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A podcast that brings together primary care providers, healthcare planners, patients, innovators and others to talk about the changes that are happening in primary care in British Columbia.
Morgan: Are you hearing more about social
work and primary care with the rollout
of the PCNs across British Columbia?,
are you looking to learn more about
what social workers in primary care
do in clinics and how they work?
Yeah, me too.
Sarah: In this episode, we're gonna
talk about social workers and mental
health counselors in primary care teams.
Morgan: Now, obviously not all
primary care teams have social
workers or counselors right now, but
this is important to think about.
We're gonna do a bit of a deep dive
here as there's a lot of need for more
mental health support, and we know that
a lot of communities are seeing the
addition of new social workers funded
through the primary care networks.
Sarah: I think one thing that I've
realized in our exploration of what social
workers can add in primary care is that
there's a lot a social worker can do in a
team and can add to a network of teams.
Morgan: Sarah, we explored the social
worker a little bit in an earlier team up
webinar that focused on how the Sunshine
Coast was integrating social workers
with the support of their P S P coaches.
For those of you who were interested,
I will definitely post a link in
the show notes to the webinar.
Sarah: Today we're gonna focus a little
more on the general scope , as we hear
from a few social workers and other
team members that they work closely with
Morgan: and we'll be focusing
on social work and also touching
on some of the counseling and
mental health supports as well.
, let's start by doing a little
bit of a general scope of
what social workers do, Sarah.
Sarah: So first off, social workers
can engage in assessments to screen
for risk factors, identify strengths,
and address mental health concerns.
They can also diagnose
mental health disorders.
Morgan: Social workers play a key role
in treatment and supporting management,
and they collaborate closely with patients
and families to identify different
strategies to optimize how they function.
Social workers, can help with focused
counseling and crisis management.
They're very skilled at facilitating
support groups and creating
safety plans for patients.
Sarah: They can also take on education and
advocacy roles and can consult and educate
patients and families about different
programs, forms, applications, financial
planning, advanced care planning.
They really support patients with a
lot of the reports that often need to
be made to access other resources and
this kind of navigation support with
all the paperwork, can get primary
care providers really excited when
they think about a social worker.
Morgan: So There's so many
forms and I know as a family
doc, that's what I think about.
I need help and social
workers can help with forms.
But it's so much more than that and
I, I think we wanna highlight this
episode that social worker's role
is not just helping with forms.
There's so much more.
Sarah: Right.
And I think it's that key role in kind
of supporting referrals and collaboration
across a patient's whole circle of care.
that is really the space
where social workers shine.
Morgan: We have access to the PCN
Toolkit, social work scope of practice.
we'll link that as well cause
it's a nice handy reference.
And Sarah, I know that you decided
to add the role of mental health
counselor into this episode
as there's some scope overlap.
But these two roles are different.
So let's set up the
difference a little bit.
Sarah: Right, and when we started
this episode as a non-clinician,
I had lots of scope questions,
so I had to go and look for this.
It's worth noting here that there's a
whole range of professionals who provide
different kinds of counseling and support.
The primary difference I think, between
a social worker and mental health
counselors is the scope of what they
do and their educational background.
Both roles have expertise that
overlap when it comes to supporting
mental health and wellbeing, and
both can provide crisis support.
Morgan: there's a difference in scope
with social workers and the different
kinds of mental health counselors,
based on the training that people
have had, their positionality.
Social workers, they're a
registered profession so their
scope is more well defined.
Sarah: From our experience in communities,
Morgan, the support that counselors
and social work roles are able to
provide is in really high demand.
Mental health, at social determinants of
health, and social work and counseling
roles are often among the first considered
when clinical teams are thinking
about, okay, we have a primary care
network now we have some opportunity
to maybe add some roles to a team.
That's really what we've
seen on the ground.
Cayce: We have such a broad scope of
work that we do that is not always
easily defined in a healthcare context.
I see people who are experiencing either
acute or chronic social or systemic
structural barrier type problems that
could be poverty ,trauma , conflict
in families and in relationships
Morgan: Cayce's a social worker
who's been integrated into a PCN.
