The National Social Work Program Office
implemented the Social Work PACT Staffing Program in collaboration with the Office of Rural Health (ORH
) beginning in FY16. Jennifer Silva, LCSW-S, is the National Program Coordinator and Jaime Halaszynski, LCSW, is the Project Assistant for the Social Work PACT Staffing Program in VA’s National Social Work Program Office.
Veterans with complex health conditions must sometimes navigate a bewildering array of VA providers and supportive services. Rural Veterans often face additional challenges to receiving timely care due to appropriate providers being geographically dispersed or simply unavailable in their region. PACT social workers address Veterans' psychosocial needs and increase their access to needed care. A social worker might arrange transportation to appointments, or in-home support for a Veteran with functional disability. Social workers integrated within patient-aligned care teams (PACTs) may be especially suited to identify risk factors for depression among older Veterans. Social workers spend more time meeting with caregivers and assessing issues that can have a profound effect on mental health, e.g., social support, social isolation, housing needs, and economic distress, that are often not the focus of a primary care visit. Timely care and support such as these examples ultimately reduce the need for unplanned hospital stays, emergency department use, and nursing home care, which are stressful for the Veteran and costly to the system.
“I have witnessed the…proactive outreach to Veterans to offer services and coordinate care. Social workers…are making a difference.” – Program Stakeholder
As of 2014, many rural VA Patient Aligned Care Teams (PACTs) were not fully staffed with social workers. To address this deficit, in May 2016 the National Social Work Program Office implemented a program called the “Social Work Patient Aligned Care Team Staffing Program.” The program placed additional Master’s level licensed social workers in rural VA PACTs. By increasing the number of social workers in primary care teams, specifically in diverse geographic settings, the Social Work PACT Staffing Program is increasing access to VA care and services for rural Veterans.
The Social Work PACT Staffing Program is increasing access to VA care and services for Veterans throughout the US
A PACT social worker is often the first provider a Veteran meets at a VA hospital or clinic. When social workers are embedded in rural clinics at adequate staffing levels, the focus shifts from reactive, crisis-oriented intervention to proactive outreach and case management services, which promote Veteran health and wellness. Social workers in the program meet with Veterans, their families, and caregivers to identify challenges related to social determinants of health including access to care, economics, housing, psychosocial concerns, functional limitations, and support network deficits. Additionally, suicide risk can be identified by PACT social workers, providing vital access to services for Veterans who may not otherwise seek mental health care.
"Recently, a Veteran disclosed that they were having suicidal thoughts and we did a warm handoff to the PACT social worker for evaluation. This led to a safe outcome for the Veteran and a plan for follow-up. The Social Worker was really vital in getting them help." – Program Stakeholder
"She has been awesome! We work together by keeping track of who the other needs to speak to and if I get a Veteran on the phone that she needs, I transfer them and vice versa. It's cutting down on the Veteran getting multiple calls and possibly missing out on crucial information."
Portia Cornell, PhD, of the HSR&D Long Term Services and Supports (COIN-LTSS) Center in Providence, Rhode Island partnered with the National Social Work Program Office to design a partnered evaluation of the Rural PACT SW Initiative. The Social Work Effectiveness for Rural Veterans Evaluation (SERVE) QUERI includes data evaluation of the program’s effectiveness in improving Veteran health outcomes and interviews with front-line social workers. The product of the SERVE QUERI evaluation will be an in-depth appraisal of the Social Work PACT Staffing Program. This evaluation will influence VA national practice by improving implementation of the Social Work Practice Model; targeting high-risk Veterans through case finding with the Care Assessment Needs (CAN) score and evaluation using case management tools; and by providing evidence of the impact of social work case practice on Veterans’ care. Findings were included in a recent article in the journal Health Affairs, entitled Embedding Social Workers In Veterans Health Administration Primary Care Teams Reduces Emergency Department Visits.
The SERVE QUERI evaluation in the Knowledge-to-Action framework.
- The Rural PACT SW Initiative improved primary care delivery, helping Veterans get timely treatment and avoid unnecessary urgent care. Among Veterans experiencing high utilization of health care, there was a 4% decrease in Veterans who had one or more hospital admissions and a 3% decrease in Veterans who had one or more emergency department visits after the introduction of a social worker.
- In Fiscal Year (FY) 2019, funding supported 74 social workers and provided social work services to 44,942 Veterans. Among these, 59% of the Veterans served lived in rural or highly rural areas. Evaluation data showed that the introduction of a social worker increased social work encounters among all Veterans who received care by 33 percent.
- Most sites that obtained ORH seed funding reported that embedding social workers in rural areas led to significant increases in Veteran satisfaction, greater access to care, and an overall shift in culture on best practices for care coordination for rural Veterans.
Portia Y. Cornell, PhD, is a health economist and program evaluator, and health science specialist at the Providence VA Medical Center, and an investigator at the Brown University School of Public Health.
Delivery of the Social Work Practice Model is a best practice and will become the ‘new normal’ across all PACT teams. In FY 20, training and support is being provided to 66 new social workers at twenty facilities. Each site begins with a cycle of initial engagement and funding, and transitions to sustainability and spread of the model. The Social Work PACT Staffing Program is collaborating with the Office of Patient Centered Care and Cultural Transformation to infuse Whole Health concepts within existing PACT social work practices; improving health outcomes and aligning with VA’s priority of improving customer service.