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Cubicle Bound: Social Work Practice in a Managed Care Setting
By Aaron Kesselman, LMSW

A decade ago, I worked for a small community-based agency counseling adults with mental health conditions and chemical dependencies. It was the first time I worked with clients directly, and I quickly learned how to be a diligent and empathetic listener. I also learned that in order to make sound clinical judgments, it is important to heed nonverbal indicators such as a client’s mannerisms, hygiene, and affect. I became aware of how clients viewed me, learning the therapeutic value of a subtle nod, the benefit of sustaining eye contact, and the comforting effect of a compassionate smile. The telephone played an auxiliary role in my work. I used the phone, of course, but only for simple tasks that required quick resolution. The majority of my direct client work was conducted during face-to-face sessions.

Since that job, I have continued to work in a clinical capacity, first with homebound elders and now with the visually impaired. In my current position as a social worker for a long-term managed care program, my direct client work is conducted almost exclusively over the phone. Face-to-face interaction is rare, limited to the occasional home visit or when a client comes to my office to sign a form. My reliance on the phone is not symptomatic of having a poor work ethic. I am not a jaded, unmotivated social worker who goes about his day perfunctorily, preferring not to see his clients in person. Cubicle-based, telephonic client work is expected of me. As a social worker engaged in managed care, it is my job.

In today’s turbulent economic climate, city, state, and federal budget cuts have eliminated many social service programs. The remaining programs have been forced to make do with smaller staffs working with disproportionately large caseloads. As a result, an increasing number of social workers have gravitated toward larger, corporate settings where they can receive higher pay, greater job security, and more comprehensive benefits. Many companies have established employee assistance programs, where social workers are hired to assist employees with a variety of issues, ranging from advanced care planning education to caregiver support. An increasing number of law firms now hire social workers as client advocates, resource specialists, and legal assistants. Social workers are also fast becoming fixtures of managed care organizations where our skill sets are used to assist existing and prospective clientele. For many social workers, particularly those who have grown comfortable working for community-based agencies, managed care social work might seem to go against the grain of traditional clinical practice. However, for social workers who have typically felt underappreciated and overwhelmed in their professional lives, working in managed care may seem like a sensible career destination.

A Social Worker’s Role in Managed Care: Benefits
Managed care social workers are both learners and nurturers. We benefit from the expertise of other healthcare professionals and, in turn, share our own unique clinical insights and steadfast commitment to compassionate care. A managed care social worker’s role is multifaceted: Sometimes we work as case managers, and sometimes as auxiliary members of an interdisciplinary team. Other times, we are assigned to cases for the purpose of executing one or two immediate tasks (i.e., referring a client to mobile crisis or adult protective services). Regardless of the role, a social worker’s presence on a managed care team ensures that someone is on board to serve as an ethical compass.

In managed care, my office is a cubicle and my phone is the lone portal through which I can gain insight into a client’s life. Surprisingly, I have found that from baseline assessment to termination, there is virtually no aspect of clinical practice I cannot conduct over the phone. In fact, there are many clients who prefer to work with me by phone. This is understandable since a client who struggles with simple tasks such as bathing and dressing may find routine travel to my office to be taxing. If the client is bed bound, the prospect of me coming to his or her home, hovering over him or her like a hawk with good bedside manner, may be equally unappealing. From my point of view, working with a client over the phone is far more convenient than a three-subway transfer, a 20-minute walk, and climbing five flights of stairs. Routine fieldwork can burn out even the most vibrant social worker. Managed care provides the perfect elixir: Social workers can now conduct comprehensive direct client work without ever leaving the office.

My belief in the effectiveness of phone-based client work is not merely conjecture; it stems from experience. My work with one particular client perhaps best illustrates the positive impact of managed care social work practice.

Ms. M was a 48-year-old woman who was frail, homebound, and visually impaired. She needed help with a variety of issues, ranging from the implementation of home care to the provision of transportation services. The day I was assigned to Ms. M’s case, I called to introduce myself and conduct a routine psychosocial assessment. Ms. M answered the phone, stated that she was feeling overwhelmed, did not want to talk, and hung up. Undeterred, I continued my outreach efforts.

Our subsequent discussions improved. Our conversations lengthened and Ms. M slowly let down her guard. Still, despite my repeated efforts to engage her, our relationship at times seemed more reminiscent of taskmaster-servant than client-social worker. “I want more home care hours. I need my Medicaid recertified. I need food stamps,” she would tell me. Still, I chose to stay positive. I trusted that the rapport we had slowly built was significant; her decrees were not simply orders being barked out by someone short on diplomacy but rather sure-fire signs that we were developing a trusting relationship.

