Social Workers Down the Hall: A Case Study of Integrated Care


Coastal Family Health Center NP Teresa Foley
Coastal Family Health Center Nurse Practitioner Robyn Wheeler examines a patient.

Hoyt Williamson recalls a patient with hepatitis C who needed help with medications and another he suspected might be bipolar. For Raffinee Hathorn, it was hoping for improvements in a patient’s type 2 diabetes and high blood pressure.

Angelica Trieu was concerned about a child’s mental health after an issue at school. Abigail LaFleur needed to find an Alzheimer’s support group in Slidell, Louisiana.

In each case – and in thousands more over nearly seven years – a social worker was literally steps away, available to offer additional patient services to those primary medical care providers at Coastal Family Health Center, which operates 13 facilities in 10 cities in south Mississippi.

The social workers were first introduced into the Coastal care environment in early 2012, as part of the Mississippi Integrated Health and Disaster Program, an award made to the University of Southern Mississippi’s School of Social Work as part of the medical settlement following the Deepwater Horizon oil spill of 2010.

The MIHDP grant was a part of a four-state Gulf Region Health Outreach Program, which was established as part of the settlement to oversee programs addressing mental and behavioral health issues related to the disaster.

While the grant expired in November 2018, its past outcomes with patient care and future impact to Coastal’s personnel makeup are both significant. Over the life of the grant, eight full-time social workers and a total of 82 graduate-level student interns (13 per academic semester on average) were responsible for 8,572 care appointments covering 4,430 patients across seven Coastal facilities.

Larry Knight, chief operating officer for Coastal since 2013, says the company expects to continue employing social workers to provide integrated care post-grant: “Absolutely, yes, that is our plan.”

A Model for Delivering Mental, Behavioral Health Care

The primary goals of integrating social work services was to increase capacity for mental and behavioral health evaluation and treatment, and also to educate patients and help them manage chronic health issues such as diabetes, high blood pressure and obesity – all conditions that may have been exacerbated in the aftermath of the oil spill.

The social workers at Southern Miss have seen the benefits of integration to patients, both in health and mental health.”

“We have a clinic almost fully dedicated to the mental health needs of the Gulf Coast, which was quite significant after (Hurricane) Katrina and the oil spill,” Knight says. He credits the Southern Miss social work MIHDP team with helping to extend those mental health capabilities, not only with the integration of social workers but also by helping Coastal create a system of care that would support a psychiatrist and psychiatric nurse practitioners and establishing policies and procedures.

The success of the grant project with Coastal gives the School of Social Work an impetus for creating similar integrated care programs statewide.

“The social workers at Southern Miss have seen the benefits of integration to patients, both in health and mental health,” says Michelle Brazeal, the MIHDP project director and an instructor in the School of Social Work. “While the grant is ending, the School of Social Work would like to see this model of health care offered throughout the state. We have begun reaching out to other agencies to offer them support and technical assistance in designing and implementing integration projects.”

Just a Few Doors Away

Knight agrees. “I will tell you that very rapidly our providers – once they realized the benefits to take those complicated patients that were having those behavioral health challenges and doing warm handoffs and getting them over to a behavioral health specialist to work with – they realized it was very important to them, and very beneficial,” he says.

In my clinic, the social workers are down the hallway.”

“I think the studies and the data will show that the patients are benefiting from that service we are providing, and it frees up our health care providers to do what they are trained to do on the primary care side. So that means working on the same hallway, being totally integrated into the clinics. … (Social workers) are part of the huddles in the morning, they are part of the healthcare team; it’s just that they have their specialty and their component.”

Several Coastal practitioners – Williamson, Hathorn, Trieu and LaFleur – say almost the same thing, word for word: The convenience of having a social worker on site, easily accessible “down the hallway,” made their jobs easier and also significantly improved the quality of care for patients.

So, too, for Darryl Adams, a primary care nurse practitioner at Coastal for 3½ years and the company’s new deputy medical officer. She did not have access to a social worker before coming to Coastal.

“We were in a remote location, very rural, and there was no behavioral health,” she says. “There were not counselors or anything else to rely on. I wished that for my patients all the time, every day.

“So having the ability to walk down the hall and introduce my patient to the counselor. … If they had a minute, they would do the first initial assessment right then. In contrast, it’s that disconnect of ‘go here.’ And then the patient leaves my clinic and you don’t know if they ever went. You don’t know if they were able to get the appointment, how far out their appointment was.

“But in my clinic, the social workers are down the hallway. I can walk the patients over, they can see this is right here in my own clinic. The convenience of it makes them able to use that service. It’s much more valuable.”

A Spectrum of Services

On any given day, social workers might be involved in something as significant as administering tests to see if a patient is suicidal to something seemingly as mundane as helping schedule follow-up appointments to ensure patients’ continuity of care. But both extremes – and everything in between – are equally as important.

Every time they would come up with something, I would be like, ‘Oh, you can do that?’ ”

Social workers also:

  • conduct research to find information or resources about patients’ conditions;
  • help educate patients about their conditions and assist in monitoring progress through clinical tests
  • develop plans or consult with a nutritionist for healthier meals;
  • provide counseling – either at a clinic location or through an outreach program at Moss Point schools – to children who may be experiencing issues such as bullying, self-harming or ADHD; and
  • work with at-risk populations such as the homeless, undocumented immigrants, and local Hispanic and Vietnamese communities.

Medical providers are sometimes surprised at the types of services social workers can offer.

“Every time they would come up with something, I would be like, ‘Oh, you can do that? Oh, you can call the parents and do all this for me?’ ” Dr. Wendy Williams, a pediatrician in Biloxi, says with a laugh. “And they’re like, ‘Yeah,’ and I was like, ‘Wow.’ Sometimes it takes time to build that trust because a lot of times I’m not ready to give up stuff. But I’m learning ‘I can do that for you’ is very helpful and useful.”

Patient Volume and Positive Outcomes

In particular, the project succeeded in terms of increasing Coastal’s capacity for treating patients with depression and anxiety and the homeless population; and in improving patients’ health with improvements to high blood pressure.

(Social workers) were very useful in our chronic condition management.”

Of the 4,430 patients seen by social workers, screenings detected:

  • 3% (1,432) were positive for moderate or severe depression
  • 8% (1,409) were positive for moderate or severe anxiety

Depression: In data reported through the federal Health Resources and Services Administration’s Uniform Data System (UDS), Coastal showed a marked increase in the percentage of patients screened for clinical depression, from 61.43 percent in 2014 to 96.2 percent in 2017 – an increase of 56.6 percent.

“Now we have the PHQ2 and the PHQ9 tests (for depression) that are administered upon immediately coming into our clinic,” says Knight, the COO. “Where in the past, we did not have those. So now we are able to detect if someone is having suicidal thoughts. So I would suspect they were always there in the past, it just wasn’t our focus and we weren’t able to record it or detect it or diagnose it as much as we are now.” 

Hypertension: For blood pressure readings, the average systolic (138 to 133.8) and diastolic (83.4 to 80.7) readings dropped over the course of the project. In 2016, the systolic (129.8) and diastolic (79) averages hit their best marks.

“Some of our social workers were treating more of, as far as chronic conditions go, diabetes, hypertension and mental health issues,” Adams says. “They were very useful in our chronic condition management, and I would refer my patients to them if they had uncontrollable diabetes and hypertension, and they would get that chronic condition counseling.”

Homeless: Social workers conducted 880 screenings of 780 homeless patients during the project. UDS reports showed Coastal at a four-year high for percentage of homeless patients treated, 10.9 percent, in 2017.

Want More Information on the Integrated Care Model?