliative care social worker I was speaking about yesterday. She’s dealing with this really complex situation with a patient who has longterm houselessness. And the hospitalist said to the patient, we’ll find you a place to live before you’re discharged. And that’s probably not possible. [laughs] And so I think, I think one of the things it’s helpful, if people ask before they promise services that we may or may not be able to deliver on.

Ryan: I wish I could say I didn’t see this all the time. But often a very eager and well-intentioned clinician will tell a patient…without consulting anyone… that they can go to rehab or get home services that a social worker or case manager could literally tell you in 6 seconds flat won’t be possible with their particular insurance. 

Gaby: Yikes I can totally see myself doing this as an intern.

Ryan: Yep, I’ve definitely done it.. And then guess who’s forced to go in and undo the damage? The case managers and social workers! Which usually doesn’t lead to a satisfied patient. And can contribute to lots of frustration for our colleagues.

Gaby: And I bet if that’s repeatedly happening that can fracture our sense of cohesiveness and lead to burnout. 

Ryan: I’m afraid so. So the biggest take-away for this point is to be realistic of the limited resources our case manager and social work colleagues have in their toolboxes. And the more specific our question is, the better.

Point 3

Shreya: And once they are involved with that specific Q, the third point that SWs and CMs spoke about was the misunderstanding and tensions that can come with some of the “behind the scenes” work.

Ryan: And by “behind the scenes work”, I know you’re referring to paper-work, right Shreya? Our favorite!!!

Shreya: Ughh… hope you are kidding there

Ryan: Clearly! It’s what every clinician dreads… peer-to-peer reviews, wheelchair scripts, letters of medical necessity for hospital beds. 

Susan: Where doctors unfortunately get harassed by those of us trying to get pre-authorizations is that we often need the physician to either write a letter or sign off on why this particular treatment is essential for this patient’s care. 

Ryan: It’s interesting that Susan uses the word “harassed” here. Gosh, I hope that I’m not giving off that vibe. I get that we often feel inundated with these requests and I worry that some of that push-back can get misdirected and we end up shooting the messenger with rude tones or eye rolls. 

Shreya: Yes, many times as clinicians we only see that one extra phone call we have to make or piece of paper we have to sign, but don’t see the very time consuming behind the scenes work that our SW/CMs are doing to even get us to that point. 

Todd: We’ll get a call from the oxygen company and you know, then you sit on the phone with them and talk to them and they’re like, well we can’t do it. And I’m like, well what do you need that so that we can get it. And then, you know, I’ve gone on this back and forth thing now like five times and that’s when they usually come to the physician. So know that, you know, by the time we get to you and knowing that it can be covered, that and then it has to be worded that way. We’ve had, you know, maybe five conversations up until that point. So we’ve spent a lot of time on that too.

Shreya: That’s Todd Selmer a registered nurse case manager at the University of Utah. And since talking to him, I’ve been looking more at the CM notes. Some of the documentation reflects this run-around “called X nursing home Y times, got put on hold for Z minutes, transferred to different unit and told to call back tomorrow.” 

Ryan: And when we are finally pinged about that last bit of paperwork, it can seem in that moment, frankly, less important. We are not saying that this makes  that “extra-thing-to-do” is an easy pill to swallow, but now understanding all the work that goes into it, I’m hoping all of us, myself included, can be a little less “emotionally charged” when it comes our way. 

Point 4

Shreya: A lot of that behind the scenes work like prior auths or letters of medical necessity is dictated by insurance policies. And, insurance is a pain point for us all.

Ryan: Preach.

Shreya: But from the perspective of a case manager, they point out its when we don’t not taking into account the patient’s insurance status, particularly with choosing medication options during the hospitalization or for their long-term trajectory:

Todd: If they don’t have insurance that’s going to cover, you know, let’s say it’s Lantus and we’re going to have to put them on as a 70/30 which is like $25 where the Lantus is let’s say $260. One of the big things is to start looking at that during the treatment process so we can work with our, our medical team and say, “Hey, did you know they’re unfunded? You have them on Lantus, can we switch them to something else so we can get them on a, an insulin regime that is going to work when they leave the hospital with, with the funding that they have if it’s out of pocket, if it’s insurance and what the coverages are.”

Shreya: I’ve seen this too often – we titrate a patient’s hyperglycemia on glargine. And say the CW comes in on Monday and point, “OH wait – the pts insurance won’t  cover that.” And we change to 70/30 insulin or a cheaper regimen an hour before discharge. Which means you are GUESSING how they are sugars will respond. 