I actually got to meet Cayce in some
of the primary care graduate work.
Now, in his role, he supports
multiple clinics across the
region that he works in.
Cayce: for instance, I might see somebody
with a new diagnosis of cancer, who
has to take time off work, has to find
a way to get to the lower mainland
to attend oncology appointments.
Might want to seek some counseling for
themselves and for their family, and I
can help them at all of those stages.
But the idea is that I would get involved
at an early stage in whatever issue
is affecting people to actually help
hopefully prevent people from getting to
more complicated stages in their lives.
Obviously I can't disrupt the
progress of an illness, but sometimes
psychosocial interventions can
prevent people from really spiraling
out of control and possibly losing
housing or a job or a marriage..
Sarah: Danielle Parent is another
social worker that we connected
with, and she works in an urgent and
primary care center where she sees
patients with more urgent care needs.
So her focus is a little different.
Danielle: I describe it a little bit
as a generalist social work role.
And what I mean by that is We know
a lot or a little about a lot of
things , so we help support people
coming into the clinic, and helping
individuals navigate the system whether
it be like health resources, community
resources and government resources
depending on the client's need.
we do also provide a lot of mental
health and substance use support
for individuals and another role of
ours is, crisis intervention often
we're that first point of contact
Morgan: so Danielle highlights the
navigation support that's so key,
and this is particularly important
when people aren't well connected to
primary care and they're in crisis.
. So connecting patients to the various
resources and providing that extra
support can be a huge benefit and
go a long way in addressing issues.
And if that isn't addressed,
it can result in people
falling through the cracks.
Cayce: What's unique about my
role, unlike any other PCN that I
am familiar with, is that I will
see people, from birth to death.
So I see children, I see
people who are under 18.
And that's not typical of Health Authority
employees in PCNs but our division made
the case that this was important because
especially in a small community like
this, there's really not a lot of support
for youth and that's been my favorite
part is working with families, working
with children who are going through a
whole range of struggles in their lives.
And certainly I'm not happy
that they're going through those
struggles, but I'm happy that I'm
able to jump in because there really
isn't anybody else who can do it.
Sarah: And, you know, Morgan, this
longitudinal perspective and, the ability
to care for the full range of patients
that Cayce frames here is interesting.
And I know that many roles in
primary care teams work in this way.
Until these recent conversations with
social workers, I think my understanding
of the social work role had really
been kind of limited to the crisis
and intervention side of things.
Both Cacye, who we just heard from again,
and Kaila McGann, a social worker with
a community health center, spoke to the
flexible and more longitudinal support
that they're able to provide to patients.
Kaila: I really see my support and
approach to folks is very humanized,
very strength-based, and building their
capacity so that they can have confidence
to take this, whatever their goal is, and
run with it for the rest of their journey.
And so rather than just a bandaid,
rather than just one reach in for
crisis support, it's more about how
can I carry you and walk with you
so that you can do this on your own
and be independent and feel strong.
Morgan: So this is a place where the
counseling role can be different.
Of course, there's also longitudinal
relationships in counseling, but often
in primary care counseling can be shorter
and focused around particular challenges,
and I think this is often the case in
primary care networks when counselors
are working across multiple clinics.
,
Sarah, for us, where we've had the
luxury of having counselors as part
of our team for years, very much
the counselors have longitudinal
relationships with patients and they may
see them intensely for a short period
of time, and then not for a while.
And then again, A year or two
later intensely for a while, and
that can be really powerful to
have that continuity and trust.
Tess Bantock is a counselor who works in
a C H C team along with a social worker.
Tess: you did bring up nature walking
as well, and that's something I love.
I think people are
always surprised by that.
Like, oh, we can go for a walk.
You'll meet me by the
river, I can bring my dog.
that really surprises people.
I've also, you know, for
those who have less mobility,
just go sit in a park bench.
Let's hang out, let's have some
tea, have that connection as well.
Bringing that to anyone
who might need it.
