N A S W S t a n d a r d s f o r

Social WorkPractice

i n H e a l t h C a r e S e t t i n g s

N A T I O N A L A S S O C I A T I O N O F S O C I A L W O R K E R S

N A S W S t a n d a r d s f o r

Social WorkPractice

i n H e a l t h C a r e S e t t i n g s

National Association of Social Workers

Darrell P. Wheeler, PhD, ACSW, MPH

President

Angelo McClain, PhD, LICSW

Chief Executive Officer

Health Care Standards Expert Panel

Lisa E. Cox, PhD, LCSW, MSW

Terrie Fritz, LCSW

Virna Little, PsyD, LCSW-R

Shirley Otis-Green, MSW, ACSW, LCSW

Anthony Yamamoto, LCSW

NASW Staff

Stacy Collins, MSW

©2016 National Association of Social Workers.All Rights Reserved.

Contents

5 Introduction

9 Goals

10 Definitions

14 Guiding Principles

16 Standard 1. Ethics and Values

17 Standard 2. Qualifications

18 Standard 3. Knowledge

22 Standard 4. Cultural and Linguistic Competence

24 Standard 5. Screening and Assessment

27 Standard 6. Care Planning and Intervention

29 Standard 7. Advocacy

31 Standard 8. Interdisciplinary and Interorganizational

Collaboration

33 Standard 9. Practice Evaluation and Quality

Improvement

34 Standard 10. Record Keeping and Confidentiality

37 Standard 11. Workload Sustainability

39 Standard 12. Professional Development

40 Standard 13. Supervision and Leadership

42 References

45 Acknowledgments

5

Introduction

Since the early 20th century, social work hasbeen an integral component of the U.S. healthcare system, and the profession continues toplay a leadership role in the psychosocialaspects of health care. Today, social workersare present in settings across the health carecontinuum, including prevention and publichealth, primary and acute care, specialty care,rehabilitation, home health, long-term care,and hospice. Professional social workersprovide services to individuals and familiesthroughout the life span, addressing the fullrange of biopsychosocial–spiritual andenvironmental issues that affect well-being.Social work’s strengths-based, person-in-environment perspective provides thecontextual focus necessary for client- andfamily-centered care and is unique among the health professions.

A hallmark of social work’s commitment tohealth and well-being is the profession’scontinued focus on the issue of health careinequality in the United States. People livingin poverty and communities of color continueto experience disproportionately higher ratesof acute and chronic illness, due to unequalaccess to health care services, lack of healthinsurance coverage, poverty, discrimination,and other social determinants of health. Socialworkers recognize that reducing healthdisparities can only be accomplished byaddressing the biopsychosocial–spiritual needsof individuals and families, as well as thesystemic issues that contribute to poor health outcomes.

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The Evolving U.S. Health Care System

The U.S. health care system is in an era ofunprecedented change. In recent years, thenation has witnessed continuing high rates ofuninsurance (13 percent of the U.S.population, or 42 million people, wereuninsured in 2013 [U.S. Census Bureau,2014]), inadequate coverage, escalating healthcare costs, erosion of employer-based healthinsurance, and increasing demand for healthcare services as the baby boom generationenters retirement. The Patient Protection andAffordable Care Act (ACA) (2010) wasdesigned to address these issues. The goal ofthe ACA is to expand access to affordable andcomprehensive health coverage, improvepatient outcomes, and increase the efficiencyand cost-effectiveness of the health caredelivery system. The ACA invests heavily incare delivery models that promotecoordination of acute and postacute care andgreater integration of primary and behavioralhealth services.

Challenges for the Profession

Their long-standing role in the health systemnotwithstanding, social workers practicing inhealth care settings today face significantchallenges. Ongoing changes in the financingand delivery of health care and a shortage ofsocial work effectiveness data have contributedto the reduction of social work services incertain health care settings. Increasingly,health care social workers are supervised byindividuals without social work degrees, andtasks previously performed by social workersare often assigned to other personnel,including nurses, paraprofessionals, andvolunteers, in an effort to reduce costs.

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Opportunities for Social Work in the ACA Era

Despite these challenges, health care socialwork is poised to experience a resurgence inthe ACA era. With its emphasis on the “tripleaim”—improving the patient experience ofcare (including quality and satisfaction),improving the health of populations, andreducing the per capita cost of health care(Institute for Healthcare Improvement,2014)—the ACA strengthens social work’straditional role in health care and offers newopportunities for the profession.

The ACA promotes care delivery models, suchas the patient-centered medical home(PCMH) and accountable care organization(ACO), which are designed to improve healthoutcomes and control health care costs. Tosucceed, these models will rely on socialworkers skilled and competent in health carenavigation, behavioral and mental healthintegration, chronic care management, andcare coordination, among other skills. Theaging of the population will necessitate a needfor social workers skilled in transitioningpatients between different settings and levelsof care and managing complex discharges.

The anticipated influx of patients into thehealth care system resulting from the ACAinsurance coverage expansion will increase theneed for social workers who are educated andtrained in working with diverse populationsand with clients who have challengingphysical, behavioral, and mental health needs.Greater emphasis on community-based carewill require social workers skilled in reducingnonmedical barriers to health care access. Asimportant, expanded social work involvement

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in these roles and settings presents anopportunity to advance the evidence base forthe profession.

Prevention and public health, traditional socialwork roles, have gained renewed importanceunder the ACA. With its ecological viewpoint,the social work profession is well-positioned totake a leadership role in new ACA preventioninitiatives, including workplace wellness, homevisiting, and smoking cessation programs. Socialworkers are also well positioned to participatein macro-level prevention efforts, such as policychange to reduce obesity, which can improvepopulation outcomes more efficiently thanindividual-actions at the clinical care level.Furthermore, new research fields, particularlypatient-centered outcomes research andcommunity-based participatory research, offer anopportunity for social workers to contribute tothe prevention and public health research base.

