Letter from the ChairAs a result of the passage of Affordable Care Act and other new policies, there is an increased

emphasis toward an interdisciplinary approach in which services are geared toward the patient as

the core focus; this is often referred to as “patient-centered services.”

In this issue of the Health SectionConnection, the article, Emergency Care and Behavioral Integration:

Where Do We Fit? How Do We Grow? written by Erin L. Richmond, MSW, a graduate of the University

of Missouri provides an overview of how the mental health and medical models have been merged in

order to manage patients’ health care needs from a multidisciplinary prospective.

The second article, UM Psychosocial Acuity Scale—An Update From the Field provides an overview of a

psychosocial acuity scale developed at the University of Michigan that is designed to be used across all

social work systems. The acuity scale can help social workers prioritize clinical needs and align proper

resources for their clients. The article was authored by Stacey Klett, MHSA; Nina Abney, LMSW; Alethia

Battles, LMSW; Janice Firn, LMSW; and Aimee Vantine, LMSW; all from the University of Michigan.

As social workers we should remember what one great philosopher once said, as we work toward

getting the results that we strive for: “Do, or do not. There is no try” (Yoda).

Rahikya Orr-Wilson, MSW, LCSW, LICSW

Chair, Health Specialty Practice Section

HealthFALL � 2016

SECTIONCONNECTION

NASW SPECIALTY PRACTICE SECTIONS

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

NASW Practice & ProfessionalDevelopment BlogWhere can you find the latestinformation posting about socialwork practice? Visit the NASWPractice and ProfessionalDevelopment Blog. Designed forNASW Section members and socialworkers in practice, it offers trendingtopics, valuable resources, andprofessional developmentopportunities. Learn more atwww.socialworkblog.org/practice-and-professional-development/.

IT’S A FACT: Heart disease and diabetes are among the

Rahikya Orr-Wilson, MSW, ChairElizabeth Cerbone, MSW, LSWJames E. Phelan, LCSW, BCDThomas W. Sedgwick, ACSW, LCSW, CCMKarla T. Washington, PhD, LCSW

HealthCommitteeMembers

INTEGRATION 101Historically, the health caresystem has been separatedbetween medical and mentalhealth care. This dichotomy hascreated a fragmented system inwhich we see rising costs forboth medical and mental care,a lack of appropriate referrals,and the misrecognition ofcomorbid physical andbehavioral conditions. Accordingto Moore (2015), “It has beenestimated that by 2020, nearlyone-third of all Americans(almost 160 million people) willhave at least one chronic

disease to manage and the costof health care will consumeover 20 percent of the GrossDomestic Product(p.1).” Toaddress this concern, the ObamaAdministration implemented theAffordable Care Act in 2010,which aimed to increasepatient-centered care throughoutthe health care delivery system(Moore, 2015). This push hasbeen seen mainly in the primarycare setting with the developmentof patient-centered medicalhomes (PCMHs). These facilitiesinclude multidisciplinary teamsof physicians, nurses, and

behavioral health consultants(BHCs) who work together tomanage patients’ health careneeds and chronic conditions.

BHCs occupy a unique rolewithin the primary care setting,as well as the behavioral healthfield in general. The principalrole of the BHC is to help patientsmake behavioral changes tobenefit their physical health,mental health, and overall well-being. They traditionally spend15 to 30 minutes with a patientand provide action-orientedand skill-based interventions for

patients to practice and developoutside of the clinic. While aBHC has the knowledge andskills to address the moretraditional conditions associatedwith mental health, such asmood disorders and anxiety,they are just as likely to workwith patients to address weightloss, diabetes management,chronic pain, smoking cessation,hypertension, and many otherphysical conditions. It is BHCs’ability to develop and addressthe connections betweenphysical and mental health thatmake them beneficial for the

NASW PRESIDENTDarrell Wheeler, PhD, MPH, ACSW

CHIEF EXECUTIVE OFFICERAngelo McClain, PhD, LICSW

NASW STAFFDirector, Professional andWorkforce DevelopmentRaffaele Vitelli, CAE

Specialty Practice Section ManagerYvette Mulkey, MS

Senior Practice AssociateLisa Yagoda, MSW, LICSW

Project CoordinatorRochelle Wilder

EMERGENCY CARE ANDBEHAVIORAL INTEGRATION:Where Do We Fit? How Do We Grow?ERIN L. RICHMOND, MSW

most common consequences of lifestyle choices.

integration of health care. Associal workers, we are qualifiedfor such a position because ourprofession recognizes theintertwining of variousdimensions of individualfunctioning and we areadaptable to different servicesettings (Patient-CenteredPrimary Care Institute, 2013).

