JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP112 – Population Health: Social Work practice in the Primary Care Setting

Jun 11 2019
5:00 pm - 7:00 pm

PP112 – Population Health: Social Work practice in the Primary Care Setting

The ever-changing healthcare landscape has affected the Primary Care Practice setting. Social Determinates of Health, as defined by the World Health Organization (WHO), are “avoidable inequalities in health between groups of people…”  Therefore, the management of populations requires a team approach.  At Cleveland Clinic the model is multi-disciplinary & includes social workers, physician providers, registered nurses, medical assistants, care coordinators, pharmacists, and behavioral health.  

A comprehensive patient assessment is essential to understand patient needs. Understanding the patient and care-partner health literacy level is essential.  This area of assessment provides a foundation for clinicians to understand the patient’s health knowledge.   The social worker can use clinical judgment to provide the appropriate professional role as patient advocate, educator, facilitator, broker to efficiently impact psychosocial barriers.  Communication with the PCP, and consistent patient messaging, promote successful care-plan development and sustainment. 

Further, the social workers leverage their assessment skills to support collaboration with the additional stakeholders including behavioral health, medical professionals in home care, insurance case managers, skilled nursing facilities, and government and regulatory programs

A standardized social determinates of health screening tool was developed. This annual screening is administered leveraging multiple technologic platforms, including the electronic medical record, or at the office visit. The goal of the screening tool was established to understand psychosocial barriers to healthcare including access to personal care, transportation, housing & food.



1. Understand the role of social work in Population Health

2. Understand how to maximize patient contact, through telephonic outreach and social work practice

3. Understand the best practice for collaboration between inpatient and ambulatory care teams