One morning, Ms. M called me in a panic. She explained that she had lost her glasses. Legally blind, Ms. M said she was virtually helpless without them and needed a replacement pair right away. I placed a quick call to her nurse case manager, then her vision clinic, and finally her optometrist. Before long, I had arranged to have Ms. M get a new pair. From that point on, Ms. M expressed an appreciation for our work together. She became easier to engage and assess.

We soon started discussing long-term goals, not simply short-term solutions. Our telephone discussions became deeper and more meaningful. Eventually, without ever meeting her in person, we managed to construct a healthy clinical relationship. When it came time to terminate, our work had paid dividends. Ms. M had grown empowered. I, in turn, had newfound faith in the effectiveness of managed care social work practice. Ms. M perhaps best summed up the value of our work when she recently told me, “You know, even though I never met you, I think you’re the best social worker I ever had.”

A Social Worker’s Role in Managed Care: Challenges
My work with Ms. M demonstrates how the phone can be an effective tool in clinical practice. Still, I am aware of its limitations. Social work is holistic, requiring routine evaluation of the complete individual. A social worker cannot fully assess an individual he or she cannot fully see. My cubicle is not a private office and similarly, the phone is not a window. If a client has bruises or scars, or displays other signs of physical abuse, they will not be evident over the phone. When working with a client by phone, I must remain aware that my perceptions of a client may be inaccurate. For example, silence on the other end of the phone line may indicate a captivated listener, but it also may be signify that a client is busy looking for a remote control that has fallen behind the couch.

Clinical social work requires a great deal of focus. Unfortunately, managed care organizations—housed in large, labyrinthine, sterile office environments where each cubicle is practically stacked up against the next—provide a working environment better suited for telemarketing than social work practice. My own workspace is small and exposed. With no door to close, it is difficult to fend off unwanted visitors or buffer outside sounds. When a nearby officemate is griping about a difficult client (or for that matter, which of their favorite celebrities just got voted off Dancing with the Stars), solid, focused clinical work becomes difficult to achieve.

The tone of the managed care environment can challenge social workers in another way. In 1996, the HIPPA was created to ensure that in today’s healthcare setting, patient confidentially can be maintained. However, HIPPA’s enactment also gave rise to a highly regulated, highly policed healthcare environment. Internal and external audits now linger over managed care programs like ominous rain clouds. To safeguard ourselves and our companies from an accusation of any wrongdoing or legal breach, managed care social workers are often preoccupied with reviewing case notes, hovering over fax machines, and diligently disposing of patient-sensitive material. For social workers—many of whom predicate their work on close client contact—it is unsettling to think that persistent concerns about liability may often dictate the course of a day’s work.

Looking Ahead
There was a time in my career when I worked with clients primarily in-person. Now I work with them over the phone confined to a cubicle. I am aware that there is an irony to my own career trajectory: I have arrived at a job where I work with the visually impaired and I cannot see them. Perhaps there is a way to utilize new technologies to make our clients more visible. Perhaps we can use video conferencing systems to communicate with clients remotely. New computer-based technologies now provide us with the convenience of the telephone while keeping clients literally framed in our view. Implementing a video conferencing system seems like a sensible solution. Still, we must consider that many of our clients are elders and medically frail. In many cases, they are cognitively impaired or have mental health conditions. Is it realistic to expect our clients to operate and maintain such high-tech gadgetry? Additionally, most of our clients are poor. If implemented, how would these systems be paid for?

As I continue to grapple with the challenges inherent to managed care social work practice, I sometimes feel overwhelmed. Consequently, I am starting to crave a supportive community. I would like to have a dialogue with other social workers with similar work experiences. Unfortunately, one of the salient limitations of managed care social work practice is that we are seldom permitted to leave the office to attend professional training and networking events. Despite the recent advent of Web sites, listservs, e-newsletters, and Webinars, there is no adequate substitute for face-to-face contact. To grow as a community, to foster our professional development and competency, managed care social workers need to attend trainings that take place outside the immediate work environment. Employers should consider access to such trainings not as a privilege but a necessity. Attending community-based trainings geared toward promoting professional development will not hinder a social worker’s ability to contribute to company growth, but rather enhance it.

Ten years ago, if you asked me whether I thought I would ever be a managed care social worker, I probably would have responded, “I’d prefer not to be.” However, the course of my career has been full of surprises. As it stands now, I am a managed care social worker intent on acting as a catalyst for positive change.

— Aaron Kesselman, LMSW, works for a managed long-term home care program in New York City. From 2007 to 2009, he served as president of the Manhattan Borough-wide Inter-Agency Council on Aging, an advocacy organization seeking to educate and empower Manhattan’s elder population. He also serves on the faculty at Fordham University’s Graduate School of Social Service.

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