HOW MIGHT IT LOOK IN THEEMERGENCY DEPARTMENT?In the US, emergencydepartments (EDs) have becomethe main point of access forindividuals experiencingsymptoms of both physicalconditions and mental healthconditions. Okafor et al. (2015)note, “The overuse of US EDsby mental health patients whoare not in crisis and poor accessto appropriate inpatientpsychiatric care reflect anongoing crisis in the mentalhealth system.” They also statethat an individual’s number ofvisits to the ED will increase ifhe or she suffers from a physicalillness in addition to a mentalillness. To address the overuseof the ED, the researchersdeveloped “Psychiatric FastTrack Service,” or PFTS, withthe aim of integrating behavioralservices into the ED and servingas a protocol for the exchangeof referrals between the ED,psychiatric services, andoutpatient services. To test fasttrack, a licensed clinical socialworker and a consultingpsychiatrist were added to theED’s team at Grady Hospital inAtlanta, Georgia, and a diagramwas developed to showcase theflow of integration ofbehavioral services into the ED.

The fast track consisted of threecategories: ED, psychiatricemergency services, andoutpatient services. The ideabehind these three categorieswas that patients could

potentially be funneled into themost appropriate services basedon their presentation. The threepatient presentations were“medically stable, psychiatricallyunstable;” “medically unstable,psychiatrically stable;” and“medically stable, psychiatricallystable.” A fourth presentationwas then included in the EDcategory: “medically unstableand psychiatrically unstable.”This presentation is where thebehavioral integration trulybegan. When a patientexperiencing both medical andpsychiatric problems arrived inthe ED, the emergencyphysicians had the ability tothen stabilize the patientmedically while the behavioralspecialist had the ability tostabilize the patientpsychiatrically or behaviorally.

The results of this integrationshowed improvement in variousquality metrics between January2011 and May 2012. Thesequality metrics included lengthof stay, time to triage, dispositionto discharge, admissiondisposition to departure,psychiatric length of stay, anduse of restraints. While thismodel improved the quality ofthese measures, the researchersstate: “As a result of this pilot,several areas were identified astarget areas for initiatives toimprove quality that directlyrelate to our integration efforts.This included the care forpatients with an underlyingpsychiatric issue who present tothe ED through the detentionsystem, and the medical carefor patients with comorbidacute medical and psychiatricissues” (Okafor et al., 2015).

Integrative fast tracks such asthe one discussed do provide afoundation for the integration ofbehavioral health services intoEDs across the United States,

but the focus of integration mustthen switch to the questioning ofwhat brief behavioral servicescan be utilized to benefit patientspresenting with chronic medicalconditions, acute mentalconditions, and a combinationof the two. Ideally, theintegration of BHCs as membersof the ED team would allow forbrief behavioral interventions todecrease symptoms of mentalillness and increase patients’self-management of chronicphysical conditions.

POTENTIAL TECHNIQUES:WHAT A BHC CAN DOMany treatment modalitiescommonly utilized by BHCsallow them to complete briefand focused assessments andintervention plans. These includemotivational interviewing,behavioral activation, solution-focused therapy, relaxationtraining, and various cognitive-behavioral approaches. Briefintervention techniques fromthese different modalities canbe utilized with patients withina 15- to 30-minute time frame,which would translate well tothe ED environment.

Brief intervention techniques,which are utilized in the primarycare setting and may beplausible in emergency care, include the following(Patient-Centered Primary CareInstitute, 2013):• Behavior modification• Values clarification• Goal setting and action stepplanning

• Mindfulness• Motivational interviewing• Problem-solving• Relapse prevention planning• Relaxation skills• Scheduling social andphysical activities

MODALITY ILLUSTRATIONWhile there are many kinds ofmodalities that may be used, itis sometimes easier tounderstand how they may beutilized in the primary care oremergency settings by viewingone specific modality in detail.Acceptance-CommitmentTherapy (ACT) can demonstratehow a specific treatmentmodality may be utilized in theprimary care setting and is aform of therapy that hasbranched out of the category ofcognitive-behavioral therapiesand is recognized as atherapeutic approach that canbe modified to work with alarge range of individuals andpresenting problems. Its mainpurpose is to help individualsreact to situations in aconstructive manner, as well asto negotiate and acceptchallenging thoughts andfeelings rather than to avoid orreplace them.