Sarah: So Tess and Kaila work together
in a CHC and they often work together
to decide how to best meet the needs of
particular patients and who's gonna be
the best fit in different circumstances.
And when you do have roles in a team
with these overlapping aspects of scope,
these conversations working on how you're
gonna work together, and I know we keep
saying this, but they're so important.
Morgan: Yeah, in BC right now, think
having both counselors and social
workers on the same team is pretty rare,
except in community health centers.
We've had the luxury at Cool Aid to have
social workers only relatively recently
along with the counselors that we have.
But we're seeing more of this now
at the primary care network level.
And I think the addition of these types
of roles is super important to patients,
in primary care networks, but also that
clarity is needed so that patients get to
the right team members to support them.
Sarah: Right.
And that getting to the right team
members, I think the value of these roles
in a team, when we think about the ideal
state of wraparound care in primary care,
the first thing I think I really heard
in our conversations here about social
work and the counseling roles was really
the flexibility of folks in these roles.
This emphasis on being in-house
specialists that can compliment the
longitudinal care provided by a physician.
Tess: Now , we have two individuals
who specialize, you know, working
in youth and working with children.
Getting that support for those kids which
is all in-house which, on the larger
scale when you look at the community
health center and how many family doctors
we have and the longitudinal care that
comes with being a family physician,
we get to fit in there quite nicely.
people aren't just one person.
They are their family and their
support network and their whole life.
And so it's cool to be
able to serve that as well
Morgan: So I like that Tess highlights
that supporting of families and creating
those support systems for communities.
And this is something that I think
we heard Cayce also speak to earlier.
Many counselors and social workers
are also able to do outreach and
to see patients where they're at.
Both Kaila and Cayce talked about the
importance of being able to connect
with patients in the community.
Kaila: I have a gentleman who was admitted
to the hospital for diabetic concerns and
I said to him, Hey, what are you doing?
He's like, well, I'm in the hospital.
And I said, well, I'd
love to come see you then.
What floor are you on?
And what room?
I'll be there.
I brought him a coffee.
We had a visit at his bedside
and he's like "you do this?".
And I said, well, we're human.
You might need some TLC and
some check-in right now.
You're in the hospital and I'm
here just to see how you are
Cayce: I will see people at home when
they don't have the ability to come to
the clinic either because of mobility
limitations or there's no bus that
goes to where they're living cause
we're in a fairly rural remote area.
Or if there is a matter of safety
in the home that the physician
wants me to take a look at.
Something I might do that people
aren't aware of is I will do a home
safety assessment quite frequently.
So, perhaps it's a, an older adult
living alone who hasn't come to their
last three appointments hasn't picked
up their medication, and there are
some questions about whether they are
at risk living alone so I will go and
visit them and spend some time with
them, and sometimes that's hour long
visits over the course of many months
to build up some trust with them.
To really understand
where they're coming from.
And then I can make a recommendation to
the physician or I can start to gradually
bring that person back into the clinical
setting where they see their physician.
So set up some way of getting
them to their appointment.
So it's this reattachment
kind of, work that I often do.
Sarah: And without team members who
are able to do the follow up really
actively to connect with people and
connect them to other services, the
patients who are in the most need can
really easily get lost in the system.
Cayce: Earlier this year, I was
contacted by a landlord who was
concerned about their tenant who
hadn't been paying rent on time and was
possibly living in unsafe conditions.
The landlord got my phone
number from the clinic, they
called to speak with the doctor.
The MOA said, well, the doctor's
not available, but our social
worker is here, so I'll put you
through to the social worker.
so After that conversation, I was
able to reach the doctor who said, I
absolutely support you doing a home visit.
It would be a good idea
to see how they're doing.
So then I called, the patient wasn't
able to reach them, and called a
home care nurse who did know the
patient and had seen them recently.
And we did a joint visit together
and it turned out that yes, this
person had some cognitive changes and
was less on top of their finances.
Had also had some falls that were
unreported, And so with the help of
this home care nurse and the physician
and then bringing in a community
physiotherapist, we were able to
put in a care plan to support the
patient to remain at home safely,
Morgan: I love this story.