Purpose of the Standards for Social WorkPractice in Health Care Settings

These standards articulate the necessaryknowledge and skills health care social workersshould possess to deliver competent and ethicalservices in today’s health care environment;provide benchmarks for quality social workpractice for use by health care employers; andassist policymakers, other health professionals,and the public in understanding the role ofprofessional social workers in health caresettings. These standards are intended toguide social work practice and may be applieddifferently, as appropriate, to different healthcare settings.

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Goals

The specific goals of the standards are to

� Ensure that social work practice in healthcare settings is guided by the NASW Code of Ethics (NASW, 2008)

� Enhance the quality of social work servicesprovided to clients and families in healthcare settings

� Advocate for clients’ rights to self-determination, confidentiality, access tosupportive services and resources, andappropriate inclusion in decision makingthat affects their health and well-being

� Encourage social work participation in thedevelopment, refinement, and integration ofbest practices in health care and health caresocial work

� Promote social work participation insystemwide quality improvement andresearch efforts within health careorganizations

� Provide a basis for the development ofcontinuing education materials andprograms related to social work in healthcare settings

� Promote social work participation in thedevelopment and refinement of publicpolicy at the local, state, federal, and triballevels to support the well-being of clients,families, and communities served by therapidly evolving U.S. health care system

� Inform policymakers, employers, and thepublic about the essential role of socialworkers across the health care continuum.

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Definitions

Social Worker

Within the United States, a social worker is anindividual who possesses a baccalaureate ormaster’s degree in social work from a school orprogram accredited by the Council on SocialWork Education. Although all 50 states andthe District of Columbia license or certifysocial workers, licensure and certification lawsvary by state. Each social worker should belicensed or certified, as applicable and required,at the level appropriate to her or his scope ofpractice in the practitioner’s jurisdiction(s).

Client

Client refers to the “individual, group, family,or community that seeks or is provided withprofessional services” (Barker, 2013, p. 73).For purposes of these standards, the term“client” refers to an individual. The term“patient” is more commonly used by socialworkers employed in health care settings.

Biopsychosocial–Spiritual Perspective

A biopsychosocial–spiritual perspectiverecognizes the importance of whole personcare and takes into account a client’s physicalor medical condition; emotional orpsychological state; socioeconomic,sociocultural, and sociopolitical status; andspiritual needs and concerns.

Bioethics

Bioethics is “the analysis and study of legal,moral, social, and ethical considerationsinvolving the biological and medical sciences”(Barker, 2013, p. 41).

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Case Management

Case management is a collaborative process toplan, seek, advocate for, and monitor services,resources, and supports on behalf of a client.Case management enables a health care socialworker to serve clients who may require theservices of various health care providers andfacilities, community-based organizations,social services agencies, and other programs.Case management limits problems arisingfrom fragmentation of services, staff turnover,and inadequate coordination among providers.“Care coordination,” “care management,” and“patient navigation” are sometimes usedinterchangeably with “case management”(Barker, 2013).

Cultural Competence

Cultural competence is “the process by whichindividuals and systems respond respectfully andeffectively to people of all cultures, languages,classes, races, ethnic backgrounds, religions,and other diversity factors [including, but notlimited to, sexual orientation; gender, genderexpression, and gender identity; and familystatus] in a manner that recognizes, affirms,and values the worth of individuals, families,and communities and protects and preservesthe dignity of each” (NASW, 2007, pp. 12–13).

Health Disparities

Health disparities are preventable differencesin the incidence, prevalence, mortality, anddisease burden that are closely linked withsocial, economic, and environmentaldisadvantage. Health disparities adversely affectgroups of people who have systematicallyexperienced greater obstacles to health basedon their race or ethnicity; religion;

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socioeconomic status; sexual orientation;gender, gender expression, and genderidentity; age; mental health; cognitive, sensory,or physical disability; geographic location; orother characteristics historically linked todiscrimination or exclusion (Centers forDisease Control and Prevention, n.d.).

Social Determinants of Health

The social determinants of health are factorsthat affect a wide range of health and quality-of-life outcomes and are responsible for mosthealth disparities. These factors include income,housing, education, employment, and access tohealth services, among others. Social determinantsof health are shaped by the distribution ofmoney, power, and resources (Centers forDisease Control and Prevention, n.d.).

National Standards for Culturally and

Linguistically Appropriate Services in Health

Care (CLAS Standards)

The National Standards for Culturally andLinguistically Appropriate Services in Healthand Health Care (the CLAS Standards),developed by the U.S. Department of Healthand Human Services (HHS), are intended toadvance health equity, improve quality, andhelp eliminate health care disparities byproviding guidance to health careorganizations for implementing culturally andlinguistically appropriate services (HHS,Office of Minority Health, 2013).

Patient Protection and Affordable Care Act

(ACA) (2010)

The ACA is a broad-based federal law thatseeks to reform the U.S. health care deliverysystem by expanding health insurance

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coverage, enhancing quality of care, improvinghealth outcomes, regulating the health insuranceindustry, and reducing health care spending.

Patient-Centered Medical Home (PCMH)

The PCMH is a health care delivery modelaccountable for meeting the large majority of aperson’s physical and mental health care needs,including primary, acute, and chronic care.Within a PCMH, an individual has anongoing relationship with a primary careprovider who directs and coordinates his orher care across all elements of the broaderhealth care system, including physicianspecialty services, hospitals, home health care,and community services and supports (Agencyfor Healthcare Research and Quality, n.d.-a).

Integrated Care

Integrated care is a health care deliveryapproach in which primary care, mentalhealth, and behavioral health care services aresystematically coordinated and available in onelocation (Substance Abuse and Mental HealthServices Administration & HHS, HealthResources and Services Administration, Centerfor Integrated Health Solutions, n.d.).

