Elizabeth Cole

Abstract
While the United States Healthcare System is riddled with problems, there is not enough focus on prevention. A first line of defense that is underutilized is the Social Work profession. While there isn’t a multitude of studies regarding the effects of social work on general healthcare outcomes, the few that have been done have been overwhelmingly positive. In one case, social workers intervened in high risk pregnancies and lowered the admission rates of NICU patients by 15% over a three-year period. There is an additional study showing that underage at-risk females were educated by a female health educator about the risks of unprotected sex. Through this intervention, the rates of sex without contraceptives dropped by a considerable margin throughout the study. While there needs to be more research in this area, the research that has been done has shown a positive influence on the effects of social work as a preventative measure in the healthcare field.
Introduction
According to the International Federation of Social Workers, “Social work is a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversities are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledge, social work engages people and structures to address life challenges and enhance wellbeing” (IFSW, 2014). Social Services in America is typically referred to as “welfare” to the uninformed. These programs include the popular Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicare and Medicaid. While Medicare and Medicaid are a type of health care program, social service programs are not typically associated with bettering our general health. In all actuality, social service programs have been studied and have shown a positive impact on certain wellness areas such as prenatal health and STD prevention in adolescent females. If we were to invest more in social worker related programs, we could then lower the cost of healthcare in addition to reaping the benefits of being healthier. While there has not been an abundance of studies done, the few that have been completed show promising results for why we should invest more in social programs as a society.

Reduction in Neonatal Intensive Care Admission Rates
Pregnancy is the primary indicator for Medicaid eligibility. Women from poorer backgrounds tend to have higher risk pregnancies than their more well-off counterparts. Therefore, delivery and Neonatal Intensive Care Unit (NICU) admissions account for a large portion of the Medicaid budget. The Monroe Plan for Medical Care (MP) serves over 3,000 providers in the Rochester, New York area, which accounts for over 73,000 patients throughout the region. As MP works with BlueCross BlueShield, it is financially responsible for all the Medicaid Managed Care recipients, hence their desire to lower NICU admission rates and reduce the cost of pregnancy and delivery. During the late 1990’s the NICU admission rate was over 100 per 1000 births. In 1997, MP adopted a community case-management program designed to combat NICU admission rates significantly. “The medical literature reports that there are many risk factors that significantly affect birth outcomes for low-income and working-poor women, including medical comorbidities, mental health and substance abuse issues, smoking, previous preterm birth, and social-related problems such as social isolation, spousal abuse, and homelessness” (Hobel et. al., 1994).
Having identified what makes their patients at risk, MP created a community-based case management program designed to combat NICU admission rates in the patients. MP worked with other Medicaid Managed Care providers as well as their Obstetrics/Gynecology Advisory Committee to develop “Healthy Beginnings”, a prenatal care program. The objective of this program was to reduce NICU admission rates by 15% in three years and to maintain that reduction in the following years. Before 1997, general practitioners rarely notified MP about their patients becoming pregnant, at a rate of less than 3%. In late 1997, MP designed a prenatal registration form (PRF) for practitioners to alert them to a patient’s pregnancy and include any high-risk factors that might be involved. “The PRF assess risk categories of social risk factors, maternal medical history, psychoneurological history, maternal obstetrical history and previous infant findings” (Stankaitis, Brill, & Walker, 2005). In order to ensure submission of the PRF, MP reimbursed practitioners $30 for each one submitted. This raised submission rates to 85% in 1998. However, the timeliness of submission was a problem as most general practitioners didn’t submit their PRF’s until the third trimester, thus making it more difficult to implement adequate prenatal care for high risk women. “In April 2001, Healthy Beginnings implemented a tiered payment system for the submission of the PRF in which the program would pay practitioners $50 for submission in the first trimester, $30 in the second trimester, and $20 in the third trimester” (Stankaitis, Brill, & Walker, 2005). Because of the tiered payment schedule, submissions in the first trimester increased to 60%. After submission, a perinatal nurse coordinator reviews the PRF and determines if there is a high-risk situation. According to Stankaitis, Brill, and Walker (2005):
Individuals with medical complications of pregnancy receive complex case management, home care services, or skilled nursing services as required. The perinatal nurse coordinator refers all pregnant enrollees identified as high risk because of psychosocial problems to the BabyLove Program. This community-based program has a strong history of working effectively with high-risk pregnant women, with the added feature of social work supervision that is necessary to effectively provide outreach. The BabyLove Program offers home visits, arranges transportation, provides links to support services and social work services, and connects high-risk pregnant women with other critically needed services (p. 168).
The results of the Healthy Beginnings Program were successful in more ways than anticipated. NICU admission rates from 2001 to 2003 were decreased 8.8%, 8.9%, and 5.7%, respectively. In addition to the decreased NICU admissions, preterm birth (< 32 weeks) and low birth weight (< 1900 g) were also significantly lower. Admission rates for Medicaid recipients in upstate New York remained generally unchanged, and the requirements for NICU admission remained the same during the same time period, thus indicating that the Healthy Beginnings Program had a positive effect on high-risk pregnancies and deliveries in their patients. In addition to the health benefits of the Healthy Beginnings Program, Stankaitis, Brill, & Walker also found that for every dollar spent of the program, $2 was saved (p. 170). These savings have been calculated to save over 1.8 million since the program’s implementation.

