The Time is Right for Social Work: Social Workers Make a Difference at St. Peter's Health

What are social determinants of health? According to the US Department of Health and Human Services: ocial determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. The five key domains include economic stability, education access and quality, health care access and quality, neighborhood and built environment and social/community context.”

Social workers play an integral and unique role on St. Peter's clinic-based care teams by empowering their patients. "The patients do the work. We help empower them to advocate for themselves and point them in the right direction. Much of what we do is give them life-long tools that they can use to create change," says Emili Miller, LCSW.  

Social workers also bring a different perspective to the clinic setting. They can spend more time exploring things like the patient's background and "home life," which can be hard to fully understand during a clinic visit with a provider about a specific health issue. "We consider culture, economic factors, past trauma, all that may impact patients and why they do what they do. We can provide a valuable lens to the providers," says Emili.  

 St. Peter's Primary Care Provider and Addiction Medicine Specialist Dr. Kyle Moore and Physician Assistant Megan Zawacki, PA, work closely with the clinic-based social work team and believe they are instrumental members of the care team. 

According to Megan, "I couldn't do my job without them."

Their jobs come with a high degree of reward, like when they can help guide a patient or family that simply 'didn't know where to start.'  

However, it also comes with challenges. "Right now, housing is a huge challenge," according to Mattie. "Waitlists are long, prices are high, and there are people who make too much to qualify for some resources but don't make enough to pay for what they need. It is hard when I can't find any resources to offer."  

Did you know? Local organizations across all sectors are working together to tackle the local housing crisis. St. Peter's is proud to participate in collaborative efforts and recognizes that housing IS health care. St. Peter's currently employs staff members dedicated to working with community partners to support effective housing solutions through projects like the FUSE initiative (frequent users of the system's engagement). The Montana Healthcare Foundation and private donors through the St. Peter's Health Foundation are generously funding the effort. The effort aims to improve outcomes for people who are homeless or unstably housed and who are also high-cost, frequent users of community systems like the emergency department and law enforcement resources.  

Housing isn't the only limited resource impacting the physical and mental wellbeing of local residents. "We have limited specialized care for mental health locally and statewide," says Emili. "COVID-19 has improved this since there are more virtual options, but it can still be challenging to find specialized mental health and psychiatric care for patients." 

For St. Peter's, employing social workers as part of the care team is an investment in patients and preventative health. "We are proud to be leading the way with integrated care teams," shares the President of the St. Peter's Medical Group and Primary Care Provider, Dr. Todd Wampler. "Not everywhere will you find the wrap-around support that you receive at St. Peter's. We understand that so much of your health - the majority - is determined by factors outside of the exam room. Our social work team does a phenomenal job connecting the dots to ensure people can live their healthiest lives possible." 

According to Laurell, "emotional stability is a big part of home health." She says that many of her patients are alone and isolated, making home health an incredible blessing. "We can help patients shorten their stay in the hospital and stay in their home longer, with their pets, with their familiar furniture. And many patients get better faster, being in a familiar environment with the supports they need."

Home health patients' support after a stay in the hospital varies. Home health social workers like Laurell connect patients to in-home support through caregivers, meals and transportation providers, emergency alert systems, advance directive planning and longer-term care planning (e.g., assisted living or skilled nursing facilities). 

Change, and lots of it, describes the period following debilitating illness, surgery or hospitalization. Often, people must become accustomed to new medications, increased mobility challenges, a new diagnosis, or the need for additional help. "I try to help patients understand that not all change is bad. Sometimes the help that I know is best for the patient can be hard to accept. And while my goal is to help people be self-determinant and independent, I also realize that what they choose to do or not to do ultimately has to be their choice."

When St. Peter's enrolls a patient in the home health program, the team gets to work quickly. "We have to build rapport with the patient fast because typically, we only work with someone for between ten and 60 days." And even though Laurell and the entire home health team's relationship with each patient rarely exceeds a few months, the impact on the patient and the rewards for the caregivers are substantial. "When you can visit with someone that you barely know, and you can see them breathe a sigh of relief, and they tell you that they'll be able to sleep tonight... that's why I do this work."

A team of caregivers: The success of the home health program at St. Peter's is because of the team-based approach to care. Home health nurses, home health aides, physical therapists, occupational therapists, and speech therapists work together to care for patients. Much of the clinical team's success is due to the home health administration team's work behind the scenes, too, from receiving referrals to enrolling patients. According to Laurell, "people like Margot [Dollan] and Janice [Spencer], if we didn't have them, it would all fall apart."

As the employee behavioral health specialist and a licensed clinical social worker (LCSW), Tina is committed to providing behavioral health counseling, support and referrals to St. Peter's employees at no cost. 

Her days are busy. Staff will stop by her office at the Regional Medical Center (hospital) for brief 1:1 counseling sessions. Staff in a department may experience a tough or tragic situation, and she's called in to debrief and provide support. She has scheduled appointments with staff members confronting mental health issues throughout the day. She also creates new wellness programs to support staff wellbeing and completes community outreach, like a program she's hosting in partnership with East Helena schools titled "It's Not All Cupcakes and Cashmere: It's compassion fatigue." 

"I love working 1:1 with staff and seeing them grow, watching the transformations happen," says Tina. "It is also very rewarding to see the potential transformation of an entire organization, to know that I'm making a difference."

Employee assistance program: Tina works closely with a strong network of other local social workers, therapists, psychologists and psychiatrists. She frequently refers St. Peter's employees to local mental health professionals for ongoing, longer-term counseling and care. St. Peter's employees and their families have access to these services through a comprehensive, no-cost employee assistance program.

