Bridging the Gap in Health Care

It’s a sunny Tuesday afternoon in November 2022, and about a dozen older Black women are gathered in a room in the Thelma Lovette YMCA in Pittsburgh’s Hill District. Robin Sheffey, a program manager for the Pittsburgh nonprofit organization Steel Smiling, speaks with these women about their mental wellness every two weeks.

“Ladies, we are mothers and we are sisters, but we have to love ourselves first,” says Sheffey as the women, several of them using walkers, settle into their seats.

This session, which is being held two days before the Thanksgiving holiday, features a mindfulness exercise to instrumental music, tips for self-healing, and the reminder to the women to love themselves.

“When’s the last time anybody hugged themselves?” asks Sheffey. “Let’s do it now.”

Asked what they have planned for that week, the ladies’ conversation naturally turns to cooking and preparations for everything from candied yams to Cornish hens. As they exit an hour later, they are reminded to talk to someone if they feel stressed and to find the time to just sit and relax a bit.

This population is an important one for mental health workers to reach. Steel Smiling founder and CEO Julius Boatwright (MSW ’11) is positioning his organization as Pittsburgh’s Black mental health intermediary. He says that Black community elders hold crucial life lessons.

“Older Black women possess stories that have the potential to transform generations,” he says. “Robin’s group helps to validate the women’s lived experiences while also providing them with peer support.”

The social determinants of health

The health outcomes of the women who meet regularly at the YMCA depend on far more than their genes or the medical care they receive. They are closely related to their lived experiences—their childhood upbringing, the house where they live, whether there is a store nearby that sells healthy foods, or even how safe they feel walking around at night. These social determinants of health are shaped by many factors, including social policies, political systems, and systemic inequalities.

A study cited by the National Academy of Medicine found that medical care itself only accounts for 10-20% of the contributors to people’s health outcomes. By contrast, social determinants play a much bigger role, making up 80-90% of the contributing factors. Addressing these determinants appropriately is fundamental to improving health and its long-standing inequities.

This is nothing new to social workers. Considering someone’s housing or access to food speaks to social work’s core values. What is new is that more and more social workers are entering the medical field to help bridge that gap. And the University of Pittsburgh School of Social Work is a driving engine behind that initiative, with several core programs that are training students to become a vital part of any medical team.

Programs, fellowships, and a certificate

Pitt Social Work has long offered a certificate in integrated health care (IHC) and fellowships that focus on health and the ways that physical health and mental health treatment and services need to be approached in an integrated and holistic way. Over the years, the Cannon, Baker, Hartford, Roth, and other fellowship programs have given students extensive and in-depth experiences in health care settings. This strong tradition continues with the following current programs:   

The Behavioral Health Scholars Program focuses on children and adolescents with behavioral health needs. The federal Health Resources and Services Administration (HRSA) funds this initiative, in which second-year master’s students learn about integrated treatment models so that the needs of these young people can be addressed in a variety of settings.

The Coalition for Opioid Addiction Leadership Fellowship, also HRSA funded, is open to second-year master’s students and places them in settings where treatment for people with opioid use disorders is desperately needed. These fellows learn interventions that treat these disorders and have field placements on interprofessional teams of providers.

The Roth Fellowship is open to bachelor’s and first and second-year master’s students and helps them to develop a deep understanding of the connection between behavioral health and physical health in a field placement with UPMC Health Plan. The insurer funds the program and places students in a variety of clinical experiences but always in an integrated health team setting.

The Hartford Partnership Program for Aging Education places bachelor’s and master’s students in settings with older adults. Student placements may range from palliative care and community-based providers that help individuals age in place to work focused on policies that impact the service delivery system for older people.

Students in all four of these programs receive stipends of up to $10,000 and participate in special monthly seminars with social workers from integrated health care professions.

Beyond these specific fellowships, the IHC certificate prepares master’s students specializing in direct practice with the skills to work in numerous health-related settings. In all, about one-third of the school’s 459 students are being trained for working in integrated health care settings.

Pitt Social Work Professor Daniel Rosen says that there has been a greater awareness on the part of health systems in the past 15 years that social workers possess the clinical skills and experiences to really engage all patients, especially those with greater risk factors, in the kind of support that goes way beyond the doctor’s office.

“Health care happens between visits,” he says. “We cannot expect a doctor to be able to get into the root causes of the upstream factors that are impacting someone’s life and to be able to do the care coordination piece around that. Our health care system is not set up for that.”

Rosen says that a great example of this work is a recent two-year project that examined the social determinants of oral health. Social work students joined a new training series in pediatric dentistry for students at the University of Pittsburgh School of Dental Medicine. They were able to shed new light on why some people can’t adhere to a strict dental care regimen.

