GE Healthcare Camden Group Insights Blog

Navigating the Social Worker’s Role Within a Care Team

Posted by Matthew Smith on Oct 20, 2015 1:48:39 PM

By Megan Calhoun, MS, MSW, Senior Consultant, The Camden Group

Care TeamSocial determinants of health are a leading healthcare topic due to their association with costly and potentially avoidable events, including Emergency Room visits and hospital admissions. Living alone, experiencing loss, insufficient finances, a lack of caregiver support, or a limited education have all been shown to impact the occurrence of these potentially preventable events(1). Recent reimbursement changes emphasizing elements of the Triple AIM and value in healthcare are driving organizations to focus on minimizing these events by deploying care management resources aimed at meeting the social needs of patients.

Effective care management requires a highly specialized, interdisciplinary team focused on meeting the medical and psychosocial needs of a patient. With readmission penalties, reimbursement strains, and a shift towards patient-centric, coordinated care, organizations are looking to invest in care management teams that can effectively manage the patient across all settings of care and avoid unnecessary inpatient admissions. Social workers have specialized education and training that enable them to provide necessary social services and serve as an integral part of the care team; they possess skills to view the patient in the context of their entire situation, engage the patient in a plan of care, and reduce unnecessary admissions stemming from psychosocial issues. 

Engaging the Patient In a Care Plan

The key to any intervention is a patient’s engagement in the development of their care plan and subsequent adherence to the agreed upon goals. Social workers are trained in the skills necessary to develop rapport with patients and do not proceed with care planning or interventions until the proper foundation for this working relationship is built. Patience, compassion, and integrity are key components in this process along with a strong focus on meeting the patient where they are. Developing this relationship can be a fragile process and one that takes time; often, the patient just needs someone to listen to them. Medical social workers are often not under the same time constraints as physicians and nurses and can spend more time with their patients to fully develop this relationship. The goal of this process is to ensure that the patient feels fully supported as they strive to achieve their goals and that the care plan is created jointly between the interdisciplinary team and the patient. The patient will feel accountable for their self-management if they are engaged in the care planning process and feel as though their goals are achievable. The patient should feel comfortable reaching out with any questions or concerns and the social worker should make the patient feel as though all concerns are validated. Utilizing a social worker appropriately and to the top of their license can help alleviate time constraints on nurses, nurse practitioners, and physicians.

A Role Within Team-Based Care

It is widely accepted that psychosocial issues and a lack of appropriate social support are primary causes for care transition failures, readmissions, and lack of care plan adherence. In a team-based care management model, the perspective of the social worker helps to ensure that the patient remains at the center of the care plan and that interventions take into consideration the patient’s current medical, emotional, cognitive, and financial status. The biospychosocial approach employed by social workers to assess a patient may uncover social determinants of health status that get overlooked during a standard physical or office visit. Many of these issues stem from a lack of adequate resources and lead to costly, unexpected admissions and Emergency Room visits. A patient may be repeatedly presenting at the Emergency Room because bed bugs are preventing him from sleeping comfortably at home; he has been unable to pay the electricity bill; or, he does not know where else to get a free meal. A complete biopsychosocial evaluation will enable the social worker to determine whether the patient needs resource management and education, additional care management support from a clinical perspective, or mental health treatment. When needs are identified, arrangements can be made to connect a patient and their family to resources for medication funding, transportation, housing, warm meals, legal support, and a host of other  necessary supports that can make caring for a chronic condition easier. Through relationships with community-based resources, social workers can connect patients to less costly resources and services that are not typically included in the clinical plan of care but can be supportive, and at times even more effective. Barriers are identified and assessed and the social worker works continuously with the patient and his family to overcome these barriers. 

Evaluating Social and Medical Concerns

Social workers can expand a team’s view of the patient and thus the success of the care plan. They are taught to view the patient within an entire system, that is, within the context of their family, friends, resources, and community members; they evaluate a patient’s health in the context of the patient’s needs, expectations, rewards, and available support system. They put themselves in the patient’s role and assess how these interconnected systems are affecting the patient. For instance, many underlying problems for patients with chronic conditions and multiple co-morbidities are not medical in nature, but due to a lack of social support. Through the lens of a social worker, issues are uncovered which, if left untreated, could exacerbate medical conditions and drive unnecessary clinical costs. Often, non-traditional and non-clinical solutions are identified and implemented. For instance, the installation of an air conditioner may be all that is necessary to keep a chronic asthmatic out of the Emergency Room. Utilizing systems theory allows social workers to clearly see the interplay between social and medical concerns and address the real root of the problem. 

