Is There a Social Worker in the House? Health Care Reform and the Future of Medical Social Work

As medicine has become increasingly sophisticated and technologically complex, medical education and medical care have come to rely on increased specialization (Moore & Showstack, 2003). Dividing providers into specialties, however, has also led to a fragmented care delivery system in which a patient might go to one clinic for a check-up, a mental health service provider for treatment of anxiety, another service provider for rehabilitation after addiction, urgent care for a toothache, a specialist for diabetes management, and an imaging center for cancer screening. Fragmentation leads to lapses in communication among providers, which can be costly in dollars (when care is duplicated) and in outcomes (when prescription errors occur, for instance, or when diagnoses fail to take mental health into account). This fragmentation has measurable consequences: The number of specialty physicians per population has been associated with higher mortality, shorter life span, and low birth rates (Shi, 1994). Recent health reform legislation aims to correct fragmentation by providing incentives to reorient health care around primary care and for existing practices to transform into medical homes (Kocher, Emanuel, & DeParle, 2010). The medical home offers a single place for the coordination of all outpatient care needs, including behavioral and dental health. The model imagines a site where patients access care easily, where interdisciplinary care teams understand each patient's history and needs, and where the method of payment reflects the coordination necessary for delivery of individualized care (American Academy of Pediatrics, 2002). Although definitions vary from single-site clinics to multiple-site primary care networks, the Agency for Healthcare Research and Quality (2011b) outlines five core medical home attributes: They must be patient-centered, comprehensive, coordinated, provide superb access to care, and have a systems-based approach to quality and safety. The medical home model purports to be a transformation of primary care that would set the foundation for a sustainable health care system by keeping people healthy.