“The dental students couldn’t understand why children, in some cases, were not brushing their teeth at night. It’s because their parents were not at home—they were working a night shift,” says Rosen. Similarly, suggesting a diet of fresh fruit and vegetables may not mean much to a family living in a food desert. Someone with transportation barriers may have trouble getting to a dental appointment in Oakland, even if they live only a mile away.

“It was incredible to hear the dental residents talk about how valuable it is to have the social work piece,” says Rosen. “Social workers look at the why.”

Rosen says that he has seen former social work students move on to careers in hospital emergency rooms, in cancer wards, and as part of a team of paramedics. He says that addressing the lived experiences of individuals, especially those facing barriers to care, is what social work has always been about.

Students enrolled in IHC classes cover topics like health policy and medical terminology so that when social workers are part of a team, they can speak the same language as the doctors, nurses, and physical therapists and can effectively contribute their knowledge, perspectives, and professional expertise within the interdisciplinary team.

Big voice in a small town

That is the exact situation Tanisha Bowman (MSW ’16) experiences daily in her role as a palliative care social worker at Butler Memorial Hospital, where she helps people come to terms with serious life-limiting illnesses. She assists them in getting their affairs in order and coming to peace with what’s happening and connects them with any support they may need, be it help for anxiety or walkers or grab bars for their home. She and her five-member team also deal with patients at the hospital’s busy outpatient clinic.

“We don’t work with a medical hierarchy on this team,” says Bowman. “We all bring something to the table. We are all equal. We all have a superpower.”

Bowman says that in her past life as a social worker in general practice, she came to expect not to be heard or listened to. But that changed when she came to Butler Memorial Hospital.

“I walked in here—a Black woman with purple hair [and] covered in tattoos—and whatever my lane is, that’s my lane. I was brought here to tell them what was missing,” she says.

She says that her nursing manager may spend an hour on the phone with patients, just listening. Bowman sometimes attends their funerals. Her staff is leaning more into community work, including Bowman’s building a grief wall at the hospital. Covered with 100 mums that community members replaced with small white paper cranes, it commemorated National Grief Awareness Day. She is building longer-term relationships with her outpatients.

Active in leadership and advocacy for years, Bowman has presented at several conferences, most recently presenting with her colleagues on the concept of the interdisciplinary health care team. She loves bringing all that passion to her job.

“I drive an hour to get to work for a reason,” she says.

Making a difference in Boston

Farther north, at Massachusetts General Hospital, Ji-Eun Choi (MSW ’20) is a clinical social worker at Internal Medicine Associates, the hospital’s largest primary care clinic with more than 100 doctors and two social workers. She sees patients who have symptoms of mild to moderate depression and/or anxiety.

Choi often works with patients who have physical health conditions, such as long COVID. She has seen firsthand how closely physical and mental health conditions are intertwined and how they impact many aspects of her patients’ lives. After working with Choi, the patients tell her they are much better able to handle their stressors.

“With every patient, I feel as though I am contributing in a significant way,” says Choi. “I feel appreciated by the medical team and the patient, and that really keeps me going.”

Choi spread her wings far and wide during her time at Pitt. She interned at Family Resources’ therapeutic preschool, designed for children needing behavioral and emotional support, and at Positive Health Clinic, an HIV clinic of the Allegheny Health Network. She had her own caseload and worked alongside infectious disease doctors and social workers.

“I was very much part of the team,” says Choi, who earned an IHC certificate alongside her Pitt Social Work degree.

Choi also has volunteered with people who are unhoused and currently does pro bono work for people who are seeking asylum in the United States. Choi says that hearing their stories can be incredibly difficult, “but it reminds me why I chose this field in the first place.”

It’s not all work for this busy social worker. She was a flute player for the Duke University Symphony Orchestra while getting her undergraduate degree there in neuroscience. Not only does she regularly video chat with the former members of the flute section, but they all recently met up at a friend’s wedding and performed for the bride, also a flute section alum. According to Choi, serving as a member of the orchestra and as its president during her senior year taught her skills she brings to the job today, like organization and collaboration.

“I feel that health care is a team sport,” she says.

Leading the way

Jeff Bolton (MSW ’79) is the recently retired chief administrative officer of Mayo Clinic, where for eight years he was responsible for all administrative functions in shared services, education, research, and clinics. He saw many social workers provide a critical liaison between the providers and the patients’ families.

Bolton says that the brothers William and Charles Mayo were ahead of their time, bringing social workers on board in 1921.

“Very early on, there was a recognition that social, economic, and emotional challenges can contribute to a patient’s illness or interfere with successful treatment,” he says.

