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Health benefits of primary care social work for adults with complex health and social needs: a systematic review

2016; Wiley; Volume: 26; Issue: 1 Linguagem: Inglês

10.1111/hsc.12337

1365-2524

J.C. McGregor, Stewart W Mercer, Fiona Harris,

Healthcare innovation and challenges

Health & Social Care in the CommunityVolume 26, Issue 1 p. 1-13 ReviewFree Access Health benefits of primary care social work for adults with complex health and social needs: a systematic review Jules McGregor MA (Hons) MSW MRes, Corresponding Author Jules McGregor MA (Hons) MSW MRes jules.leith@googlemail.com Health and Social Care Department, City of Edinburgh Council, Edinburgh, UK Correspondence Jules McGregor Health and Social Care Department City of Edinburgh Council 3/6 Wellington Street Edinburgh EH7 5EE, UK Email: jules.leith@googlemail.comSearch for more papers by this authorStewart W. Mercer MBChB PhD FRCGP, Stewart W. Mercer MBChB PhD FRCGP Department of Primary Care Research, University of Glasgow, Glasgow, UKSearch for more papers by this authorFiona M. Harris MA PhD, Fiona M. Harris MA PhD NMAHP Research Unit, University of Stirling, Stirling, UKSearch for more papers by this author Jules McGregor MA (Hons) MSW MRes, Corresponding Author Jules McGregor MA (Hons) MSW MRes jules.leith@googlemail.com Health and Social Care Department, City of Edinburgh Council, Edinburgh, UK Correspondence Jules McGregor Health and Social Care Department City of Edinburgh Council 3/6 Wellington Street Edinburgh EH7 5EE, UK Email: jules.leith@googlemail.comSearch for more papers by this authorStewart W. Mercer MBChB PhD FRCGP, Stewart W. Mercer MBChB PhD FRCGP Department of Primary Care Research, University of Glasgow, Glasgow, UKSearch for more papers by this authorFiona M. Harris MA PhD, Fiona M. Harris MA PhD NMAHP Research Unit, University of Stirling, Stirling, UKSearch for more papers by this author First published: 05 April 2016 https://doi.org/10.1111/hsc.12337Citations: 36AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Abstract The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self-management of long-term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care. What is known about this topic Multimorbidity is common, even in the working age population. In deprived areas, psychological distress has been identified as the most significant co-morbidity. Effective treatment and self-management are undermined by patients' complex social need and low quality of life. What this paper adds Patients with complex health and social needs may derive measurable improvements in subjective health, functioning and self-management and reduced psychosocial morbidity. Interventions with a dual individual/social focus may enable patients to make better health decisions. Social work interventions may help to reduce the burden of chronic psychosocial need on clinicians and contribute to identifying at-risk groups. Background Multiple morbidity Chronic disease and mental ill-health represent the biggest burden on health systems in the UK (Department of Health 2013) and account for 80% of all general practice (GP) consultations (Department of Health 2004, Scottish Government 2013). The combination of these conditions can lead to significantly poorer health outcomes and reduced quality of life (Naylor et al. 2012, Mercer & Wyke 2012). Recent primary care research reveals a growing burden of multiple physical and psychological morbidity in the working age population (Barnett et al. 2012, Lawson et al. 2012). In deprived areas, psychological distress is identified as the most significant co-morbidity (McLean et al. 2014). GPs report that effective treatment and self-management of illness and disease are undermined by patients' complex social need and low quality of life (O'Brien et al. 2011, 2014). A recent systematic review on the management of multimorbidity in primary care concludes that there is little evidence for effective interventions to improve health outcomes, especially in deprived areas (Smith 2012). These findings reflect evidence from across the UK and in US health systems, of a patient population characterised by deprivation and psychosocial complexity, generating ‘constant demand’ in primary care (Firth & Ronalds 1997). Patients presenting with issues such as somatisation, depression and chronic stress are generally not seen in secondary mental healthcare (Firth et al. 2003), and research suggests they will continue to seek help from trusted primary care providers (Rock & Cooper 2000). However, primary care clinicians lack the time to provide preventive interventions and optimise chronic care (Allen et al. 2004), and may be reluctant to deal with psychological morbidities, which they refer to as ‘opening a can of worms’ (Netting & Williams 2000). A recent US study describing the involvement of ‘care managers’ in primary care practices with patients with multiple social, physical and mental health conditions concluded that this approach allowed the facilitation and co-ordination of access to health and social services, and may reduce high utilisation (Williams et al. 2014). Social work in primary care The inclusion and potential of social workers in primary care teams to address a range of psychosocial and environmental barriers to health has been extensively discussed. Clinical social workers, as allied health professionals, are well established in the US healthcare system, often providing specialist mental health interventions as part of multidisciplinary teams (Bauer et al. 2005, Sommers