A woman's purse is stolen while walking in downtown Baltimore. She is upset and frightened, yet she does not stop to report the theft as she passes a police station. Instead, she walks to the nearest hospital and asks its social work department for assistance.
A retired taxi driver who lives alone and has no family is frequently hospitalized because he forgets to take his many medications and cannot care for himself. In the hospital, he confesses that he likes to be there because the hospital gives him what he needs most — people who care for him and about him.
These incidents are common in America today. Hospitals often provide extraordinary care for a variety of complex medical and surgical problems. Yet, they struggle to care for people with chronic psychiatric and medical ailments that result from environmental circumstances: homelessness, domestic and community violence, substance abuse, insecurity and loneliness. These problems are difficult to treat or manage especially when resources are insufficient. To meet these needs, hospitals will have to rethink their roles, particularly in the new health care landscape created by the Affordable Care Act.
Throughout history, hospital care has reflected society's understanding of human illness. In ancient and medieval times, hospitals could only provide spiritual solace, charity and comfort. During the 20th century the discovery of effective drugs and new technologies not only enhanced patient care but also enabled hospitals to measure health outcomes and charge and collect fees for their services efficiently. Particularly since the 1960s, hospitals have been driven by financial incentives and government regulations. They are reimbursed for their efforts to make sick people better but not for keeping them from becoming ill either through prevention or education. Policy, therefore, encourages hospitals to reflect the best in technical medical care but not public health initiatives. Hospitals are now instruments of social policies that reward expensive but profitable procedures yet fail to address the root causes of illness.
Hospitals are now faced with the need to adapt quickly in response to the complex medical, psychiatric and social problems that many patients present. The Affordable Care Act, known as Obamacare, can help hospitals address the multiple problems presented by patients that require more than medical solutions. The ACA challenges hospitals to develop community-based programs that address the environmental and socio-economic factors that create illness and lead to frequent readmissions. Hospital care will have to focus on non-medical barriers to health care and the unique needs of patients by developing and coordinating inter-disciplinary community health teams and patient-centered medical homes. Students in medicine, nursing and other allied health fields who traditionally trained in hospitals must now be educated in hospital-sponsored community-based programs.
Much of this is not new. A century ago a public health focus on patient education and prevention shaped hospitals in this country. Community outreach programs already exist in many hospitals, such as innovative partnerships with churches that provide health screenings and education, particularly to racial minorities and the elderly. Transitional health guides, usually trained nurses and social workers, are working with patients and their families in the community to help them follow prescribed medical advice and to navigate the complex health care system. In Maryland, these guides will soon be placed in primary care clinics to identify patients' behavioral issues and link them to psychiatric and substance abuse treatment.
Rosemary Stevens, a historian and sociologist who has written extensively about hospitals, says that hospitals are remarkably adaptive institutions that can rise to this challenge. As the above vignettes reveal, most patients still trust hospitals to care for their needs. This same trust must now be created between hospitals and their surrounding communities. Hospitals need to emphasize community-based volunteerism and become effective leaders in public health. Knowledgeable community members need to participate on hospital boards, and hospital administrators need to be involved on community boards.
These changes will occur over time if the will exists. However, they require hospital staffs to develop enhanced skills in internal and external communication, the use of social media, interdisciplinary teamwork, inter-organizational collaboration, and negotiation of complex systems. This will require changes in how all health professionals are educated.
A century ago, Dr. Richard Cabot recommended that hospitals recruit social workers to collaborate with physicians because "medical ills are largely social and social ills are largely medical." Health care reform creates the opportunity for hospitals to realize Cabot's dual vision of improving patients' well-being and reducing health inequities through their wisdom, experience and moral leadership.
Anne P. Hahn is a hospital social worker and a member of the Advisory Board at the University of Maryland, School of Social Work. Her email is firstname.lastname@example.org. Michael Reisch, is the Daniel Thursz Distinguished Professor of Social Justice at the University of Maryland, School of Social Work. His email is MREISCH@ssw.umaryland.edu.
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