The use of social workers within an interdisciplinary team continues to be a model for success. Their work complements that of nurses, physicians, and pharmacists and helps to view the patient in his entirety, not just as a medical condition. 

Sources: Calvillo-King, Linda, Danielle Arnold, Kathryn J. Eubank, Matthew Lo, Pete Yunyongying, Heather Stieglitz, and Ethan A. Halm. "Impact of Social Factors on Risk of Readmission or Motality in Pneumonia and Heart Failure: Systematic Review." Journal of General Internal Medicine. 28.2 (2013): 269-82. Print.


Ms. Calhoun is a senior consultant with The Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. Her experience includes care model design and implementation that spans the continuum. She may be reached at mcalhoun@thecamdengroup.com or 310-320-3990. 



Topics: Value-Based Healthcare Team, Care Team, Megan Calhoun, Social Worker

Top 10 Critical Success Factors for Care Model Redesign

Posted by Matthew Smith on Jun 24, 2015 12:33:27 PM
By Bridget Gulotta, MBA, MSN, RN, Senior Consultant, and 
Teresa Koenig, M.D., MBA, Chief Medical Officer, The Camden Group

Care Model Redesign, The Camden Group, Population HealthAs the healthcare landscape shifts from volume-based fee-for-service reimbursement toward value-based risk sharing payments and penalties, organizations must develop new and innovative strategies across all care delivery channels. In order to move to true value-based care, financial models must be aligned, and the quality and overall patient health and outcomes must be addressed. Care model redesign is a necessary solution to achieve success and long-term sustainability.

The process of care redesign entails a systemic shift in the way care is delivered across the continuum with input from leadership, acute and post-acute clinical and administrative staff, and community partners and stakeholders. To ensure effective and efficient integration and strategic alignment, a governing steering committee should be established, and their vision and recommendations implemented by working groups that focus on distinct components. The following represents the top 10 considerations needed to implement transformative care.

1. Use an interdisciplinary care team approach supported by plans of care. Focusing on the accountability and improvement of the care delivered across settings for all dimensions of health and associated costs is a collaborative approach. It includes different disciplines working together to share knowledge and skills to guide and impact patient care. A physician drives the clinical care but collaborates with the entire team, with the ambulatory care manager as the consistent thread who follows the patient throughout the continuum of care. The patient and his/her family or caregiver is an integral part of the care plan development. The developed goals are patient-centric and focused on the patient’s preferences and wishes, taking into account specific cultural and linguistic needs. Each provider and/or discipline contributes to and aligns care with the patient’s plan and goals.

2. Target care from both a medical condition(s) and social determinant perspective. In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum, with a focus not only on the clinical aspects of care, but of equal importance, and at times more important, the social determinants of health. This includes access to care, caregiver support, behavioral health, social economic status, health literacy, adequate food and shelter, addiction, etc. Key components of a “whol-istic” approach include: patient/family engagement, tools for effective self-management of chronic conditions, an individualized comprehensive treatment and continuum-based care plan, health education for disease and medication management, primary care, and care management follow up – all supported with appropriate community-based resources.

3. Facilitate new patient identification, and identify high-risk population(s) to address barriers to care (e.g., poverty, behavioral health, health literacy, social support, etc.). The use of risk stratification is necessary to manage patient populations and identify high risk and risk rising patients who need proactive and careful management. The development of interventions to address individual clinical and social needs is recommended to improve the success rate of transitioning the delivery of care across settings. Risk stratification methods enable the prioritization of clinical workflows by cohorting patients for population health and disease and chronic care management programs. Additionally, they help ensure patients receive an assessment and inclusion into the appropriate case management programs. Homegrown and proprietary platforms exist, but all stratification models should include the critical components of comorbidities as well as (but not limited to) age, poor pain control, and low functional status or cognitive deficits to calculate a risk score.

