Share The Health

Breaking Down Barriers to Care: The Social Worker's Role


Regardless of how well they are managed, complex medical conditions such as congestive heart failure, diabetes and chronic obstructive pulmonary disease occasionally flare up-- landing many in the hospital for intensive treatment. Once symptoms are under control, patients leave the hospital with a plan of care that may include follow-up appointments, dietary restrictions, a prescription for additional exercise or other lifestyle changes, and new medications, treatments and therapies.

For the patient with a strong support system, following a plan of care is less difficult. But for those without resources, the road to better health means trying to navigate around barrier after barrier.

Unfortunately, these patients frequently end up back in the hospital very quickly—sometimes in a matter of weeks or even days. These re-hospitalizations create increased anxiety, unexpected costs and added inconvenience for the patient and their support system.

Given our aging society, and the many demands for limited health care dollars, finding ways to reduce readmissions is more critical than ever. At FMH, social workers are playing a key role in a variety of programs aimed at decreasing readmissions by easing the transition between hospital and home for patients.

Some studies estimate that 50-60% of relapses following hospitalizations are due to social issues. Patients with a poor understanding of their conditions may not understand the importance of making those recommended lifestyle changes. A language barrier may interfere with their comprehension of discharge instructions. A lack of insurance or limited income may get in the way of their scheduling of follow-up appointments, or filling prescriptions. The absence of transportation or child care can make it difficult to actually make it to their appointments.

One way FMH is trying to address these issues is by embedding social workers in the Emergency Room. After stabilizing the patient, if the ER staff determines they need a more complex intervention, they get a social worker like Nicole Wetzel involved to serve as the coordinator of a more long term plan of care.

Wetzel and others help connect these patients with the care they need; often starting with a visit or two to the hospital’s own free CARE Clinic. While the clinic’s nurses focus on teaching these patients about their diseases—how to recognize symptoms, and the importance of adherence to diet, exercise and medication regimens—social workers like Wetzel help identify community agencies and independent resources to equip them with the tools and support they need to succeed.

“When you don’t have support, managing a chronic disease is scary and intimidating,” said Wetzel. “Our job is to see patients through to the next step on the road to feeling better. We’re here to help.”