Chronic Care Model

The chronic care model is a widely usedapproach to chronic illness management thatadapts the acute care delivery system to moreappropriately meet the needs of individualswith chronic illness (Agency for HealthcareResearch and Quality, n.d.-b).

Accountable Care Organization (ACO)

An ACO is a group of physicians, hospitals,and other health care providers who share

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responsibility for providing coordinated careto patients. Within an ACO, providers arefinancially incentivized for meeting specificquality and utilization benchmarks for adefined patient population (Centers forMedicare & Medicaid Services, n.d.).

Evidence-Informed Practice

Evidence-informed practice is practice basedon the best available research, practiceexpertise, and available resources.

Guiding Principles

The NASW Standards for Social Work Practicein Health Care Settings reflect the followingguiding principles of the social work profession:

� Self-determination: Social workers respectand promote the right of clients to self-determination and assist clients in theirefforts to identify and clarify their goals.

� Cultural competency and affirmation of thedignity and worth of all people: Socialworkers treat each person in a caring andrespectful fashion. With skills in culturalawareness and cultural competence, socialworkers affirm the worth and dignity ofpeople of all cultures.

� Person-in-environment framework: Socialworkers understand that each individualexperiences a mutually influentialrelationship with her or his physical andsocial environment and cannot beunderstood outside of that context. Thisecological perspective recognizes thatsystemic injustice and oppression underliemany challenges faced by clients.

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� Strengths perspective: Rather than focus onpathology, social workers elicit, support, andbuild on the resilience and potential forgrowth and development inherent in eachindividual.

� Primacy of the client–social workerrelationship: The therapeutic relationshipbetween the social worker and the client isintegral to helping the client achieve her orhis goals.

� Social justice: At all levels, from local toglobal, social workers promote and advocatefor social, economic, political, and culturalvalues and institutions that are compatiblewith the realization of social justice.

� Importance of social work research: Socialworkers promote the value of research as ameans of improving the well-being ofindividuals, families, and society;strengthening the current workforce; andmaintaining the social work profession’s rolein health care settings.

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Standards

Standard 1. Ethics and Values

Social workers practicing in health caresettings shall adhere to and promote the ethicsand values of the social work profession, usingthe NASW Code of Ethics as a guide to ethicaldecision making (NASW, 2015a).

Interpretation

The primary mission of the social workprofession is to enhance human well-being andhelp meet the basic human needs, with specialattention to the needs of people andcommunities who are vulnerable, oppressed,or living in poverty. Social workers have anethical obligation to address the health careneeds of these groups and advocate for changeto ensure access to quality care.

The profession’s mission is rooted in corevalues that have been embraced by socialworkers throughout the profession’s historyand highlight social work’s distinct purposeand perspective. These values—service, socialjustice, dignity and worth of the person,importance of human relationships, compassion,integrity and competence—constitute thefoundation of social work and underlie thepractice of social work in health care settings.

The NASW Code of Ethics establishes theethical responsibilities of all social workerswith respect to their own practice, clients,colleagues, employees and employingorganizations, the social work profession, andsociety. Acceptance of these responsibilities—which include upholding a client’s right toprivacy and confidentiality and promoting

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client self-determination—fosters competentsocial work practice in health care settings.

In a health care system characterized bytechnological advancement and rapid changein care delivery and financing of health careservices, ethical dilemmas among and betweenclients, families, health care professionals, andorganizations are potentially numerous andcomplex. The NASW Code of Ethics andprevailing clinical bioethics provide afoundation for social workers to manage suchdilemmas. Health care social workers have theresponsibility to know and comply with local,state, federal, and tribal legislation,regulations, and policies, addressing topicssuch as guardianship; parental rights; advancedirectives; and reporting requirements forabuse, neglect, exploitation, suicide, and threatof harm to others.

When an ethical dilemma or conflict occurs,the health care social worker is expected toemploy available mechanisms, including socialwork supervision, peer review, institutionalethics committees, and external consultation,to resolve the dilemma.

Standard 2. Qualifications

Social workers practicing in health caresettings shall possess a baccalaureate ormaster’s degree in social work from a school orprogram accredited by the Council on SocialWork Education, shall comply with thelicensing and certification requirements of thestate(s) or jurisdiction(s) in which she or hepractices, and shall possess the skills andprofessional experience necessary to practicesocial work in health care settings.

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Interpretation

Social work degree programs provide thefundamental education and training requiredfor all social work practice specialties. As anarea of specialization within the social workprofession, health care social work requires adistinct skill set and knowledge base, asoutlined in these standards. Ideally,prospective health care social workers shouldhave prior health care–related educational oremployment experience. At a minimum, it is ahealth care social worker’s responsibility to

� Acquire and maintain social work licensureor certification, as available, for the socialworker’s educational level and professionalexperience

� Abide by a defined scope of practice, asrequired by state law or regulation

� Adhere to supervision requirements� Pursue ongoing professional development

activities, to acquire the competencenecessary to perform job responsibilities.

A health care social worker whose responsibilitiesinclude the diagnosis of mental and behavioralhealth conditions and/or the provision ofpsychotherapy must have a master’s degree insocial work and should either be licensed atthe clinical level or, if the licensing jurisdictionallows, perform clinical tasks under supervision.

Standard 3. Knowledge

Social workers practicing in health caresettings shall acquire and maintain a workingknowledge of current theory and evidence-informed practice, and shall use suchinformation to ensure the quality of socialwork practice.

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Interpretation

As health care professionals, social workersrequire specialized knowledge and skills. Thisknowledge and skill base can be obtainedthrough multiple approaches, includingcoursework and field practice in a social workdegree program, specialty practice credentialsearned after graduation, health care–relatedemployment experience, and ongoingcontinuing education. Developing a knowledgeand skill base is a cumulative process thatrequires a commitment to career-long learning.