According to Larmar,Wiatrowski, and Lewis-Driver(2014), “Unlike cognitive-behavioral approaches thatreinforce the dynamic interplaybetween cognition, behavior,and affect and the focus onreplacing maladaptive thoughtprocesses with healthiercognitions, ACT teachesindividuals to ‘just notice,’accept and embrace privateexperiences and focus onbehavioral responses thatproduce more desirableoutcomes.” ACT functions onthe acronym FEAR (F: Fusion ofthoughts, E: Evaluation ofexperience, A: Avoidance ofexperience, R: Reason-giving).In response to the concepts inthis acronym, ACT utilizesvarious mindfulness techniques,including acceptance ofthoughts and emotions, cognitivedefusion, awareness of themoment, and observation of

self. In addition, there are sevencore processes that could beimplemented with patients inthe ED (Larmar et al., 2014): • Confronting the system• Recognizing control as theproblem

• Identifying cognitive defusionand mindfulness

• Developing a transcendentsense of self

• Promoting acceptance andwillingness

• Clarifying values• Establishing commitment

The types of interventions thatrelate directly to the coreprocesses of ACT and can betaught to patients in 15 to 30minutes include mindfulnessskills such as diaphragmaticbreathing, body scanning, andgrounding. Values clarificationexercises may also be utilizedto help patients identify andsolve conflict between their corevalues and emotional orbehavioral responses to negativeevents. Because ACT is rootedin cognitive-behavioral therapy,various handouts can beprovided for the patient tocomplete after leaving the ED.This helps patients to betteraccept their negative thoughtsand feelings while developingtheir self-management skills.

CASE STUDYA 27-year-old man presents tothe ED for the fourth time inthree months with shortness ofbreath, sweating, and anelevated heart rate. Each time,his EKG comes back withinnormal range. The ED physiciancontacts the BHC to speak withthis patient about anxiety andpanic. The patient reports to theBHC that he has been under ahigh volume of stress latelybecause of financial concerns.He has also quit exercising butfeels he has great familysupport and wants to be presentfor his family. The BHC first

provides education to the patienton primary care clinics withinthe area and what kind ofhotlines he can call rather thangoing to the ED. The BHC thenprovides psychoeducation onanxiety and panic beforeteaching the patient mindfulnessand relaxation techniques,including diaphragmaticbreathing, sensory stimulation,and body scanning. The BHCalso discusses the patient’svalues with him, including thevalue of family, and provides avalues clarification exercise forhim to complete at home. Thetimeline of this visit fits wellwithin the BHC role and readsas follows: • BHC introduction: 3 minutes• Biopsychosocial assessmentof patient: 10 minutes

• BHC interventions: 7 minutes• Total time spent: 20 minutes

FIRST STEPSAs social workers, our valuesand ethics tell us to help patients,increase their self-determination,and influence systematic changeto benefit the individuals we

with whom wehave workingrelationships. The idea ofintegrating true behavioralintervention into the ED settingis novel. For this reason, thereare crucial first steps we musttake to nourish this concept andcreate sustainable change inresearch, funding and advocacy.

As the integration of behavioralhealth into medical settingscontinues to grow, it is part ofour responsibility to grow withit and innovate new ways toreach populations in need.

Erin Richmond, MSW, LMSW, is a recentgraduate of the University of MissouriSchool of Social Work and is employedas a mental health therapist withEyerly Ball Community Mental HealthServices in Des Moines, IA. She may bereached at erinrichmond@outlook.com

REFERENCESLarmar, S., Wiatrowski, S., &Lewis-Driver, S. (2014).Acceptance & commitmenttherapy: An overview ofapplications and techniques.Journal of Service Science andManagement, 7, 216-221.

Moore, R. (2015). Measuringthe impact of recognizedpatient-centered medicalhomes (PCMH). Retrievedfrom http://scholarscompass.vcu.edu/cgi/viewcontent.cgi?article=5115&context=etd.

Okafor, M., Wrenn, G., Ede, V.,Wilson, N., Custer, W., Risby,E., …Satcher, D. (2015).Improving quality ofemergency care throughintegration of mental health.Community Mental HealthJournal, 52(3), 332-342.doi: 10.1007/s10597-015-9978-x.

Patient-Centered Primary CareInstitute. (2013). Primary carebehavioral health toolkit.Primary Care BehavioralHealth Introduction andFoundations Training byMountainview ConsultingGroup. Retrieved from:www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf.

ABSTRACTThe UM Psychosocial AcuityScale (“the scale”), developedby the University of Michigan(UM) Health System Departmentof Social Work, measures thepsychosocial acuity of patientand family situations across acomprehensive health system,including inpatient andoutpatient, primary care andsubspecialties, mental andphysical health, and disciplinesranging from pediatrics togeriatrics. Following challengeswith implementation of thescale and gathering reports ofmeasures, we are currentlyutilizing the scale to do whatwe set out to do: couple acuitymeasures with productivityinformation to tell a morecomplete story of social workcontributions and aid inaligning social work resources.