It highlights such an great example
of the breadth and scope and how
social workers will adapt to the
situation and engage even the landlord.
It's not something that we do as
primary care docs all that often.
Sarah: And this was also
across multiple systems, right?
Primary care, but also touching
on housing, and tenancy, finances.
Tess and Kaila, the counselor and
social worker duo we heard from earlier,
had a great way of framing the way
they see their own roles in the team.
Tess: It's very cool to
be able to work in a team.
Kaila and I have kind of had
these labels of bridge and anchor.
How do we get people to where they need to
go, and then how can we ground them there?
How can we support them in
creating this for themselves
Kaila: The physician is supporting
the individual on their medical
needs and completing the medical
paperwork that we can't support.
And I am the social worker that works
with the individual to get them financial
security, make sure their rent is paid.
And so that's my realm
working within my scope.
And then Tess is making sure that they're
anchored and grounded and really working
on that therapy so that they can do life.
I can see all three of those
scopes working so tight knit
because of that team-based care.
And we're all activating our skills
and our scope to best serve this
one individual that has complex
needs, but we all need each other.
Morgan: So the bridge and the anchor.
I love that.
And there's another side of
this that really emerged as a
theme in the conversation with
several different social workers.
And that is the role they held in
connecting patients to the other
resources that we talked about
before, but connecting into the
community to fill in what would
otherwise be gaps in their care.
Kaila: I'll share a story, which
is really a beautiful story, is I
have this lovely gentleman I support
with one of our family physicians.
He needed a new set of dentures.
And we all know it's not just teeth.
It's your diet, it's your confidence.
Um, Unfortunately those
can be up to $4,000 for a
gentleman on retirement income.
I reached out to local nonprofits
and organizations and we let him
know this fella's story and the need.
They issued a cheque for him to
purchase a new set of dentures.
And that was asking for help when I
didn't have a resource for this gentleman.
And not only did they write the
check, but they invited us to one of
their meetings and they honored us.
They had a dinner for us and we just
celebrated that beautiful support.
And we really actually have
those lifelong connections now.
So it's not always about the financial
aspect, I really wanted to highlight
community support cause we don't have all
the resources, we don't have all the know
we ask for help and we team up and I think
we rely on our community just as much as
our community relies on our professions
.
Sarah: And that was a great example
Kaila gave us of that connector role.
I think there's also the very real kind of
administrative burden that social workers
are able to alleviate for patients in her
role in the urgent primary care center,
Danielle sees this added value daily.
Danielle: when it comes to social work
or different follow ups you know, we
are able to support someone in the
short term, while maybe linking them
up to other community resources if
they are needing longer term support.
So for, some individuals when it comes to
applications, it's not uncommon that it
will take one, two, or three appointments
and so it can get a bit time consuming,
for sure but with social work too, we are
actually able to book appointments, which
I find is really helpful, especially for
individuals who might not have a phone or,
have limited access to transportation.
Morgan: I think these navigator roles,
there's lots of examples, and the
whole different ways of supporting
bridging and anchoring people into
community I think is so important.
And the more we realize, this value,
the more valuable having social
workers in our team is gonna be.
We connected with Amy Huff, who's
a PCN transformation lead who
has a background in social work.
She gave us some other
interesting perspectives as well.
Amie: and I think that social work
in healthcare in general has come
a long way and our value and sort
of status and acceptability in
healthcare has come a long way.
I remember starting out in practice,
almost 20 years ago, fighting for
one of five social work positions
in the whole, like Okanagan area.
And now, there's probably hundreds . So
I think physicians and nurses and , other
allied health professionals realize the
value of that, social work, skillset.
Connecting with social and community
resources, grief, loss, some of that
clinical counseling work, connecting
to other systems, social determinants of
health, which we know are really drivers
of health and wellness in general,
and , can improve health outcomes.
Sarah: For this season, we've been
connecting to folks who hold a whole host
of roles in primary care teams, and one
of the questions we asked everyone was
to reflect on their experiences working
with other roles in the team and what
they learned from the social worker
and counselors that they worked with.