Given the growing complexity of servicesdelivery systems and client needs, evenexperienced health care social workers mayencounter situations requiring knowledge andskills beyond the scope of their usual practicesetting. In such situations, the health caresocial worker seeks supervision, consultation,and continuing professional development, asdescribed elsewhere in these standards, to ensureshe or he has both the requisite knowledge ofhealth care delivery systems and the skills toserve clients effectively. In addition, the socialworker may need to collaborate with healthcare and other services providers on behalf of aclient, or refer a client to other social workerswhose expertise is more suitable to the client’sneeds and circumstances.

Knowledge and skills that are essential to socialwork practice in health care settings include,but are not limited to, the following areas:

Physical and mental/behavioral health

� The interplay between the physiologicalelements of acute, chronic, and life-limitingillness and biopsychosocial–spiritual healthand well-being

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� Concepts and theories associated with life-span development, neurobiology, andbehavioral change

� Grief, loss, and bereavement� Depression, anxiety, and other mental

health conditions� Addiction and other behavioral health

conditions� Sexual health� Concerns related to sexual orientation, gender

identity and expression, and gender roles � Basic medical terminology� Knowledge of common health conditions� Counseling and behavioral change

intervention

Health care delivery system issues

� The health care continuum� The unique needs of marginalized,

oppressed, and diverse populations � Health disparities and the social

determinants of health � Evidence-informed approaches to health

care, including the PCMH, integratedprimary and behavioral health care, ACOs,and the chronic care model

� New health care policies and deliverysystem changes resulting from the ACA

� Basics of health insurance coverage,including Medicare, Medicaid, theChildren’s Health Insurance Program, andcommercial insurance plans

� Health care system trends, includingongoing health care infrastructure changes

� Accreditation and regulatory standardsgoverning health care settings

� Thorough knowledge of community resources� Micro-, mezzo-, and macro-level preventive

health care

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Roles and responsibilities of social workers in

health care settings

� Understanding of common ethical and legalissues in social work practice in health caresettings

� Biopsychosocial–spiritual assessment� Use of the strengths perspective� Client and family engagement in all aspects

of social work intervention� Case management/care management/care

coordination/health care navigation� Discharge and transition planning� Client concordance with and adherence to

the plan of care� Advance care planning� Palliative care, including pain and symptom

management� Hospice and end-of-life care� Identification of child/elder/vulnerable adult

abuse, trauma, neglect, and exploitation� Crisis intervention � Facilitation of benefits and resource

acquisition to assist clients and families,including an understanding of relatedpolicies, eligibility requirements, andfinancial and legal issues

� Advocacy with other members of theinterdisciplinary team and within the healthcare institution to promote clients’ andfamilies’ decision making and quality of life

� Client, family, interdisciplinary, andcommunity education

� Family systems issues, including the impactof health care concerns, illness, and diseaseon family relationships; life cycles; andcaregiving roles and support needs

Research and evaluation

� Research and evaluation methodology

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� Social work outcome/practice evaluationapproaches

� Opportunities for social work participationin institutional quality improvementprograms and research projects

� Client and family education regardingopportunities for clinical trial participation

� Ability to analyze research results andincorporate findings into practice,organizational quality improvementinitiatives, and advancement of the socialwork profession

Standard 4. Cultural and Linguistic Competence

Social workers practicing in health caresettings shall provide and facilitate access toculturally and linguistically appropriateservices, consistent with the NASW Standardsand Indicators for Cultural Competence in SocialWork Practice (NASW, 2015b).

Interpretation

The increasing racial, ethnic, and linguisticdiversity of the United States requires healthcare social workers to strive continuously forcultural competence. Recognition andaffirmation of cultural and linguistic diversityare critical to both therapeutic alliances withclients and cooperative working relationshipswith colleagues. Given the many facets ofculture, every interaction between a healthcare social worker and a client is potentially across-cultural exchange, as two individuals areunlikely to be identical in every aspect ofcultural identity.

The practice of health care social work requiresan understanding of the broad scope ofdiversity in the United States. Client diversity

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is expressed in many ways, including race,ethnicity, socioeconomic class, sexualorientation; gender, gender expression, andgender identity; religion, age, health andfamily status; cognitive, physical, or psychiatricability; and sensory differences, preferredlanguage, immigration status, degree ofacculturation, level of formal education, andliteracy, among others. Health care socialworkers must also recognize that cultural self-awareness is an integral component of culturalcompetence. Such awareness entailsunderstanding how one’s own cultural values,beliefs, biases, experiences, and perceptionsaffect interactions with clients and colleagues.

Health care social workers must acquire across-cultural knowledge base to provideeffective, culturally competent practice. Inparticular, social workers must develop andmaintain an understanding of the history,traditions, rituals, values, family systems, andcommunication patterns of major clientgroups served, as well as an understanding ofthe influence of culture on help-seekingbehaviors and perceptions of health, illness,health care treatments, disability, caregivingroles, and death and dying among client/patientgroups served. Social workers should alsorecognize how societal oppression and privilegerelated to cultural and linguistic diversity (suchas racism, sexism, homophobia, ageism, orxenophobia) affect clients’ biopsychosocial–spiritual well-being, access to and use ofsupports and services, and health outcomes.

Health care social workers should advocate fororganizational practices and policies thatpromote and support cultural diversity among

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staff and throughout the health careorganization. These may include hiring andretention policies that ensure various clientgroups are represented among personnel andinstitutionwide education and training programsto develop specialized expertise (such asbilingual and bicultural skills) among staff.