BACKGROUNDPsychosocial acuity can bedefined as the severity of illnessor client condition that indicatesthe need for the subsequentintervention (Huber & Craig,2007). After researching existingacuity models, we determinedthat the available scales did notprovide the scope needed to

capture the psychosocial acuityof patient and family situationsacross our comprehensive healthsystem. We began developingthe scale in 2011, published itin Social Work in Healthcare inJune 2014, and fullyimplemented the scale acrossthe University of MichiganHealth System (UMHS) in June2014. Acuity measures arerecorded, along with patientservices data, when clinicaldocumentation is completedwithin our electronic medicalrecord. Following the publicationof the scale, several healthsystems—U.S.-based andinternational—have partneredwith us to receive training onthe scale and advice on itssuccessful implementation.

CURRENT STATE Scoring situational acuity: Currently, MSW and BSW staffutilize the scale on a daily basisto record acuity on all directinteractions with patients andfamilies and/or on behalf ofpatients and families. Clinicianshave expressed that once theybecome familiar with the scale,scoring patient and familyencounters takes very little time.In addition, clinicians have

shared that their documentationhas improved since theimplementation of the scale,given that their psychosocialassessments and progress notesare more comprehensive, andmore completely highlight theareas of highest acuity.

Our first lesson learned wasrelated to initial scores ininpatient areas. The originalscale included the word“normative” in Level 2 of thecoping/mental health domain.It was noted that in the areas of highest medical acuity (i.e.,intensive care units),psychosocial acuity scoreswere consistently low. Althoughmedical acuity does not alwaysdictate psychosocial acuity, itwas concerning that in areaswhere it could be safe to assumefamily members are experiencingthe most difficult moments oftheir lives, their psychosocialacuity scores were low. Giventhis discovery, committee

members met with agroup of intensive careunit (ICU) social workersto understand how thescores were being determined.It was revealed that MSWs’were utilizing the scale from theframe of reference on how mostfamilies cope normatively in theICU setting. For example, aparent whose daughter is dyingin the ICU may be copingnormally, as most parents in asimilar situation wouldconsidering the fact that theirdaughter is dying, but to a non-ICU clinician, normativeadjustment would look verydifferent. The fact that one’schild is dying in the ICU is not anormative experience for aparent. Therefore, the word“normative” was removed fromthe scale. The term wasmisleading, as what isnormative in one area ofclinical care may be verydifferent from what is considerednormative in everyday life.

UNIVERSITY OF MICHIGANPSYCHOSOCIALACUITY SCALE—An UpdateFrom the FieldSTACEY KLETT, MHSA • NINA ABNEY, LMSWALETHIA BATTLES, JD, LMSW • JANICE FIRN, PHD, LMSWAIMEE VANTINE, LMSW

The second lesson learned wasthe need for greater utilizationof the gray boxes at the top ofthe scale to determine acuity.The gray boxes highlight whatinterventions will be needed(though we are scoring prior tothe intervention). Using theabove scenario, it is commonfor a parent whose child isdying to require support, so inmost cases, a situation asdescribed would be a Level 3for the coping/mental healthdomain. This holds true forother domains as well. If afamily has transportationavailable through their insurance,but do not know how to accessthat service, such that theyrequire support or coaching,the transportation and locallodging domain would have anacuity score of 3, regardless ofthe fact that they have this as abenefit through the insurance.In the updated training, moretime was spent emphasizing theuse of the gray boxes to helpclinicians determine theappropriate acuity level.

Reporting on measures: The acuity report is quitevoluminous as every patientencounter can have as many asseven acuity scores. It tookabout a year to develop areport that provided all theinformation needed providinglarger, rather than very small,increments. Acuity measurescan be reported based on timeframe, clinician, clinicallocation, score, or domain.

In reviewing the acuity of patientand family situations, we candetermine if particular clinicalareas have patients with higheror lower psychosocial acuityand which domains seem toreflect the highest needs.Recently, we have utilized acuitymeasures to align resources anddetermine the most appropriatelevel of social work servicesrequired (i.e., BSW or MSW).Instances with higher acuityscores in tangible domains suchas transportation/local lodgingor insurance/finances mightsuggest the need for greaterBSW services, rather thanadditional MSW resources. Ofcourse, these scores are utilizedin partnership with productivityinformation to share a morecomplete story.