"One of the things that I've been doing is working with women who score high on the Edinburgh Postnatal Depression Screening," says Lyndsay. The Edinburgh screening helps identify mothers on the labor and delivery unit who may be at higher risk for postpartum depression or other perinatal mood disorders, common conditions that impact one out of seven women after childbirth. "If a woman scores high on the screening, I will work with them to make sure they have the support and resources they need once they go home so they can receive ongoing support and the right types of care."

It can be challenging for social workers like Lyndsay to recognize that they don't control the outcome for the patient. "I can give patients information or advice, but I also have to respect that they have autonomy and the ability to make their own decisions."

For Lyndsay, the most rewarding part of her job is hearing from a former patient. "When I hear that I make a difference, that feels good," says Lyndsay. "Even if it was just connecting them to the right organization in the community." 

It takes a team: Lyndsay works closely with colleagues, specifically the St. Peter's team of registered nurse care managers and social service coordinators. Together, the team creates discharge plans for patients, refers them to the others who can offer the help they need once they leave the hospital and provides vital education to ensure their health and safety once home.

Karissa typically meets patients and their families when she and a hospice nurse visit their home for an initial intake visit. Patients are referred to hospice by medical providers when they have a prognosis that will likely result in six months or fewer to live. 

Karissa says the initial intake visit can be overwhelming for the patient and family because no one wants to die. As a result, the team tries to keep the intake informative. They introduce themselves, give an overview of hospice and encourage partnership for one of the hardest time in their lives, both for the patient and their loved ones. Hospice focuses on the quality of life and healing over the coming days, weeks and months. The hospice team attends to the patient and family to provide care, education, and support for end of life. A hospice nurse visits all patients at least once per week for medication management. Home health aides work with patients closely to help complete everyday living tasks like bathing, services for spiritual support are offered, and volunteers are placed where useful. Karissa visits most of her patients at least once a month, although she often sees patients and their loved ones weekly. 

According to Karissa, everything is "real" at the end of life. "Where you went to school, where you shopped, how much money you made, none of that matters. What matters is relationships and continued family dynamic resolve. It really helps put what is important into perspective: living well, saying your goodbyes, forgive me, and I love you." Supporting people to be present with death and dying is what keeps Karissa going.

But Karissa's relationship with a patient's loved ones doesn't stop at the time of death. Karissa has one message for the community: "treat your grief. When left untreated, it comes out sideways. After experiencing a death or loss of any kind, your mental health needs attended. You need to process your grief and learn coping mechanisms that work for you to reconcile what once was to what is now," she says. 

Karissa and other hospice team members are committed to helping people work through grief and bereavement. Loved ones have access to bereavement care for 13 months after the death of a loved one who was in the St. Peter's hospice program, including; mailings, individual 1:1 counseling sessions and group sessions are available.

Karissa shares that after the initial condolence call within 72 hours after death, the team makes another call about six weeks later to introduce the bereavement program. Grievers frequently experience a "numb stage," which wears off, and as the rest of the world returns to normal, the bereft are trying to adjust to a new normal. Monthly mailings also go out to let people know that support is available and that Karissa and many other people at St. Peter's hospice care.

Did you know? Hospice care at St. Peter's is made possible because of dedicated, talented caregivers, including; social workers, hospice nurses, home health aides, and more. Additionally, the program is also made possible due to over 50 remarkable volunteers and community financial support. Volunteers visit patients in their homes and so much more. Volunteers make "tuck-in calls" every Thursday where they call patients and/or loved ones to ensure they are "tucked-in" or ready for the weekend: they have questions answered, adequate supplies and medication.

Education and community outreach are key parts of St. Peter's hospice. Karissa and other hospice team members share their time and talents by providing community outreach services, like at local retirement homes and nursing facilities, where they educate other caregivers about hospice care when hospice care is appropriate. The team also completes education and outreach with other community partners, including Carroll College and the Public Library. The hospice experts teach students (e.g., pre-medicine and psychology) about hospice care, end-of-life and grief.

Jen shares that her days are filled with one-on-one conversations with patients, education sessions with patients and family members, meetings with other caregivers, and lots of research on available support options for her patients. "This is a team-oriented place," says Jen. "The dialysis team is so committed to their patients. We are working together as a team to help patients maintain and improve their medical wellbeing and other parts of their life."  

Did you know? St. Peter's home dialysis program leads the way in Montana. Typically, over 40% of patients on dialysis (peritoneal or hemodialysis) at St. Peter's receive treatments at home, ensuring treatments can better fit into people's lives. The national average is only around 10%. The success of the St. Peter's home dialysis and kidney transplant efforts are due to the entire dialysis team's commitment, led by Nephrologist Dr. Robert LaClair, to provide the highest-quality, nationally-ranked care.

Jen works with patients who receive dialysis in the clinic and patients on home dialysis. She also works with patients on the list to receive kidney transplants. "This dialysis clinic, in particular, is very diligent and makes sure that qualified and interested patients connect with a transplant center." Over the past year, five patients from St. Peter's have received kidney transplants, a remarkable statistic for a center of its size. 

Jen shares that the road to receiving a transplant can be a long one. "Once they've chosen a center, I stay connected with the transplant center, so I can help answer questions and support the patient on their journey." 

It is common for dialysis caregivers to build long-term relationships with their patients, often seeing and caring for them multiple times each week. The national average life expectancy for a patient on dialysis (without a transplant) is five years, and most patients come into the unit to dialyze at least twice per week. 

While Jen is relatively new to the position, she is already building relationships with the patients she helps support. 

"There is a lot that is rewarding about this job," says Jennifer. "It feels good to be able to advocate for people. When I can help someone find their voice for their concerns or share their questions, that's rewarding."