et al. 2000, Wetta-Hall et al. 2004). Interdisciplinary primary care may improve quality of care, quality of life and functional autonomy in multimorbid patients (Boult et al. 2009). Discussion continues around the potential of generalist social work interventions to address issues such as early risk identification (Ross et al. 2004a,b), polypharmacy (Rinfrette 2009), somatisation (Berkman 1996), rehospitalisation (Sharifi et al. 2012) and disease management (Claiborne & Vandenburgh 2000, 2000), particularly among vulnerable populations. It has been suggested that primary care social work can improve medical outcomes by addressing psychosocial and environmental aspects of chronic conditions such as cancer (Francouer 2001), hypertension, infectious diseases and depression (Cook et al. 1996, Firth et al. 1999). Comprehensive assessment of risk and complexity and co-ordination of effective responses by social workers has been described as a ‘critical clinical role’ (Amdur et al. 2011). However, while a considerable literature addresses the potential benefits, and suggests that primary care staff value social work interventions particularly in older or deprived populations where they may impact positively on clinical burden (Del Toro et al. 1994, Badger et al. 1997, Mizrahi & Rizzo 2008), a lack of rigorous evidence has inhibited policy development (Keefe et al. 2009). In the UK, despite early evidence suggesting general practice-based social work may be an effective mechanism for joint working (Williams & Clare 1979, Corney & Clare 1983), little evidence of specific improved health outcomes has been identified, and development of social work roles in this setting has been ad hoc (Le Mesurier & Cumella 2001). The literature on attachment schemes includes few effectiveness studies. Commentators have suggested a combination of organisational and policy barriers has undermined practitioners’ efforts to collaborate across organisational boundaries in healthcare settings, not least due to social services’ increasingly restrictive eligibility criteria (Ross & Tissier 1997, Lymbery 1998) and a mismatch between managers’ and practitioners’ perspectives of ‘what social work is’ (Brand et al. 2005). Non-mandatory social work intervention can be difficult to define as it takes a number of forms and may involve multiple components; however, the globally accepted definition by the International Federation of Social Workers and the International Association of Schools of Social Work, is that whether involving direct therapeutic casework or case management, social work is characterised by a holistic focus on the whole of the person's life situation, social and structural context, and has relationship and well-being as the bases of intervention. Intervention happens where people interact with their environment and is, crucially, informed by principles of human rights and social justice (IFSW and IASSW joint statement 2014). Mullen and Shuluk (2011), discussing outcomes of social work intervention in the context of evidence-based social work practice, conclude that while there is a considerable body of empirical evidence suggesting that social work interventions are effective across a wide range of social problems and populations, and generally benefit recipients, research informing evidence-based practice has focused on less complex, individual-orientated psychotherapeutic interventions. The lack of controlled studies and systematic reviews means conclusions about comparative effectiveness of more complex or socially orientated interventions are difficult to draw, and the evidence base for primary care social work is particularly sparse. A need for research on the health outcomes of social work interventions has been identified (McGuire et al. 2005, Bywaters 2011). Social work has been described as highly contextualised (Moren & Blom 2003, Cree et al. 2014), therefore evaluation must be conducted, and outcomes understood, in context in order to understand impact and predict transferability of interventions between populations. Research is needed to address the differential effectiveness of interventions (Mullen & Shuluk 2011) in order to add to knowledge about what works, for whom and in what circumstances. Aims This review seeks to address the broad question, ‘what is known about the health benefits of social work interventions in primary care settings for adults with complex health and social needs?’ Methods This review, conducted between July and September 2013, is informed by the ‘subtle realist’ approach to complex interventions outlined by Mays et al. (2005), which suggests that multiple explanations or descriptions of phenomena relate to an underlying reality, and that synthesis promotes greater understanding of this reality. Inclusion/exclusion criteria The inclusion and exclusion criteria for this review are shown in Table 1. Table 1. Inclusion/exclusion criteria Inclusion criteria Exclusion criteria Adults Children and young people <16 years Social work interventions based on or attached to primary care or community health services, including as part of multidisciplinary care teams Interventions limited to those for the geriatric population such as falls, dementia or arranging hospital discharge or homecare Interventions comprising a single component for a single outcome, such as alcohol brief intervention 1990–2015 Articles published prior to 1990 Publication types: peer-reviewed primary research articles and systematic reviews published in English Publication types: non-peer-reviewed articles, commentaries, study protocols, conference