Ryan: I know it’s hard to add another thing to keep in mind! But some EMRs can actually (if you can believe it) be helpful with this – by either allowing us to add an insurance column to our inpatient lists or adding it to the top banner, making it front and center. 

Shreya: OH YES! Plug for that – I recently added the insurance status column right after the patient, room # and it’s been easy  and useful to get a quick heads up if a patient is uninsured or medicaid and let me loop in the CM early in terms of expensive meds.

Ryan: And especially because some hospitals have charity care or extra services for uninsured patients, our SWs and CMs can help pull in how to still access some of these treatment options.  

Todd: Some of the IV stuff, we have an infusion team that works in our hospitals, so we’ll give them a heads up when we think someone’s going to need, you know, six weeks or a month of an antibiotic for osteo and we’ll have them do a test claim to see, you know, what their insurance is going to cover, what’s the out of pocket for the patient. And so anytime we’re looking at like big ticket items or would that, you know, you realize that have gotten denied by insurance before is you got to keep those in the back of your head when you’re starting to send a patient out.

Shreya: While I wish I had this all stored in the back of my mind, I feel learned those big ticket items that may not get insurance coverage trial by fire and getting some deep sighs for not looping people on the earlier side.

Ryan: All the time! I spoke to some of our case managers here about what those common big-ticket items are and the ones that we came up were the DOACs, certain insulins or newer diabetic regimens, oral chemotherapeutic agents, newer antiplatelets like Ticagrelor. So with these.. giving a heads up to the CM allows them to run that test claim of how much a med will cost and then they’ll go and talk to the patient to see if they can afford it.  If not, back to the drawing board and discharge delayed! 

Point 5

Shreya: Very similar to being mindful of the patient’s insurance status with big-ticket medications options, we also heard from the SWs and CMs, about being mindful of how a patient’s insurance status can impact the patients disposition.

Todd: I think the main thing is, is not giving us the information soon enough when you know that they’re going to have some dispo problem. Um, I, I think one of the big things that I see in our, in our meetings is, is that we’ll hear from PT that oh a patient needs a skilled nursing facility and then we look at the insurance and we’re like, ah, sorry, they’re unfunded. And then that’s like, “Oh, now we’ve got to start shifting gears and figure out what we can do for them to make them have a discharge.”

Ryan: Now wouldn’t it be great if we had 15 hours to be on pre-rounds, being as thorough as possible with things like insurance for every patient. Likely not gonna happen in this lifetime. But I do think, with experience, we can learn which patients have risk factors that lead to dispo issues. 

Gaby: Hopefully we’ll help give you framework for dispo options based on insurance with the next IPE episode. 

Shreya: Another dispo point is on collaborating on how we can help move a pts care forward, especially after the pt is not medically active anymore or is unfortunately a “rock”.

Todd: If you hear your case managers just saying like, wow, the patient will make a choice, they won’t make a choice and you know, push them to, you know, get with that patient because that is where you’re really going to get your days on the end that you are going to be staying in the hospital where you’re, you stand around and be like, we’re just waiting for auth. But one of the big driving forces of that is being proactive when patients come in and getting that choice, helping them, guiding them in the direction of picking a facility.

Shreya: It’s easy when a patient who is waiting for a SAR to just pop-in and out of a room, esp on this busy days I just have to ration my time but Todd’s point is well taken – when I do go in, ask about how he or she may be thinking about the options for facilities and maybe I can help navigate some of that.

Ryan: I’ve definitely had CMs on my team thank me for that extra nudge or info I collected to get things moving for a patient.

Gaby: It’s almost like a two-hit hypothesis.

Ryan: Uh – a what?

Gaby: It can sometimes take multiple different members of the care team to nudge a patient towards a final decision about their dispo options. So it’s not redundant for an intern to go talk to a patient about dispo if the social worker’s already been in. It’s just part of the process!

Part 3: Improving Teamwork

Shreya: Hearing about some of these areas of better collaboration that SWs and CMs shared makes me reflect on a quote that I found a few years ago a MedEd article  from 1974. 

Gaby: I love this quote. Let me share it with the audience:  “It is naïve to bring together a highly diverse group of people and expect that by calling them a team, they will, in fact, behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the 2 hours on Sunday afternoon when their work really counts. Teams in organizations, though, seldom spend 2 hours per year practicing when their ability to function as a team counts 40 hours a week.” 

I don’t even like football and I love this quote.

Ryan: Exactly, it is naive to bring together a resident, attending, CM, SW and nurse and think that just because we call it a “team” that they will in fact behave like a high functioning team, without any practice or pause.