4. Expand utilization management (“UM”) focus from episodic to complex chronic care, post-acute care or community-based care delivery needs. UM is increasingly important to manage healthcare costs and services across the continuum. Traditional UM is episodic and driven by point-of-care medical necessity and appropriateness of ongoing provision of care. As alternative payment and service delivery models are developed and tested by The Centers for Medicare and Medicaid Services and adopted by private payers, the care delivered will need to be considered across the continuum. The delivery of the right care at the right time in the right setting is evolving the role of UM. It requires considering a longitudinal approach to care provided outside of the four walls of the hospital, moving away from acute episodes to proactive delivery of complex, chronic care that maintains a patient’s health in a community-based setting.

5. Align primary care physicians (“PCPs”) incentive compensation to encourage coordination and access to all care team members. As the care delivery model for PCPs continues to move toward patient-centered models by organizing as a medical home or medical neighborhood, compensation models need to promote health outcomes and the coordination of care team members across the continuum. PCPs are tasked with driving care through a proactive, collaborative approach with patients and specialists with a focus on chronic disease management. New models of care delivered by PCPs will improve the health of populations and value for patients and compensation plans need to support the evolution of care delivery.

6. Develop new provider contracting models to address care across the continuum and engage new physicians and provider networks. As alternative payment models reward and penalize organizations for the quality of care provided, there is a corresponding need to evolve physician compensation models from a production/Relative Value Unit focus to one of value. Contracts need to clearly define the organizational strategy and goals as well as the expectations and accountabilities of the contracted providers. When designing compensation models, key factors to consider include aligning organizational and system goals with physician goals, identifying the appropriate quality benchmarks, and determining the proportions of compensation tied to risk, productivity goals, and quality.

7. Include value-based incentives and key performance metrics to provide appropriate and accountable care. Reporting quality measures is a familiar practice for providers who have participated in pay-for-performance programs such as Physician Quality Reporting System or the Hospital Inpatient and Outpatient Quality Reporting Systems. To promote appropriate and accountable care, existing and new value-based model metrics are now tied to incentives and penalties for providers to prove they are not only decreasing the overall cost of care delivered but are meeting quality standards. As payers continue to expand patient populations required for reporting financial and quality metrics, effective management and alignment of contract incentives is needed to ensure that care is delivered efficiently to lower costs but also improve the quality of the care delivered.

8. Create clinical data analytic functions and integrate relevant data sources (e.g., practice management, claims, financial, pharmacy, etc.) to support clinically data-driven efforts with real-time data. A robust data analytics infrastructure is necessary to integrate varying tools and data sources and to manage the vast amount of data to support real time, point of care decision-making. Health information exchanges or data warehouses are platforms to provide a solution to improve data integration functionality, aggregating data so staff spends its time analyzing data (not integrating data) and meeting organizational performance goals. The capabilities of the system should include all data sources related to clinical and patient experience, financial and cost performance, and quality data.

9. Develop robust communication, feedback, and reporting systems. The development of the most sophisticated data analytics infrastructure and the clinical information derived from the care of the patients is of little use if that knowledge is not communicated in a timely, meaningful way to the appropriate providers or systems across the continuum. If these gaps in communication of healthcare information are not addressed with the same effort as the development of information systems, the gap will continue to grow as networks expand and population panels increase. Greater consideration needs to be placed on communication enhancements to improve the quality and safety of clinical services. It is critical to view the communication needs from multiple directions – within and outside of the organization, with PCPs and community-based organizations, and between providers and their patients.

10. Develop system-wide tracking, reporting and accountability plan(s) to drive to population health-based outcomes and to compare internal and external peer group benchmarks and trends. Long-term success and intervention sustainability cannot be achieved without the continuous performance improvement and continuum based key performance indicators. Data reported in real time dashboards fosters close monitoring and analyzing both the financial and clinical data. Tracking, review, and actionability of the results will target the successes, areas of needed improvement, and the gaps in care for continued care delivery improvements.

Ms. Gulotta is a senior consultant with The Camden Group with more than 10 years of experience in the healthcare industry, including clinical experience. She specializes in clinical integration and patient care management, with a focus in quality and performance improvement, financial analysis and budget administration, as well as regulatory compliance, and strategic planning. She may be reached at bgulotta@thecamdengroup.com or 312-775-1700.