As mentioned, we have metwith staff from several institutionsnationally and internationally toprovide training on the scale.Nearly all were interested innot only learning more aboutthe scale, but also trying toimplement the scale within theirinstitution. The primary limitingfactor in their ability to moveforward was whether they hadan electronic resource to recordand export acuity scores.Institutions with electronicmedical records that could bemodified to record and reportscores have had the most successin implementing the scale.

FUTURE PLANSWe plan to focus on connectingpsychosocial acuity measuresto specific diagnosis groups,like diabetes, to determine ifpsychosocial acuity and MSWinterventions have any impacton population health and otherclinical outcomes. We are alsoreviewing scores to determine ifthere is a relationship betweenthe time spent on a patient andfamily situation compared withtheir psychosocial acuity. Ourpreliminary review is showingthat there may be a correlationto high acuity scores and lengthypatient and family interactions.Also, we intend to further exploretrends with acuity scores overtime. Currently, it appears thatacuity scores start at one point,increase, and then begin toconsistently decrease. We willcontinue to use scale measuresfrom an administrativestandpoint as well, to helpsocial work departments acrossthe nation communicate thevalue of social work and socialwork contributions to best servepatients and families.

Stacey Klett, MHSA, is a project andadministrative manager for theUniversity of Michigan Health SystemDepartment of Social Work in AnnArbor, MI. She can be contacted atsolinger@med.umich.edu.

Nina Abney, LMSW, is a social worksupervisor in geriatric social work forthe University of Michigan HealthSystem Department of Social Work inAnn Arbor, MI. She can be contactedat rabney@med.umich.edu.

Alethia Battles, JD, LMSW, is a legaland guardianship program managerfor the University of Michigan HealthSystem Department of Social Work inAnn Arbor, MI. She can be contactedat abattles@med.umich.edu.

Janice Firn, PhD, LMSW, is a seniorsocial worker and clinician ethicist forthe University of Michigan HealthSystem and the UMHS Department ofSocial Work in Ann Arbor, MI. She canbe contacted at jfirn@med.umich.edu.

Aimee Vantine, LMSW, is a children’sand women’s bereavement programmanager for the University of MichiganHealth System Department of SocialWork in Ann Arbor, MI. She can becontacted at avantine@med.umich.edu.

REFERENCESHuber, D., & Craig, K. (2007).Acuity and case management:A healthy dose of outcomes,part I. Professional CaseManagement, 12(3), 132-144.

RESOURCEKlett, S., Firn, J., Abney, N.,Battles, A., Harrington, J., & Vantine, A. (2014).Developing a reliable andvalid tool to measurepsychosocial acuity. SocialWork in Health Care, 53(5),503-517.

For the complete UM Psychosocial Acuity Scale go to www.michigan.gov/documents/mdch/FORM_-_Client_Acuity_Scale_Worksheet_1_225816_7.pdf

Challenges and Complexities of Cultural Competency in Social Work Practice Tuesday, October 18, 2016 • 1:00 PM - 2:00 PM ET • 1 Cross Cultural CE Contact Hour

The Role of Social Workers in Goals of Care Conversations with Seriously Ill Patients Tuesday, November 15, 2016 • 1:00 PM - 2:30 PM ET • 1.5 Social Work CE Contact Hours

Beyond Treatment As Usual: The Case for Cognitive Remediation Tuesday, December 6, 2016 • 1:00 PM - 2:00 PM ET • 1 Clinical CE Contact Hour

Developing Cultural Humility in Social Work Practice Tuesday, January 31, 2017 • 1:00 PM - 2:00 PM ET • 1 Social Work CE Contact Hour

The 3 S's: Supervision, Self-Reflection, and Self-Care Tuesday, February 7, 2017 • 1:00 PM - 2:30 PM ET • 1.5 Social Work CE Contact Hours

More live webinars coming soon including an ethics webinar in March visit socialworkers.org/sections for details.

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Did You Know?

In recent decades, advances in

medical technologies have

changed both the trajectory of

illness and how people die.

Call for Social Work Practitioner Submissions

NASW invites current social work practitioners to submit brief articles for our specialty practice publications. Topics must be relevant to one or more of the following specialized areas:

For submission details and author guidelines, go toSocialWorkers.org/Sections. If you need more information, email sections@naswdc.org.

• Administration/Supervision• Aging• Alcohol, Tobacco, and

Other Drugs• Child Welfare• Children, Adolescents,

and Young Adults

• Health• Mental Health• Private Practice• School Social Work• Social and Economic

Justice & Peace• Social Work and the Courts