Eliza: For me, they were able to
ensure that the patient was the expert
of their own life in a way that was
incredibly empowering to witness.
As opposed to just like jumping
into the algorithm of medical
history and the red flags.
I know that patient was able to develop
a relationship with the social worker
where they would feel comfortable
taking issues forward in the future.
And so I think just really demonstrating
the skills needed to make the relationship
feel very safe and patient-centered
was something that I learned a lot
in those days that we spent together.
Sarah: That was Eliza Henshaw, a nurse
practitioner, and I think she, and so
many of the others we connected with
really emphasized the different kinds of
connections and roles that social workers
and counselors are able to support.
Shania was one of the MOAs
we heard from recently in the
third episode of this season.
In her clinic, they work with a
counselor who isn't co-located, but
is still effectively able to connect
with patients to really provide them
added support when they need it most.
Shania: The doctors are able to send
a mental health referral to her.
She'll then connect with those patients
and get them in depending on the severity,
it could be like one to two weeks.
And they just do a phone appointment
so they don't have to come in.
Sometimes when you have mental
health, you don't wanna come in and
see somebody, you know what I mean?
And to have your doctors be able to
have a counselor that's specific for the
clinic, it builds like a better rapport,
and then , she'll kind of triage if she
can continue care or they need to be
referred somewhere else, and then that's
communicated back to the physicians.
So there's a constant connection
Morgan: and Sarah, beyond the
connector pieces, we also heard
lots of stories that emphasize the
support that social workers can do to
support social determinants of health.
Thinking about patients
more holistically, perhaps.
Terri Aldridge is an indigenous
family physician who does a lot of
work at the system level as well
as supporting her own practice.
Terri: one of the things that we worked on
was like well it'd be really great to have
like a social worker kind of dedicated
to providing support for primary care
as well for a host of different reasons
including you know addressing things like
poverty and helping to address like food
insecurity and helping to do things like
fill out disability forms and all of that
And so getting to know what social work
services was already in place in Carrier
Sekani kind of helped us to develop
A system where we could enhance the
services from the primary care perspective
Sydney: I've had a number of clients
experiencing some pretty significant
mental health crises and , being able
to collaborate with our social workers
and our mental health counselors.
I don't know how I ever worked in a
facility without them before . When
you don't have them, when we're short
staffed and they're, you know, they're
not on that day, you miss their presence
so significantly because they really
contribute to some of those really
challenging situations, especially when
there are socioeconomic challenges,
mental health challenges, addictions
challenges, and just to have that member
of your team there that can help the
patient navigate through the system,
it's just such a wonderful thing to have.
Sarah: Now that second voice, sydney
Richardson-Carr is a nurse practitioner
who works at two different UPCCs.
Morgan: that added capacity for
more complex patients is essential.
It's not just useful, it's essential.
And there's another huge benefit here.
When we think about the capacity
of a team that Wendy, A PSP
coach sees in her work when she's
been supporting team-based care.
Wendy: I think that they save time.
They intervene and save a lot of time.
When they're within primary care they,
can really sit down and in partnership
with the family physician, think through
solutions and build capacity together
that helps to serve those patients
Morgan: So we've talked a lot about
the scope of social workers and mental
health counselors in primary care,
and we've heard from folks in those
roles in different kinds of settings
from in clinic to within networks.
Sarah: That's right, and I think we heard
some great examples, of these roles.
Connectors, navigators, relationship
holders, community anchors, really
enhancing the ability of primary
care teams to meet the broader
psychosocial needs of the more complex
and often marginalized patients,
particularly in times of crisis.
So bringing this back to our action
focus, Morgan, if a social worker is
joining your team, what can you do?
Morgan: So the first thing is
to recognize that including a
social worker or counselor, is
really building the team capacity.
And it does take some effort upfront.
You need to figure out how you're gonna
communicate and how you're gonna connect
and how you're gonna work together.
Cayce: I don't have the time to
have hallway conversations with
physicians, or to be clear, they don't
have the time to have the hallway
conversations with me because their
days are jam-packed . But we do a lot
of our communicating through the EMR.
