A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care.

Rose SM, Hatzenbuehler S, Gilbert E, Bouchard MP, McGill D. A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care.
Health Soc Work. 2016 May;41(2):93-100. Available at: http://www.ncbi.nlm.nih.gov/pubmed/27263199

Capacity for patients' to collaborate in their care tends to be lower than among other patients, leading to inefficient uses in medical services and higher risk of adverse events. In the course of this study, social workers engaged patients with increased inpatient and emergency department (ED) use and barriers to self-management, and evaluated them for lifetime exposure to material disadvantage and violence. Intervention focused on creating a primary care team that improved patients' self-efficacy, increased locus of control, and improved capacity for engagement. Results include a 49 percent decrease in admissions and a 5 percent decrease in ED utilization with significant cost savings. Authors recommend further study to analyze social, clinical, and financial risk in a larger sample, which may yield information about a health care provider's most at-risk patients for early targeted intervention.