There is no endpoint in the achievement ofcultural competence; rather, developing andmaintaining cultural competence is a lifelongprocess of learning and self-reflection. Todevelop and promote cultural competence atthe individual, institutional, or societal level,social workers should be guided by the NASWStandards and Indicators for Cultural Competencein Social Work Practice (NASW, 2015b). HHS’sNational Standards for Culturally andLinguistically Appropriate Services in Health andHealth Care (HHS, 2013) may also serve as aguide for social workers.

Standard 5. Screening and Assessment

Social workers practicing in health caresettings shall engage clients and, whenappropriate, members of client supportsystems, in screening and assessment, bygathering information for use in developingevidence-informed care plans.

Interpretation

Screening for psychosocial issues is now commonin health care settings. Within emergencydepartments, clinics, and other points of entry,individuals are often screened for pain, mentalhealth disorders, domestic violence, substanceuse disorders, self-harm, and distress, amongother concerns. Screening can also occurthroughout a disease trajectory. The presence

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of psychosocial screening programs hasbecome a criterion for institutionalaccreditation in certain health care settings.

Early identification of psychosocial issues canassist health care social work staff in effectivelyprioritizing situations that may affect clientsafety or indicate a high need for social workservices. Preventive screening results can alsoinform a comprehensive client assessment.Social workers should be trained anddemonstrate competency in the use ofpsychosocial screening tools used within theirinstitutions and organizations. Social workersshould also participate on institutionalcommittees that implement and monitorpsychosocial screening programs.

Biopsychosocial–spiritual assessment is afundamental process of social work practice inhealth care settings. The foundation of clientcare planning is the comprehensive assessment,which requires social workers to engage clientsin identifying their needs and strengths andsupporting clients in establishing priorities andgoals. In conducting an assessment, the healthcare social worker must use empathy, client-centered interviewing skills, and methodsappropriate to clients’ capacity. In theassessment process, social workers may findstandardized instruments helpful in identifyingand responding to client concerns. Suchinstruments are viewed as starting points inthe development and refinement of anindividualized, comprehensive assessment.

Assessment is an ongoing activity, not aonetime event. During the reassessmentprocess, the social worker and client (and, if

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appropriate, members of the client supportsystem) revisit the needs, assets, and prioritiesidentified in the initial assessment and discussthe client’s emerging concerns.

A comprehensive assessment may include thefollowing:� Behavioral and mental health status, including

current level of functioning, coping style,crisis management skills, substance usehistory, and risk of suicide or homicide

� Physical and cognitive functioning � Psychosocial–spiritual well-being, including

ability to fulfill social roles� Cultural values, beliefs, and practices � Client strengths, protective factors, and

points of resilience� Employment, educational, or vocational

history, including challenges, goals, andobjectives

� Living arrangements, including suitabilityand safety of the home environment

� Family composition, structure, and roles� Language preferences and proficiency levels� Degrees of literacy, including health,

behavioral health, and financial literacy� Risk of abuse, neglect, or exploitation of or

by the client, and underlying causes for suchmistreatment

� Social supports, including formal andinformal support systems

� Need for economic or other psychosocialresources, supports, and services

� Ability to navigate relevant service systems(such as educational, employment, healthcare, housing, legal, nutritional, socialservices, or transportation systems)

� Life-span planning (which may includeadvance care planning, anticipation of

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caregiving responsibilities, permanencyplanning for minor children, retirementplanning, or other domains)

� Client’s perceptions of changes needed toimprove her or his situation

� Identification of barriers to adherence to theplan of care.

Assessment processes should, to the extentpossible, be customized for vulnerablepopulations, including children, people withsevere and persistent mental illness,immigrants and refugees, people withsubstance use disorders, survivors of violenceor trauma, people who are homeless, andpeople with physical or cognitive disabilities.

Standard 6. Care Planning and Intervention

Social workers practicing in health caresettings shall develop and implementevidence-informed care plans that promoteclient well-being and ensure a client- andfamily-centered continuum of care.

Interpretation

Care plans outline the necessary steps—identified collaboratively by the social worker,the client, the client support system (at thecompetent client’s discretion), and othermembers of the health care team—to achievethe goals and objectives identified in acomprehensive biopsychosocial–spiritualassessment. Implementing care plans withindividuals across the life span, and withdifferent health conditions and cultures,requires health care social workers to tailorpractice techniques to best meet client needs.

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Case management—a historical function ofthe social work profession—remains anefficient and cost-effective approach to careplan implementation that can optimize clientfunctioning. Health care institutions havemultiple titles for social workers who engagein case management functions. “Case manager,”“care manager,” “care transition manager,”“discharge planner,” “patient navigator,” and“care coordinator” describe work that resembles,to varying degrees, case management. Throughcase management, health care social workersengage clients in the collaborative process ofidentifying, planning, accessing, coordinating,monitoring, evaluating, and advocating forresources, supports, and services.

Clinical social workers who are employed orcontracted to provide mental or behavioralhealth services should use evidence-informedtreatment interventions with clients. Theseinterventions may include cognitive–behavioraltherapy, motivational interviewing, chronicdisease self-management, psychoeducationalservices, brief intervention/brief therapy, andtrauma-informed care, among other modalities.

When implementing care plans, social workersshould strive to � Develop and maintain a therapeutic

relationship with the client and the clientsupport system

� Engage the client in a culturally responsivemanner and with a strengths-based approachthat facilitates, supports, and recognizes theclient’s capabilities, resources, and resiliency

� Apply evidence-informed practice models tofacilitate the client’s accomplishment ofgoals and objectives

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� Facilitate access to a range of financial,housing, health, mental and behavioralhealth, education, and community resources

� Ensure care continuity through safedischarge, appropriate transition betweendifferent levels of care, and client follow-up

� Seek consultation from health care teammembers and social work supervisors, asnecessary, to facilitate plan implementation

� Safeguard the privacy and confidentiality ofclient information.