Dr. Koenig is a senior vice president with The Camden Group who specializes in developing and designing clinical integration strategies, medical management programs, and value-based care delivery and payment models. She has worked with a variety of healthcare organizations, from individual physician groups and health systems to academic health systems and Fortune 50 companies, guiding them as they look for solutions to their specific challenges. Dr. Koenig is skilled in utilization and quality management, including setting metrics to help organizations deliver accountable care, as well as in the development of provider networks and incentive systems. She may be reached at tkoenig@thecamdengroup.com or 310-320-3990. 

Topics: Teresa Koenig MD, Care Model, Bridget Gulotta, Care Team, Care Redesign, Transfomative Care

Three Keys to Improved Medical Practice Workflow Redesign

Posted by Matthew Smith on Apr 28, 2015 3:25:00 PM

By Susan Corneliuson, MHS, FACHE, Senior Manager, and Shannon Wolfe, Senior Consultant, The Camden Group

Doctor-Nurse-Communication.jpgNew consumer-oriented service delivery sites such as retail clinics and virtual visits are popping up to fill voids in access to care. In order to successfully compete in the future, medical groups must evaluate the way they currently operate with a critical focus on managing patient access through the promotion of consumer-oriented services and efficient workflows. One way of competing in this new market is to increase access without adding locations or providers by improving the efficiency of existing locations and providers. Redesigned workflows place the patient at the center of the care model, with the goal of improving patient engagement and access to care. This results in a better patient experience and improved clinical outcomes at reduced cost.

1. Identify Care Model and Care Team

One of the key attributes in workflow redesign is to identify the care model and care team needed to ensure that providers and staff are practicing at the top of their license or skill set. This might mean transferring work from providers to clinical staff or from clinical staff to front office staff. It also entails identifying the most valuable use of all staff time. This may be achieved through effective use of technology while engaging patients through the use of patient portals, email, text messaging, and home monitoring.

2. Utilize Process Flow Mapping

Another attribute is to utilize process flow mapping to create a picture of the current-state workflows and identify areas of potential waste or bottlenecks. Once current-state workflows are mapped, utilize a team of providers and staff to create a vision for the future (or ideal state). Work as a team to eliminate as much waste as possible to move towards the future state. Establish performance targets for the ideal state and measure baseline performance to gauge progress. Conduct cycle time studies as part of the redesign effort as an effective measure of wait time (value-added vs. non-value added time). Test the redesign efforts and compare results to established targets and continue to modify until goals are achieved.

3. Optimize Technology to Meet Clinical Care Needs

Finally, ensure providers and staff are effectively trained on the practice management (“PM”) and electronic health record (“EHR”) systems and that the technology is fully optimized to meet clinical care needs. Spend time shadowing providers to evaluate how the system is used in practice and what changes can be easily made to better accommodate workflows. Make sure a local resource may be contacted with questions or advice as well as dedicated site-specific subject matter experts (“SMEs”) for immediate troubleshooting. Create a continuous learning environment, through the use of webinars, on-site educational sessions, and shadowing to increase provider/staff adoption of the technology, and reduce rework or general frustration due to a lack of training or appropriate optimization of the system.

Workflow redesign efforts, if successfully implemented, can significantly decrease non-value added time by allowing for increased time with patients and increased access to care. Improving operational efficiencies and optimizing electronic systems also increases provider and staff satisfaction thereby supporting a patient-centered environment.

Medical Practice Workflow Redesign, The Camden Group,

Susan_Corneliuson2.pngMs. Corneliuson is a senior manager with The Camden Group and has over 13 years of healthcare management experience. She specializes in physician integration strategies, practice assessments, operational improvement, care and workflow redesign, and compensation arrangements. She is the co-author of The Governance Institute’s signature publication for 2012, Payment Reform, Care Redesign, and the New Healthcare Delivery Organization. She has a strong background in physician practice management with experience in medical foundations, provider-based clinics, and specialty hospital settings. She may be reached at scorneliuson@thecamdengroup.com or 714-263-8200.


Shannon_Wolfe.pngMs. Wolfe is a senior consultant with The Camden Group specializing in the areas of physician practice operational improvement, physician compensation modeling and redesign, practice assessments, and workflow studies. She also has experience in strategic and business planning, facility planning, medical staff development and structure, market analysis, and hospital operations. She may be reached at swolfe@thecamdengroup.com or 310-320-3990.

Topics: EHR, Care Model, Susan Corneliuson, Shannon Wolfe, Workflow Redesign, Medical Practice Workflow Redesign, Care Team

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