Gaby: So how do we navigate these assumptions around interdisciplinary collaboration? How do actually build up our teams and practice working within them?

Shreya: No right answer. We are moving more and more to team based care but how do we create space to talk about how best to work with each other, hear those frustrations that come up and navigate them. A recent Q.I project I tried. I took a 5 min pause on the 1st day of an inpatient rotation at the start of multidisciplinary rounds and we actually went around and introduced ourselves and our role.

Gaby: Wait, cool – this is exactly what Drew recommended to alleviate Pain Point #1!

Shreya: Yes after we’re on the same page of who was the SW vs the CM their role or which intern was who, we  then in a very appreciative, non-judgemental way talk about – What does ideal communication look for everyone and how do we get there? 

Ryan: The underlying thing you’re doing there, Shreya, is intentionally creating that psychologically safe space.  

Shreya: Yeah it was really great to hear feedback on what is actually helpful for the nurse to hear on those rounds or have the CM feel comfortable speaking up more instead of the resident monologue running through patient. But the best part was the next week, we took time to give positive shout outs on things we talked about the past week — [not euphemistic person] it was close to magical to seeing the SW give my borderline burned out intern a shout out in front of everyone for helping out with a difficult dispo situation or the senior resident giving a nurse who went out of her way a shout out and its was eye-opening to see how far people feeling appreciated can go.  

Gaby: Dr. Daisy Smith from the ACP also spoke to us about the power of appreciation:

Daisy: I was precepting residents in clinic and uh, one of the residents was presenting a patient who, um, had been homeless with multiple complex medical problems The patient was there for followup and the resident mentioned, uh, that the patient had recently moved in to temporary housing and, um, that their medical problems were under much better control. And I said, you know, who was the social worker helped you? And she told me who it was. And I said, well, why don’t we go and find her and let’s go in and celebrate this moment with the patient together. Since then, you know, I felt like whenever I need anything in clinic, like that social worker is really, you know, she’s just so appreciative of, um, our including her in that a successful moment.

Ryan: And It’s just much more fun to come to work when you’ve developed great relationships with the people you work with. We’re all on the same team. We all got into medicine to help patients.  Yes we work under less than optimal conditions with less than optimal pressure and pace, but we do need each other to move our patients care forward and our patients need us to truly collaborate in a cohesive way!

Shreya: Absolutely. To summarize what I am taking away from hearing these SW and CM are 5 potential opportunities to better collaborate: #1 is gonna be the foundation of understanding their unique roles and responsibilities in your work setting, 

Ryan: #2 knowing the limitations of what they can practically do, #3 lets not shoot the messenger of a less than ideal system that we work and be a little bit more empathic to all the behind the scenes work that we all have do, #4 being mindful of a patient’s insurance status particularly for expensive medications and, #5 being mindful how the patient’s insurance might impact the disposition(which we will cover in the next episode).

And last but certainly not least (its a bonus point!),  the importance of taking the time to appreciate and even celebrate each other’s wins, however big or small!

We know all of this is easier said than done, when you might have more days than you’d like where you’re being pulled in every direction, but hearing the SW and CM perspectives definitely gave me food for thought and opened my eyes to opportunities to better work with each other

We would love to hear from you how you may be creatively building that psychological safety among the multidisciplinary team members. We would love to hear this episode was helpful for you, and if so how? Tell us if you are inspired to make any changes and continue this conversation with us on twitter or via email. Please share with your colleagues or team members. 

If you liked this episode, give it us a rating on itunes or whatever podcast app you use. It certainly helps people find us.  Remember you can get CME credit with ACP from this episode. Link will be in the show notes. Thank you to Arra Maklein for audio editing. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. And thank you! Take care!

References

• https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout/
• Mizrahi, T., & Abramson, J. S. (1985). Sources of strain between physicians and social workers: Implications for social workers in health care settings. Social Work in Health Care, 10(3), 33-51.
• Demoratz, M. (2018). The Social Worker Case Manager:“Owning” the Psychosocial Issues. Professional case management, 23(4), 228-230.
• American Case Management Association. (2013). Standards of practice & scope of services. Little Rock, AR: American Case Management Association.
• Wise, H., Rubin, I., & Beckard, R. (1974). Making health teams work. American Journal of Diseases of Children, 127(4), 537-542.
• Song, H., Ryan, M., Tendulkar, S., Fisher, J., Martin, J., Peters, A. S., … & Singer, S. J. (2017). Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods study. Health care management review, 42(1), 28-41.