The Safer Sex Intervention
The Safer Sex Intervention (SSI) is a clinic-based program model funded by the federal Teen Pregnancy Prevention Program, which is administered by the Office of Adolescent Health, a division of the U.S. Department of Health and Human Services. “The Office of Adolescent Health was authorized by the Public Health Service Act, they support research, services, prevention and health promotion activities, training, education, partnership engagement, national planning, and information dissemination activities” (Office of Adolescent Health, n.d.). SSI’s goal is to reduce the rate of sexually-transmitted diseases and increase the rate of condom and other contraceptive use among high-risk, sexually-active adolescent females. The grants were awarded to Hennepin County Human Services and Public Health Department in Minneapolis, Knox County Health Department in Knoxville, and Planned Parenthood of Greater Orlando in four central Florida counties.
While most of the program occurred in clinics, Hennepin County offered the program in seven school-based clinics, one STI/public health clinic, five community-based clinics, four teen health clinics, one hospital-based pediatric clinic, and one clinic for homeless youth. “The intervention is delivered in one-on-one, face-to-face sessions with a female health educator. It has two versions: The Pre-Contemplation Stage Module, which emphasizes delivering information and obtaining feedback about safer sex behaviors; and the Contemplation Stage Module, which emphasizes education, skills, self-efficacy, and self-esteem” (Kelsey, Layzer, Price, and Francis, 2018). The initial hour-long session was supplemented with three shorter sessions over a six-month period. In addition to being offered free condoms and informational materials, the one-on-one sessions included discussions about the consequences of unprotected sex, risk perception, preventing pregnancy and STIs, condoms, where to obtain condoms, secondary abstinence, and talking about sex. Over 2,000 adolescent females participated in the study. On average the women were 17.2 years of age, 17% were Hispanic, 35.8% were Black, 33% were white, and 13.6% identified as Other. Almost all participants were sexually active, although only 83.2% had been active in the 90 days preceding the introduction of the program. Roughly two-thirds of the women had unprotected sex in the 90 days before the baseline survey was conducted. Female health educators typically have a master’s degree in Public Health, Education, or Social Work. The project staff from each location attended a two-day workshop that emphasized the importance of listening and promoting conversation as opposed to educating. The biggest hurdle that staff encountered was retention rate. They found that transportation was a primary reason for the participants not attending the follow-up booster sessions. As a revsult, “it hired a transportation company to transport young women to and from sessions. In addition, Planned Parenthood of Greater Orlando received approval from the Office of Adolescent Health to offer booster sessions remotely via video conference or smart phone video chat (e.g., Skype, FaceTime)” (Kelsey, Layzer, Price, and Francis, 2018).
The conclusions of the SSI were overall positive. The percent of adolescents that were sexually active after three months fell to 74.84%, after six months it was at 75.12%. The most significant change after participating in the SSI was the decline in females that had sexual intercourse without any sort of contraceptive. Originally, two-thirds of participants were having unsafe sex, after three months that number dropped to 22.05%, and after 6 months it stayed steady at 23.84% (Kelsey, Layzer, Price, and Francis, 2018). The success of the small-scale implementation suggests that the program is enough for large-scale replication. The success was largely based on the effort given by the project staff, the training they went through, and the proviision of transportation and other means of following up at three and six months.

Conclusion
Through community based social service programs social work is evidenced to have an impact on overall healthcare in the community that is being serviced. Though more research is required, there has already been a quantitative impact on the population that specific programs are designed to help. In addition to affecting the health of the participants of these studies, there is a financial impact as well that has proven to be beneficial. Imagine if the United States were to invest more into social services throughout the country, aimed at other demographics. Based on the studies previously done, it can be inferred that a positive impact would be received. In addition to the healthcare services already provided, if more work was done aimed at prevention throughout our communities, an overall betterment of the general wellness of our population could be increased.

References
Hobel, C.J., Ross, M.G., Bernis, R.L., Bragonier, J.R., Nessim, S., Sandhu, M.,…Mori, B. (1994). The west Los Angeles preterm birth prevention project 1: Program impact on high-risk women. Am J Obstet Gynecol, 170, 54-62.
International Federation of Social Workers (2014). Global definition of social work. Retrieved from http://www,ifsw.org/what-is-social-work/global-definition-of-social -work/
Kelsey, M., Layzer, J., Price, C., & Francis, K. (2018). Safer sex intervention final impact report: findings from the teen pregnancy prevention replication study. Cambridge: MA:Abt Associates Inc.
Stankaitis, J.A., Brill, H.R., Walker, D.M. (2005). Reduction in neonatal intensive care unit Admission rates in a medicaid managed care program. The American Journal of Managed Care, 11, 3, 166-172.
U.S. Department of Health and Human services (n.d.) Office of adolescent health. Retrieved from http://hhs.gov/ash/oah