Today, Bolton says that there are 450 social worker positions throughout the Mayo Clinic system in Rochester, Minnesota; Jacksonville, Florida; and Phoenix and Scottsdale, Arizona, plus 70 clinics throughout the Midwest. In Mayo’s inpatient practice, social workers are assigned to every team. Every patient is assessed and asked about their support system and home environment. Under a social worker’s guidance, patients can frequently identify and use their own personal strengths and resources to best manage the psychosocial aspects of their illness.

Bolton has seen firsthand the skills a social worker brings to a medical team.

“They have the ability to capture the important information that patients may have difficulty sharing,” he says. He also cites social workers’ problem solving, empathy, advocacy, cultural competence, and ability to empower patients and their family members to be active in the
healing process.

Mayo Clinic is seeing fewer readmissions, and Bolton gives a lot of the credit to integrated health care teams. He adds that the pandemic took its toll on frontline workers, including social workers, so retirement announcements are becoming more common. He encourages Pitt Social Work alumni to apply at Mayo, hospitals, and other health care systems across the United States.

Tackling system-level issues

After working as a cardiac social worker in the intensive care unit at the Johns Hopkins Hospital in Baltimore, Maryland, Maria José Allen (MSW ’17) moved into a career on the insurance side of health care in April 2022. Working for the UnitedHealthcare Community Plan in Maryland, which manages Medicaid patients, Allen takes on cases in which patients have complex behavioral health diagnoses to help them get the support they need.

She is the social worker on a team of 30 people, including nurses, managers, a chief medical officer, and community health workers. A typical workday might find her at home conducting telehealth sessions or at a hospital conferring with doctors to plot out what the patient needs when they go home to avoid a readmission.

Allen’s teammates tend to send anything behavioral health related her way, and that’s fine with her, but she also frequently plays the role of coach, teaching them the skills she uses daily, like motivational interviewing.

Working on the other side of the insurance business has been an eye-opener for her.

“When I was working in a big health system’s outpatient setting, I remember being frustrated with insurance companies, thinking they were the problem. Now I see the biggest barriers are the social determinants of health. For a homeless member, for example, there’s the lack of stable housing, the lack of stable food intake, and the lack of stability for them to even take their meds on time,” she says.

Allen also is helping to launch and manage the state-funded Maternal Opioid Misuse program for Maryland, which provides support for any pregnant woman who has a history of opioid use disorders. Add that to her normal caseload and she is telephoning about 70 people a month. But the pregnant women often are difficult to reach. Even if she does find them, many are not ready or willing to participate. For those women in a good place in their recovery, undergoing a drug screening can be a trigger. Others feel that divulging details about their past is too invasive. But Allen is not discouraged. She knows that she can help some of them through her regular case management program and “is keeping tabs on some of them so they still have some support.”

She has an eye on possibly working in the policy realm in the future, saying it’s frustrating seeing the system work “top down” instead of “bottom up.”

“I feel like unless you are really seeing what is happening on the ground, you can’t really make policy that is going to truly help people without making their lives much more complicated,” she says.

On the West Coast, Henry Loubet (MSW ’75) is CEO of San Francisco-based Bohemia Health, a company that provides health care organizations—ranging from health plans to physician groups—with the strategies they need to succeed. He says that social workers play an important role in administration and management, organizational development, and population health.

While they do a lot to decrease unnecessary doctor and hospital visits, Loubet says that “the most important contribution a social worker can make in a medical setting is working with socially and economically disadvantaged populations, especially in the Medicare Advantage and Medicaid space.” These groups are those who are least likely to see successful outcomes with traditional models of care and often require the most holistic supports to bolster their medical treatment.

Back in Pittsburgh, Boatwright has a goal of seeing that every Black city resident has a positive mental health experience by 2030. He and his staff at Steel Smiling want to build a sustainable mental health infrastructure with other organizations doing mental health work with Black populations, including the Kingsley Association; the Macedonia Family and Community Enrichment Center, Inc.; Center of Life; and the Homewood Children’s Village. It’s a person-centered, community-based approach.

“We’re aware that some Black folks are just now beginning their mental health and wellness journeys,” he says. “If we can be thoughtful about connecting with them in their neighborhood spaces, we increase the probability of them gaining access to treatment.”

Boatwright also is investigating how Steel Smiling can provide financial assistance to local Black residents to help them offset the cost of mental health treatment. The goal is to remove as many barriers as possible and to meet the client where they are in the moment—in the community. Boatwright has embraced this holistic approach to wellness himself; he recently became a registered yoga instructor.

“I’m a prime example of this reality,” he says. “It’s important to expose folks to myriad wellness options so they can make the best choices for themselves.”

Whether it’s a cancer patient in Butler, a person seeking psychiatric care in Boston, or a senior woman attending a wellness workshop in Pittsburgh’s Hill District, all are being assisted by Pitt Social Work alumni who are active and valued members of medical teams.

As Bowman states: “I just want to matter—and I do.”