Standard 7. Advocacy

Social workers practicing in health care settingsshall advocate for the needs and interests ofclients and client support systems and promotesystem-level change to improve outcomes,access to care, and delivery of services,particularly for marginalized, medicallycomplex, or disadvantaged populations.

Interpretation

Social workers have a responsibility to advocatefor the needs and interests of clients and clientsupport systems. Social workers in health caresettings serve as client advocates by promotingclient access to health care, identifying andremoving barriers to services delivery, andhelping clients navigate between and amongcomplex health and social services systems.Social workers also strive to promote clients’self-advocacy skills and to enhance thecapacity of communities to support clients’biopsychosocial–spiritual quality of life.

To strengthen services and enhance clientoutcomes, social workers should promote andparticipate in quality improvement initiatives

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within their health care institutions. Qualityimprovement programs offer an opportunity forhealth social workers to advocate for theexpansion of the profession’s role in health caresettings. These programs can also build socialwork capacity for institutional leadership roles.

Social workers should play an active role incommunity education efforts, speaking onbehalf of their health care institutions aboutdisease prevention, health promotion, accessto care, and other timely health-related topics.

Health social workers must understand theconcept of health disparities—thedisproportionate burden of preventable disease,death, and disability experienced by manyminority communities, people living in poverty,and other disenfranchised groups. Healthdisparities are closely linked with the socialdeterminants of health, that is, the social,economic, and environmental conditions thatstrongly influence heath status. Populationhealth requires minimizing health disparitiesand promoting health equity among allsocioeconomic groups. Social workers have anethical obligation to address health disparitiesby educating colleagues, the media, alliedprofessionals, decision makers and policymakers,and other stakeholders on the impact of healthdisparities and unequal access to healthservices and by engaging in social and politicalaction to reduce health disparities.

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Standard 8. Interdisciplinary and

Interorganizational Collaboration

Social workers practicing in health caresettings shall promote collaboration amonghealth care team members, other colleagues,and organizations to support, enhance, anddeliver effective services to clients and clientsupport systems.

Interpretation

Collaboration between the social worker andthe client is the foundation of health care socialwork practice. Therefore, the client (and whenappropriate members of the client supportsystem) is at the center of the health care team.Within health care settings, multiple practitionersare often involved in a client’s care, makingteamwork and collaboration essential.Teamwork and good communication amonghealth care practitioners can improve healthcare delivery, resulting in better client outcomes.

Social workers should be competent in differentteamwork models that are common in healthcare settings, including multidisciplinary models(different disciplines working together, eachdrawing on their own knowledge);interdisciplinary models (different disciplinesworking in a coordinated fashion toward acommon goal for the client); and transdisciplinarymodels (a team of health care professionalscooperating across disciplines to improve patientcare through practice or research). Workingeffectively as members of a health care teamalso requires health care professionals, includingsocial workers, to engage in interdisciplinaryeducation programs. These efforts allow teammembers to learn about each other’scontributions to improving client outcomes.

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The health care social worker plays an integralrole in fostering, maintaining, andstrengthening collaborative partnerships onbehalf of clients, families, and communitiesand should demonstrate the ability to� Articulate and fulfill the mission and functions

of the employing health care organization � Differentiate social work perspectives,

values, and interventions from those ofother health care disciplines

� Ensure that the social work roles andresponsibilities are clearly delineated andcommunicated to other members of the team

� Provide psychosocial insight, guidance, andrecommendations to other members of thehealth care team regarding client and familywell-being

� Describe the roles of other health carepractitioners and organizations involved insupporting the client

� Ensure that the roles and responsibilities ofeach collaborating organization are clearlydelineated and communicated

� Communicate effectively with allprofessionals, paraprofessionals, andvolunteers involved in supporting socialwork clientele in the health care setting

� Advocate for the client’s or, whenappropriate, the client support system’sintegral role in team communications andcare planning, delivery, and monitoring

� Communicate the client’s information in arespectful and objective manner whileprotecting the client’s confidentiality andprivacy

� Foster an organizational culture thatpromotes effective, coordinated services forclients, families, and communities

� Develop and maintain partnerships across

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disciplines and organizations to enhanceaccess to and continuity of care for socialwork clientele

� Share and, where appropriate, teamleadership in planning and improvingservices to clients.

Standard 9. Practice Evaluation and Quality

Improvement

Social workers practicing in health care settingsshall participate in ongoing formal evaluationof their practice to advance client health andwell-being, assess the appropriateness andeffectiveness of services and supports, ensurecompetence, and strengthen practice.

Interpretation

Evaluation of social work practice is an essentialcomponent of social work services delivery.Evaluation entails soliciting and integratinginternal and external feedback on the processand outcomes of social work practice in healthcare settings. Ongoing formal practice evaluationis vital to ensure that services provided toclients are appropriate, effective, and timely inhelping clients achieve their goals. Moreover,practice evaluation outcomes are increasinglyused for position justification, performancereview, practice standards, goal setting, riskmanagement, utilization review, and researchefforts. Social work evaluation methods mayinclude peer review, self-evaluation,supervision, and other research methods.

Evaluation practices may include the followingactivities:� Application of appropriate tools such as

clinical indicators, practice guidelines,satisfaction surveys, and standardized

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performance assessments to evaluate clientprogress and satisfaction

� Solicitation and incorporation of feedbackfrom clients regarding the extent to whichsocial work services have helped themidentify and achieve their goals

� Solicitation and incorporation of feedbackfrom the interdisciplinary treatment teamregarding the effectiveness of social workservices and opportunities for increased orimproved interdisciplinary collaboration

� Measurement of both process and outcomeobjectives

� Practitioner, program, and organizationalself-evaluation

� Participation in qualitative and quantitativesocial work research to strengthen theevidence base for social work services inhealth care settings

� Dissemination of evaluative data to clients,payers, and other health care providers onrequest, and with consideration for clients’rights to privacy and confidentiality

� Use of internal and external practice,program, or organizational evaluators

� Application of evaluation and researchfindings, including evidence-informedpractice, to facilitate client goal setting andto enhance practice and program qualityand outcomes

� Use of peer review, supervision, andconsultation with other social workers andacross disciplines.