papers Study designs: all study designs For the purposes of this review, a social work intervention may be defined as non-statutory casework or case management addressing the identified health problem alongside and within the psychosocial and environmental context. Outcomes No limit was placed on health outcomes for this review, as it sought to discover a range of evidence for health benefits. Search strategy As the subject area was broad and relatively unexplored, a broad search strategy was developed and applied to the following nine databases: ASSIA, IBSS, Cinahl, Medline, Embase, Sociological Abstracts, Social Services Abstracts, PsycInfo, and the Cochrane Database of Systematic Reviews. Searches used both free text and MeSH or thesaurus terms relevant to individual databases. The search strategy followed the general structure ‘social work’ AND ‘primary care’. (For detailed search strategy see Supporting Materials). Internet searches of the Campbell Collaboration and Social Care Online were also carried out. Additional studies were identified from reference lists. The search was updated in April 2015; no further studies were found. Selection of studies and critical appraisal The inclusion/exclusion criteria were applied by two authors (MJM & FH) and any differences negotiated. Critical appraisal was carried out drawing on CASP tools for randomised controlled trials and qualitative studies; for study designs where no checklist was available, CRD (2008) quality assessment guidance was followed. Quality assessment was carried out by a single researcher and a sample checked for consistency by a second researcher. No studies were excluded on the basis of methodological quality. The review process relating to studies identified, screened and excluded is illustrated in Figure 1. Figure 1Open in figure viewerPowerPoint PRISMA diagram 9.04.15. Data extraction and synthesis Data were extracted into a standardised form by a single researcher and a sample checked by a second researcher. Study and intervention characteristics and key findings are summarised in Summary Tables 2 and 3 (and see Supporting Material tables). Table 2. Summary of study characteristics Study Design Aim Population Intervention Enguidanos et al. (2011) (US) Descriptive analysis Identify factors associated with successful outcomes for intervention group Patients with high healthcare utilisation and multiple chronic conditions Problem-Solving Therapy Ferrante et al. (2010) (US) Comparative analysis Understand barriers and facilitators to Patient Navigator intervention Frequent attenders with multiple and complex health and psychosocial problems Patient Navigation (link working and advocacy) Firth et al. (2004) (UK) Case file analysis Assess effect and analyse content of social work interventions Patients with enduring complex psychosocial problems Social casework Matalon et al. (2002) (Israel) Uncontrolled pilot study Assess effect on health costs, resource use and GP satisfaction ‘Difficult’ patients with multiple chronic conditions and somatisation diagnosis Biographical interviewing and case management Matalon et al. (2009) (Israel) Cross-sectional uncontrolled study Assess effect on well-being, health perception and functioning ‘Difficult’ frequent attenders with multiple chronic conditions Biographical interviewing and case management Rock and Cooper (200) (US) Natural experiment Assess effect on improved outcomes for depression and anxiety Patients with psychosocial problems Counselling, advocacy and outreach Safren et al. (2013) (US) Randomised Controlled Trial Assess effect on risk behaviour HIV+ men who have sex with men Risk behaviour counselling, proactive case management Table 3. Summary of intervention characteristics Study and Intervention Aim of intervention Intervention content Outcomes Conclusions Enguidanos et al. (2011) Problem-Solving Therapy Train patients in problem-solving skills 4–8 PST sessions with social worker. Yes or No outcome recorded in case notes. About 59% resolved within intervention period Intervention appears effective in improving self-management for older people with multiple chronic conditions Ferrante et al. (2010) Patient Navigation Co-ordinate services; assist patients with multiple chronic conditions to manage care and treatment Resource advocacy and linkage; referral co-ordination; emotional support; appointment facilitation Patient notes; Qualitative interviews. Increased resource access; lower psychological distress Intervention appears effective in supporting illness management for patients with complex needs Firth et al. (2004) Social Casework Reduce psychosocial morbidity; achieve social redress Holistic casework: Direct/therapeutic work and Indirect/facilitation and advocacy work HoNOS scale. Significant reduction in mean HoNOS scores at discharge Nuances of intervention, including relationship, are key to outcomes Matalon et al. (2002) Biographical Interviewing and Case Management Modify health resource use, improve patient-GP relationship and reduce health costs Medical and psychosocial interviews Biographical integrative group discussion; case management Reduction in mean health costs, GP visits, ED visits, inpatient days; increased GP satisfaction Integrated biopsychosocial intervention modified illness behaviour and reduced health costs Matalon et al. (2009) Biographical Interviewing and Case Management Improve well-being, health perception and health indicators Medical and Psychosocial interviews Biographical integrative group discussion; case management Significant improvement in emotional and social