Critical Thinking vs. Technology in Assessing the Social Determinants of Healthby Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP on 08/06/18
I was recently interviewed for an article on the Social Determinants of Health (SDoH), which was quite exciting. The interviewer started off by asking me a question that got my brain buzzing; “What should case managers do to identify those impacted by the SDoH?”.While the question was benign enough, it prompted an inner explosion of other questions within me.
· Why are the SDoH so challenging to so many? (easy answer: lots of moving parts)
· Why has the workforce lost sight of the didactic foundation that grounds practice? (easy answer:because organizations have goals that are fiscally and not necessarily quality driven)
· Can technology truly replace an in-person assessment? (now for the tough one……J)
Organizational Priority vs. ‘Best-Practice’
Most clinicians graduate school embracing particular theories, models, and interventions to guide their practice. However, any affinity they may have is short-lived; they become beholden to whatever new tools and processes are used by their employer. Independent of professional discipline the same evolution occurs. The didactic foundation taught in degree programs is put aside within hours, if not minutes of graduation. Granted, a great deal of content is required to fulfil those degree requirements and not all is immediately useful. As an adjunct faculty member I can honestly say the content most often retained by my students is that which is useful only in the moment. Much other valuable information gets is set aside, and often forgotten. For example, behavioral health professionals may be mandated by their agencies to use only Cognitive Behavioral Therapy as a stipulation of grant funding or some evidence-based protocol. Motivational Interviewing is now embraced as the be all to end all for every treatment non-adherent population admitted to a hospital; valuable for many but not effective for all. Physicians, nurses, and case managers suddenly decrease the scope of their assessment to only those items included in their organization’s electronic health record. The pitfall for each example is evident; practitioners end up relying on single interventions and rote processes. As a result, they lose the spontaneous ability to use critical thinking; the hallmark of independent professional practice. The SDoH encompass a number of moving parts; loss of critical thinking is a major impediment to effective intervention with the populations involved.
Is Technology Really to Blame?
While technology’s promise in health care is without question, apprehension still exists. Some experts challenge how technology and innovation have led to decreased capacity with critical thinking. Having access to platforms, processes, and products that complete a task with the click of a mouse, make life easier but don’t allow the brain to work. A wonderful article speaks to automating critical thinking skills out of health care; dependence on computerized physician order entry (CPOE) programs and computer generated checklists do little to promote independent thought on the part of clinicians. This fact becomes a challenge to reconcile when those clinicians stop actively thinking through situations, such as if a medication order is accurate, whether dosage or medication itself. Patient deaths have been tied to electronic health records. While CPOE programs prevent some medication errors, 40% of others are missed.
In today’s health care organizations, effective and lean processes are a mandate to assure organizational sustainability and financial durability. Take predictive analytics for example, which uses data mining, machine learning, and artificial intelligence to analyze current data and make calculations for the future. The ability to stratify important demographic and psychosocial data for those at greater risk of being pre-disposed to the SDoH, helps prioritize treatment team efforts. This action is especially vital in these value based times that are so financially propelled. Yet, the current literature on predictive analytics notes a word of caution in the over-reliance on technology-driven assessments of SDoH populations. A recent study demonstrated that adding social and environmental data to more traditional clinical analytics did little to improve the accuracy of predictive population health analysis. In-person interviews by staff trained in how to assess, plan, and, and locate resources (e.g. social workers, professional case managers), was as effective in the long run. As one of my esteemed colleagues says, “Anyone can check a box, but the art of assessment is totally different. That’s the difference between a trained monkey and a licensed practitioner.”
There has been emphasis in the literature on how technology is not a replacement for in-person care. It was developed to support and enhance intervention. Over reliance on tools and technology negate both foundational and advanced didactic knowledge taught in school, plus other professional grounding (e.g. mandatory continuing education requirements, specialty trainings). Has a dependence on whatever current ‘best practice’our organizations employ replaced true ‘evidence based’ practice paradigms? I’ll admit I’m known to refer to best practice as needing a reframing to ‘best practice in the moment’, to avoid reliance on obsolete thinking. The times are too fluid for anything less. However there must be a balance, as well.
Back to that Initial Question…
What should case managers do to assess the SDoH? True, there are many moving parts with the SDoH that can bias a practitioner’s ability to intentionally identify, engage, prioritize, plan, and intervene with each unique person. Technology platforms and products provide support to make processes faster, strong, and better, but do not provide the interventions that address client needs to assure the best outcomes. How fortunate for the workforce that models and templates have been created to drive that type of intentional practice.
As a clinical social worker I actively consider how I engage, assess, and intervene with each person, couple, family, group, and community; strict competencies defined by the Council on Social Work Education set the tone for each of these actions. As a professional case manager the CMSA Standards of Practice for Case Management resonate loudly; pivotal in the context of the SDoH is the Client Assessment Standard (B), which takes into account the domains of Medical, Cognitive and Behavioral, Social, and Functional. As a board certified case manager, I process how the CCMC Professional Code of Conduct and the ethical tenets of advocacy, beneficence, fidelity, justice, and non-malfeasance guide every action and interaction with clients and colleagues.
In defining key interventions to optimize my efforts with any clients struggling with social and environment factors, I may use Motivational Interviewing. I may also consider what other interventions may be more appropriate (e.g. crisis model, solution focused brief therapy). I routinely use empathic listening to engage clients, which allows me to always start where they are as opposed to where I may want them to be; an occupational hazard of the interprofessional workforce. I then make use of the eleven steps of the Comprehensive Case Management Path©, a template for case managers to guide and inform their work with clients at risk for the SDoH:
1. Suspend judgement
2. Identify/select clients
3. Identify/assess problems
6. Develop case management plan
7. Implement/coordinate care and services
8. Evaluate case management plan/follow-up
9. Terminate the case management relationship
10. Follow-up post discharge/transition from healthcare encounter
This template incorporates the steps of the Case Management Process with Critical Thinking for Case Managers; both seminal processes in their own right. These steps foster independent thought, clinical acumen, critical thinking, and the interprofessional expertise needed to maneuver the intricate psychosocial circumstances of those coping with the SDoH, plus other complex populations. The steps also advance a practitioner’s ability to focus on the individuality of each client’s situation and care. Through these crucial efforts, the unique integrity and worth of each person are respected. At the end of the day, assessment is a process the clinician drives using education, experience, plus critical thinking, and not technology alone.
Until next time...Stay Resilient