Standard 10. Record Keeping and Confidentiality

Social workers practicing in health care settingsshall maintain timely documentation thatincludes pertinent information regarding clientassessment, and intervention, and outcomes,

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and shall safeguard the privacy andconfidentiality of client information.

Interpretation

Clear, concise, and ongoing documentation ofsocial work services in health care settingsfacilitates effective communication with otherhealth care providers and organizations,thereby promoting continuity of services.Documentation serves as a foundation for careplanning and for practice and programevaluation. In addition, professionaldocumentation is often required for servicesreimbursement, utilization or legal review, anddemonstration of organizational accountabilityto payers or funding sources. The purpose ofdocumentation is to foster strong workingrelationships with, and services for, clients inhealth care settings.

Documentation of social work services shouldbe recorded on paper or electronically andmust be prepared, secured, and disclosed inaccordance with regulatory, legislative,statutory, and organizational requirements.

High-quality social work documentation includes� The client’s identifying information� Screening results� Initial and subsequent biopsychosocial–

spiritual assessments� A client care plan, with procedures for

monitoring and quantifying progress towardaccomplishment of client goals, servicesprovided, and other information about planimplementation

� Referrals to or from other practitioners,organizations, or resources, includingrationale for referrals, and other

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collaboration on behalf of the client� Dates, times, and descriptions of contact with

the client, the client’s support system, andother health care providers or organizations

� Quantifiable service outcomes � Supervision or consultation sought or

provided to enhance social work services� Transfer or termination of services� When indicated, written permission from

the client to release and obtain information� Documentation of compliance with

confidentiality and privacy rights andresponsibilities

� Accounting of receipts and disbursementsrelated to client services provision.

Health care social workers must safeguard allclient information and adhere strictly to local,state, federal, and tribal requirementsregarding confidentiality. They should informclients both verbally and in writing ofconfidentiality requirements and limitationsbefore services are initiated. This is necessaryto ensure that the client has the informationneeded to provide informed consent and tofacilitate the client’s understanding of how thesocial worker discloses client information toother health care professionals and how thehealth care organization responds to externalrequests for confidential information.

Technology, including e-mail, text messaging,videoconferences, and other mechanisms, mayincrease the efficiency of social work services,but must always be used in a professionallyappropriate manner that ensures clientconfidentiality in all venues. Disclosure ofidentifying information should be avoidedwhenever possible. In particular, social

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workers should refrain from disclosure ofclient information on social media.

Health care social workers should beknowledgeable about the confidentialityimplications of electronic record keepingspecific to health care settings. Social workersshould receive training on and demonstratecompetence in the health care organization’selectronic medical record (EMR) system andshould demonstrate competency in its use,including an understanding of the EMR’sunique confidentiality and privacy implications.Health care social workers should also beknowledgeable about the Health InsurancePortability and Accountability Act of 1996,and the Health Information Technology forEconomic and Clinical Health Act (2009).

Standard 11. Workload Sustainability

Social workers practicing in health care settingsshall responsibly advocate for workloads andscope of work that permit efficient and high-quality social work services delivery.

Interpretation

Health care organizations, social work managers,and social work staff have joint responsibilityfor establishing and maintaining a workloadthat allows for adequate and appropriateinterventions and monitoring of services andoutcomes. A workload consists of any socialwork function, including direct contact with oron behalf of clients and administrative, policy,research, or educational functions performedin accordance with a health care social workposition. The workload reflects the needs andgoals of the clientele and the health careorganization and may include social workcoverage outside of regular office hours.

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A caseload, in contrast, refers to the number ofclients served at a given point in time. Clientcaseload size directly affects a social worker’scapacity to establish relationships with andprovide services to clients. Consequently,caseload size should allow for meaningfulopportunities for client contact. The numberof clients a health care social worker can serveeffectively is limited by the degree to whichhealth care organizations serve clients in acute,high-risk situations or other circumstancesrequiring intensive, frequent contact withclients. The workload also reflects thedemands of the population served.

Multiple factors affect both caseload size andworkload manageability within health caresettings, including but not limited to� Complexity of client needs, including

patient acuity and requirements for caretransitions and follow-up services

� Availability of institutional, community, andfamily resources to meet client needs and goals

� Number of clients the health careorganization serves

� Administrative support and access totechnology.

For maximum effectiveness, the size of thesocial work staff reflects the mission of thehealth care organization, the scope of thesocial work program, and the number andcomplexity of clients served. On behalf ofhealth care social workers and their clientele,social workers should advocate for and supportresearch to determine reasonable caseloadswith diverse populations and within differenthealth care practice settings, to provideethical, quality-based services.

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Standard 12. Professional Development

Social workers practicing in health care settingsshall assume personal responsibility for theirown continued professional development, inaccordance with the NASW Standards forContinuing Professional Education (NASW, 2003)and the licensure or certification requirementsof the state(s) or jurisdiction(s) in which she orhe practices.

Interpretation

Social workers must engage in ongoingprofessional development to maintaincompetence within their fields of practice.Professional development activities relevant tosocial work practice in health care settings mayinclude developments in clinical care, researchor technology, health care policy and legislation,community resources and services, ethics, andleadership and administration, among othertopics. Numerous opportunities for professionaldevelopment exist within NASW, alliedprofessional organizations, schools of socialwork, health care institutions, and organizationsproviding services to or on behalf of variousconstituencies (such as children, older adults,or people with disabilities) at the local, state,national, and international levels.

