Is there a social worker in the house? Health care reform and the future of medical social work.

A s medicine has become increasingly sophisticated and technologically complex, medical educadon and medical care have come to rely on increased speciaHzation (Moore & Showstack, 2003). Dividing providen into specialties, however, has also led to a fiagmented care delivery system in which a patient might go to one cHnic for a check-up, a mental health service provider for treatment of anxiety, another service provider for rehabilitation after addiction, urgent care for a toothache, a speciaHst for diabetes management, and an imaging center for cancer screening. Fragmentation leads to lapses in communication among providers, which can be costly in doHars (when care is dupHcated) and in outcomes (when prescdption errors occur, for instance, or when diagnoses fail to take mental health into account). This fragmentation has measurable consequences: The number of specialty physicians per population has been associated with higher mortality, shorter Hfe span, and low birth rates (Shi, 1994). Recent health reform legislation aims to correct fragmentation by providing incentives to reodent health care around pdmary care and for existing practices to transform into medical homes (Kocher, Emanuel, & DePade, 2010). The medical home offers a single place for the coordination of all outpatient care needs, including behavioral and dental health. The model imagines a site where patients access care easily, where interdiscipHnary care teams understand each patient's history and needs, and where the method of payment reflects the coordination necessary for deHvery of individualized care (Amedcan Academy of Pediatdcs, 2002). Although definitions vary from single-site clinics to multiple-site pdmary care networks, the Agency for Healthcare Research and QuaHty (2011b) outHnes five core medical home attdbutes: They must be patient-centered, comprehensive, coordinated, provide superb access to care, and have a systems-based approach to quaHty and safety. The medical home model purports to be a transformadon of pdmary care that would set the foundation for a sustainable health care system by keeping people healthy. Medical home models must include a social lens that considers the whole person in the context of the person's larger environment; without it, medical homes may not be transformadonal enough to achieve a healthy populadon within an affordable health care system. Despite increased access to care, the tradidonal medical model has failed to resolve growing pubHc health problems such as obesity, and health dispaddes exhibited among low-income and minodty populadons include greater dsk for chronic disease, anxiety, substance abuse, and depression (Cooper et al., 2000; Mensah, Mokdad, Ford, Greenlund, & Croft, 2005; Piffath, Whiteman, Haws, Fix, & Busht, 2001; WeUs, Klap, Koike, & Sherboume, 2001). Environmental health research demonstrates that upstream factors such as a lack of community resources, environments hostile to physical acdvity, social isoladon, segregadon, crime, and discdminadon can increase suscepdbüity to health hazards and can lead to poor health outcomes (Lee, 2002; Merkin, Stevenson, & Powe, 2002; Sexton, 2000). Equipping pdmary care to achieve real gains in populadon health wiU Hkely require looking at old problems through a different lens, one that acknowledges inequaHty and incorporates social jusdce. Social workers can bdng this lens; we now have a unique opportunity to ensure that care