A Guide for Interprofessional Collaboration Edited by Aidyn Iachini, Laura Bronstein, and Elizabeth Mellin

Health social workers work with pharmacists, physicians, nurses, therapists, dietitians, chaplains, psychologists, lawyers, and policy makers. They essentially help patients navigate the system and follow through with recommended treatment and medications. They also ameliorate the power difference between patients and providers and make sure that the patient is part of the decision-making process.
The example that is run through the MIC model here is a 62-year-old black women with diabetes. She was formerly incarcerated and lives in her car. Thanks to the team’s efforts she now has housing, a full-time job, and is self-managing her chronic illness.

The key players here are mental health professionals, physicians, nurses, and social workers. In some cases the nurses and social workers get less say in decisions due to their status even though they are likely to know the patient better and have their own type of expertise. Settings include inpatient, outpatient, residential, and the community. The varied needs include social welfare, psychological, psychiatric, medical, vocational, and housing.
People with mental health issues outnumber those who have heart conditions or cancer and the costs are at the top. The lack of coordinated services contributes to unsatisfactory outcomes, which is why a holistic approach is important. It’s also a common goal to reduce institutionalization. Diverse teams with shared values and goals are desirable. Teams should have a facilitator and social workers often serve this role. The case example here is heart wrenching, but has a positive result. It’s a story you must read.

As our population continues to age there is a greater need for service by interdisciplinary teams, with dementia symptoms being the most common reason for involvement. The core team here is composed of a geriatric social worker, a geriatrician, and students studying both disciplines. This team is supplemented by patients, family members, care givers, and other agencies that provide services for the elderly. The process begins with a home visit conducted by the social worker and students. This includes a brief medical and psychosocial history along with cognitive testing, a home safety evaluation, advanced care directives, and family concerns.
After the home visit the geriatrician conducts an office visit to access physical condition. This will include lab work and imaging if needed. The team then meets to construct a plan that includes biological, psychological, and social needs. The plan may indicate the need to collaborate with other agencies and professionals. Once again, the social worker is likely to be the person that initiates and monitors the plan. In place of a single case, the MIC model here is applied to a geriatric consultation clinic (GCC).

Adverse Childhood experiences (ACE) are a focus here. The abuse and neglect that cause these experiences are usually doled out by parents who have the types of problems mentioned in previous chapters. New players here are child protection services and people running residential facilities such as foster care. Collaboration here is necessary as a social worker often works with an entire family at the same time.
There are three major public-private contract collaboration models. The vendor model prioritizes contractual compliance and completion of paid for services. Outcomes are not considered. The Vendor/Partner model uses client outcomes as a metric for contract success. The Full Partnership model focuses on outcomes with less consideration of contract completion. This presents the greatest opportunity for complete collaboration. It most closely aligns with the MIC model which is used here to track a 15-year-old female living in foster care.

Victims need to know how the criminal justice system works. They are also likely to have physical and emotional needs. They will have to deal with police, detectives, doctors, nurses, prosecutors, social workers, victim advocates, lawyers, and others. Collaborative models are clearly called for here. One popular model is the sexual assault response team SART. Social workers will interact with such teams and may even be on them. SARTs vary in the way they work as they are set up by individual communities.
The case study here involves a young woman who drank too much and flirted at a party. She left with a man who raped her at his place. A summary of how a typical SART team handled this case is described here. The SART process exemplifies the MIC model and the rest of chapter demonstrates this fact. Here the social worker has to navigate the criminal justice system from the side as the victim rather than the side of the convict that we saw in chapter 5. They may provide support during medical exams and they might provide support and testimony in court. Ideally everyone who has to interview a victim is present for a single interview. Which team member meets the victim first depends on how the victim reports the assault by hotline, police contact, or emergency room visit.