function, physical fitness, and general health (COOP) and pain (SF36) Long-term improvement in subjective health measures Improved well-being an unexpected outcome Rock and Cooper (2000) Counselling with advocacy and outreach Improve patient-specific outcomes for depression and anxiety Various psychological therapies, appointment facilitation, referrals Significant reduction in depression scores, reduced pain, reduced DNA (Hudson) Reduction in depression, anxiety and somatisation; fewer physician visits; better medical and dietary compliance Safren et al. (2013) TRB counselling intervention with proactive social work case management Reduce HIV transmission risk behaviour (TRB) 4 sessions with medical social worker: TRB educational, motivational and behavioural counselling. Individualised social work case management Self-report. No significant effect for whole intervention group. Significant reduction in TRB and odds of TRB in subgroup with depression Differential effectiveness for depressed patients suggests more intensive intervention could have greater impact on transmission Because of the heterogeneity of included studies, a meta-analysis was not possible. Instead results were combined using techniques of narrative synthesis (Popay et al. 2006). Findings Overview of evidence A total of seven papers met the inclusion criteria, describing six interventions. Tables 2 and 3 present a summary of included studies and interventions. The studies were conducted in the US (four), Israel (two) and the UK (one). Surprisingly, no other European studies were found and there were no relevant systematic reviews. Four studies measured outcomes before and after intervention, and two of these included follow-up. One randomised controlled study is included, which analysed variables for differential effects. All the interventions investigated are multi-faceted, comprising a range of psychotherapeutic and social support approaches widely found in routine practice. The majority investigate interventions by social workers; two examine a multidisciplinary intervention (Matalon et al. 2002, 2009) and three interventions target psychosocial morbidity and subjective health, health behaviour and medical compliance (Rock & Cooper 2000, Matalon et al. 2002, 2009). Health costs (Matalon et al. 2002) and material conditions (Firth et al. 2004) are also explored. One investigates effect on risk behaviour (Safren et al. 2013) and one on self-management capacity (Enguidanos et al. 2011). One qualitative study investigated implementation and impact of an intervention to assist patients to navigate health and welfare systems (Ferrante et al. 2010). The interventions target a wide range of problems, including depression and anxiety, multiple chronic conditions, somatisation, material need, health risk behaviour, health resource utilisation and self-management. Five studies describe interventions explicitly targeting complexity and chronicity of need. Synthesis All the studies describe multi-faceted interventions. Four studies specified a theoretical orientation (Rock & Cooper 2000, Matalon et al. 2002, 2009, Firth et al. 2004) and one described the choice of setting – a practice in a disadvantaged neighbourhood (Rock & Cooper 2000) – as congruent with ‘the core social work mission’. Person-change-focus: psychotherapeutic, cognitive and behavioural approaches Psychological and psychotherapeutic approaches were used in five of the six interventions, and were the main approaches used in four interventions. In the studies by Matalon et al. (2002, 2009), frequent-attender patients identified by their GPs as ‘difficult’ were referred to a multidisciplinary community intervention, the Comprehensive Consultation Clinic. Patients had an average of 10 chronic symptoms and 87% had a diagnosis of somatisation. A GP/social worker team assessed medical and psychosocial history, then used intensive biographical interviewing, family genograms and listening skills to understand patient perspectives of disease and co-construct a new narrative of illness, empowering traumatised patients entrenched health perceptions to make mutually agreed treatment decisions. The intervention continued with the patient's choice of psychotherapeutic and social support options. Two studies investigated effect on health costs (Matalon et al. 2002), well-being, health perception and health indicators (Matalon et al. 2009). The former demonstrated strong evidence for the utility of the intervention in reducing both GP consultations and health costs – annual average costs per patient fell from $4035 to $1161 – while the latter, using validated health and functional status measures at baseline and 1- to 2-year follow-up, showed statistically significant improvements in self-assessed physical fitness and activity levels, emotional and social functioning, pain and general health. Authors concluded that the intervention achieved long-term improvement in subjective health measures, and a promising approach for chronic somatisation. A randomised controlled study (Safren et al. 2013) tested the effectiveness of a standardised behavioural intervention by a medical social worker to reduce human immunodeficiency virus (HIV) transmission risk behaviour (TRB). The intervention sought to educate and train HIV-infected male patients in risk prevention techniques. High-risk patients received four sessions of TRB counselling comprising motivational interviewing and skills training. The intervention included modules on HIV education, stress, risk management, culture, drugs and relationships. In addition, proactive