There's a messenger system, so you
can send a note that's linked to
a patient's chart and that's how we
often communicate about patients.
What makes it difficult is when that's
not a method of communication that the
physician prefers or when they haven't
had a lot of experience working with
allied health . So, sometimes the work
I have to do at work is proving myself
to the physicians showing that not only
am I there to support the patient, , but
that I'm someone they can rely on.
And that usually works.
But it does take some time
Sarah: the second thing is really
thinking about space and providing,
if possible, a therapeutic
space as opposed to exam rooms.
Tess and Kaila had the opportunity
to come into a new community health
center and they kind of had this unique
chance to help design their space.
I don't think this is something that all
social worker counselor roles would have.
But they had some really
interesting reflections about
space in our conversation.
Tess: they've really
created such a cool space.
When they got this space for us, it
was very, you know, what do you need?
What works for you as a
professional and what.
What does that look like?
Kaila: what we were requesting and
what I felt our folks really would
deserve is a therapeutic space.
I think there's some maybe ties
in associations with medical
clinics and being kind of a scary
place for some people at times.
As silly as it sounds,
you know, the sense.
The smells, the pillows,
the touch, the sensory.
But also for confidentiality.
We have our windows frosted so
that when an individual is in this
space, they feel cocooned and safe
.
Morgan: So not all providers can have
the opportunity to intentionally build
their space, but I think there's a lot of
small changes that you can think about.
Even if it's a room that doesn't have
an exam table, that's a huge start.
And then the lighting, adding some
artwork, creating something that is
distinct and separate that really
helps, ground the work that social
workers and counselors will do.
I think that's really important.
The other part is not just about , the
exam room or the clinical space where
you're seeing patients, but some shared
space to work together as a team.
Sarah: And I think it's those
opportunities to share space in clinics
that really does so much to help
building relationships across a team.
So the last call to action we wanna touch
on today is something that we say a lot,
which is, you know, creating opportunities
for people to get to know each other.
Cayce gave an example of what a
great day would look like from his
perspective, that really demonstrates
this value, I think, of working together
and creating these opportunities.
Cayce: A great day, I mean, is coming
to work in the morning and maybe
one of the MOAs has decorated the
office and there's a little party
going on . So, everyone is kind of
feeling at ease and chit chatting.
And then I'm able to speak with a doctor
about someone that I have a concern about.
I might say, hey, I'm gonna go see
that patient today, do you have time
later if I call you and the doctor
says, you know what, between one
thirty and two, I have some time . So
I go and see the patient at home.
I call the doctor, they answer me.
I say actually, you know this,
I'm worried about this patient.
I'm gonna get them in my car.
I'm gonna bring them to the clinic.
So I show up, I see the patient
with the doctor, and the three of
us talk about a care plan together.
And then I can bring the person
back home and I think it's great.
The patient because they don't have
to tell their story over and over.
It's great for me because I get the
support of the physician for some
issues that are outside of my scope.
And it's great for the doctor because
someone's bringing their patient right
to them and they know that if they're,
suggesting some sort of treatment that
there is a person like me to support the
patient with following that treatment.
Morgan: So really great takeaways
from the conversation today that
I think are generalizable across
so many primary care teams.
First, figure out how you're gonna
communicate and get to know the
social worker or mental health
counselor that's on your team,
particularly if they're only part-time.
Sarah: Next, think about space
and small changes that can create
kind of those therapeutic spaces
where possible and those shared
spaces to support team development.
Morgan: And then create opportunities
for team members, providers to
work together to support a patient.
Now these can be informal.
And they can be case conferences
and they can be group appointments.
Sarah: Great, and thanks for listening.
, be sure to check out the show notes
where we're gonna link to some of the
resources we mentioned in this episode.
Morgan: And as always,
we'd love to hear from you.
If you have any ideas or stories you'd
like to share or things you'd like
us to discuss on the podcast, please
reach out at issu family med.bc.ca.
Sarah: Join us next week cuz we dive
into another role in primary care.