Employing organizations should encourageand support social workers’ participation inprofessional development activities. This can beaccomplished through organizational sponsorshipof multidisciplinary and social work–specificcontinuing education programming; promotionof supervision and mentorship opportunitiesfor social workers; and support for social workinvolvement in peer review, research,publication, and volunteer activities. To

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advance the field, social workers must take anactive role in opportunities, both within theiremploying institutions and within the largersocial work community.

Standard 13. Supervision and Leadership

Social workers practicing in health caresettings shall strive for leadership roles ineducational, supervisory, administrative, andresearch efforts within their institutions andshall mentor others within the social workprofession, to develop and maintain a robusthealth care social work workforce.

Interpretation

The purpose of social work supervision inhealth care settings is to enhance the professionalskills and knowledge of a supervisee toincrease her or his competence in providingquality services to clients and families.Supervision facilitates professional growth anddevelopment and improves clinical outcomes.

Best practice dictates that within health caresettings, social work departments be directedby a master’s-level social worker with experienceand expertise in health care practice. A licensedclinical social worker—be it the supervisor oranother individual—should be available toprovide clinical supervision for licensure, inaccordance with state licensing laws.Qualifications for social work supervisorsshould be consistent with the Best PracticeStandards in Social Work Supervision (NASW &Association of Social Work Boards, 2013).

Supervisors play a key role in the professionaldevelopment of their supervisees. The actionsand advice of the supervisor are keenly

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observed by supervisees and, consequently,influence much of the supervisees’ thinking andbehavior. Teaching is an important function ofthe supervisor, who models the behavior thesupervisees will emulate. Supervisors shouldcreate a supportive educational environment inwhich supervisees learn about the health caresystems in which they work and the clients andcommunities they serve.

To sustain and nurture the practice of healthcare social work, all experienced social workers,regardless of their supervisory status, shouldoffer guidance, mentoring, and consultation tostudents, interns, and their less experiencedpeers. Social workers in senior managementroles should provide mentorship to other socialworkers aspiring to leadership positions withinhealth care settings.

In addition, social workers should play an activerole in all types of clinical research, as well as inhealth services and quality improvement research.Such involvement not only demonstrates theleadership capability of the social workprofession, but also advances recognition amonginterdisciplinary colleagues of the essentialrole of biopsychosocial–spiritual interventionin quality care to clients and families.

In addition, social workers should play an activerole in clinical, health services, and qualityimprovement research, to demonstrate theleadership capability of the social workprofession and to advance recognition amongcolleagues in other disciplines of the essentialrole of biopsychosocial-spiritual interventionin quality services to clients and families.

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Experienced social workers should promoterelationships with schools of social work intheir states and communities to encourageinterest in health care practice through fieldplacement arrangements, joint researchinitiatives, and collaborative continuingeducation activities.

Social workers should initiate and participatein qualitative and quantitative social workresearch to strengthen the evidence base forsocial work services in health care settings andimprove the broader health care system.

References

Agency for Healthcare Research and Quality.(n.d.-a). Patient-centered medical home resourcecenter. Retrieved from http://pcmh.ahrq.gov/

Agency for Healthcare Research and Quality.(n.d.-b). Toolkit for implementing the chronic caremodel in an academic environment. Retrievedfrom www.ahrq.gov/professionals/education/curriculum-tools/chronic caremodel/chronic3a.html

Barker, R. L. (2013). The social work dictionary(6th ed.). Washington, DC: NASW Press.

Centers for Disease Control and Prevention.(n.d.). Social determinants of health. Retrievedfrom www.cdc.gov/socialdeterminants/Definitions.html

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Centers for Medicare & Medicaid Services.(n.d.). Accountable care organizations (ACO).Retrieved from www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/

Health Information Technology for Economicand Clinical Health Act, P.L. 111-5, div. A,title XIII, div. B, title IV, 123 Stat. 226, 467(42 U.S.C. 300jj et seq.; 17901 et seq.)(February 17, 2009).

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National Association of Social Workers.(2003). NASW standards for continuingprofessional education. Washington, DC: Author.

National Association of Social Workers.(2015a). Code of ethics of the National Associationof Social Workers. Washington, DC: Author.

National Association of Social Workers.(2015b). Standards and indicators for culturalcompetence in social work practice. Washington,DC: Author.

National Association of Social Workers &Association of Social Work Boards. (2013). Bestpractice standards in social work supervision.Washington, DC: NASW Press.

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Patient Protection and Affordable Care Act,P.L. 111-148, 124 Stat. 1025 (2010).

Substance Abuse and Mental Health ServicesAdministration & U.S. Department of Healthand Human Services, Health Resources andServices Administration, Center for Integrated Health Solutions. (n.d.). What is integrated care. Retrieved fromwww.integration.samhsa.gov/about-us/ what-is-integrated-care

U.S. Census Bureau. (2014). Health insurancecoverage in the United States: 2013 (CurrentPopulation Reports, P60-240). Washington,DC: U.S. Government Printing Office.

U.S. Department of Health and HumanServices. (2013). Report of the Secretary’sAdvisory Committee on national health promotionand disease prevention objectives for 2020.Retrieved from www.healthypeople.gov

U.S. Department of Health and HumanServices, Office of Minority Health. (2013).The national culturally and linguisticallyappropriate services standards. Retrieved fromwww.thinkculturalhealth.hhs.gov/pdfs/NationalCLASStandards FactSheet.pdf

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Acknowledgments

NASW gratefully acknowledges the work ofthe social work expert panelists for theircontributions to the NASW Standards for SocialWork Practice in Health Care Settings. NASWalso thanks its health care specialty credentialholders, Specialty Practice Section committeesand members, and other members for theirinput in the standards development process.

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