social work case management was provided for social needs. No effect was found for the intervention group overall, however subgroup analysis showed a significant decline in TRB and odds of TRB for those with depression. Authors suggest that the effectiveness of the intervention for those with depression suggests a need for more intensive interventions for those with psychiatric co-morbidities (Safren et al. 2013). Social workers in the study by Enguidanos et al. (2011), part of an ongoing effectiveness study, used a cognitive-behavioural problem-solving approach with older patients struggling to manage multiple chronic conditions. Social workers taught patients to identify problems, plan and carry out solutions. The main problems identified by patients were health maintenance and treatment management issues, consistent with those identified by primary care staff, followed by social problems with finance and housing. Self-identified problems were twice as likely to be solved. Problem type was not significant – increasing self-efficacy appeared to be the mechanism for solution. Authors concluded this patient-centred intervention may equip multimorbid patients with self-management skills. In the small study by Rock and Cooper (2000) evaluating effectiveness of social work intervention to improve outcomes for depression and anxiety, social workers based in a deprived practice used counselling skills, cognitive and behavioural therapies to identify and address underlying psychosocial causes including trauma, substance misuse and bereavement. Outcomes were measured using Hudson depression and anxiety scales. Clinically significant reduction in depression scores are reported, and clinic staff reported overall improved medical compliance in patients receiving the intervention. The study by Firth et al. (2004) also employed a range of psychotherapeutic methods as part of a multicomponent intervention. Social workers based in UK general practices used methods including cognitive behavioural therapy (CBT), cognitive analytic therapy, counselling and family therapy, alongside social and environmental interventions, to address complex chronic psychosocial problems. Absence of follow-up in the latter three studies means no conclusions can be drawn about longer term preventive utility (Box 1). Box 1. Psychological and psychotherapeutic approaches Evidence summary – psychological and psychotherapeutic approaches One study reported reduction in frequent GP consultations and health costs One study reported significant and long-term improvement in self-assessed health One study reported clinically significant reduction in depression, and overall improvement in medical compliance One study reported reduced sexual risk behaviour in subgroup with depression One study reported acquisition of self-management skills Social or system change-focus: case management and casework approaches All of the interventions involved, to varying degrees, facilitation by the social worker to access resources including medical treatment and community support. The qualitative study evaluated social work patient navigation for frequent-attender patients with multiple or complex health conditions identified by physicians as requiring referral co-ordination and social services (Ferrante et al. 2010). This task-focused intervention comprised linkage with community resources, appointment facilitation, assisting patient–physician communication, sourcing affordable treatment such as dentistry and follow-up of specialist referrals. The social worker felt there was insufficient time to attend to patients' psychosocial needs. Patients reported accessing services they would not otherwise, finding the service helpful and feeling supported by their primary care provider. Physicians overall viewed the intervention as providing an additional practice resource. The UK study (Firth et al. 2004) describes a comprehensive social casework model involving, in addition to psychotherapies, risk and crisis management and a range of material, social and environmental interventions. Liaison between agencies and professionals was a large part of the indirect work which also included advocacy, resource access and bureaucratic facilitation. Psychosocial morbidity outcomes were measured at discharge using a validated instrument (HoNOS; Wing et al. 1998), and worker ratings of improvement. Overall reduction in psychosocial morbidity was reported as highly significant. Workers rated two-thirds of patients improved; the high number of those rated as ‘no change’ (33%) may be partially explained by premature disengagement (Firth et al. 2004). However, the majority of contacts were office-based, despite recognition of patients' struggle to engage and high DNA rate – it is unclear whether an outreach approach may have increased successful outcomes. Other than the qualitative evaluation, all of the studies described interventions specifically intended to improve clinical outcomes relevant in the primary care context: reduction of risk and psychosocial morbidity; improved functioning, physical activity, subjective health and self-management; all demonstrated a level of effectiveness, at least during intervention. No disconfirming evidence was located. Observed effect on psychosocial morbidity and functioning appears consistent across studies which measured these outcomes. Most of the studies discussed the issue of the burden of patients with complex or intense psychosocial need on doctors. There is mixed evidence of intervention impact on clinician burden, although four studies focused intervention on ‘f