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Navigators and assisters: two case management roles for social workers in the Affordable Care Act.

Social workers can help ensure successful implementation of the Patient Protection and Affordable Care Act (PPACA, hereafter ACA) (P.L. 111-148). This became clear to me as I attempted to find my way through the 2,400-page-long ACA, looking for the "low-hanging fruit": places where there was evidence that social work would be effective and there was a natural fit because of social workers' specialized training and professional code of ethics. There are, in fact, many such places in the ACA, particularly where one encounters the terms "case management," "care coordination," and "care management"--terms that occur 39 times. With each such mention is an opportunity for social work to meet the ACA's goal of reducing costs by improving health through a set of activities that the social work profession calls "social work case management."

The National Association of Social Workers (1992) defines social work case management as "assess[ing] the needs of the client ... and arrang[ing], coordinat[ing], monitor[ing], evaluat[ing], and advocat[ing] for services" to address the client's needs; Two characteristics set social work case management apart from other kinds of case management. First, social work has a dual focus on the person and the environment. Social work's biopsychosocial focus means that social workers are concerned with the interaction between the body, the mind, and the social system. Second, social workers carry out case management by using a strengths-based approach, which focuses on strengths rather than deficits and views the community as an "oasis of resources" (Etzel-Wise & Howley, 2006).

Because of its potential to improve health outcomes and reduce costs, case management has entered a renaissance period. Indeed, we have witnessed a proliferation of various kinds of case management programs in recent years, most notably patient navigator programs (Dohan & Schrag, 2005; Freeman, Muth, & Kerner, 1995; Freund, 2011; Vargas, Ryan, Jackson, Rodriguez, & Freeman, 2008; Wells et al., 2008). The ACA invigorates this trend. In this Viewpoint, I focus on how social workers can positively impact implementation of the ACA by doing what they do well--social work case management--through two new roles envisioned by the ACA: navigators and assisters. These roles are important because they can affect the three major milestones of the ACA: people obtaining coverage

for the first time through Medicaid or the exchanges; people making efficient use of their insurance benefits; and, finally, bending the cost curve, a product of achieving the first two milestones.

NAVIGATORS

The success of the ACA will be measured initially on the basis of its performance on the first milestone: enrolling currently uninsured people in eligible health insurance programs. Previous research suggests that this is not an easy task. A recent report from the Office of the Assistant Secretary for Planning and Evaluation summarizes the evidence of "take-up rates" in Medicaid among adults (Sommers et al., 2012). The take-up rate refers to the percentage of eligible people who actually end up enrolled. Overall, studies show that take-up rotes range from 32 percent to 81 percent, but if one excludes tile studies that are known to produce upwardly biased estimates, the take-up rotes are much mole modest: between 32 percent and 52 percent. These take-up estimates are often much lower than the published take-up projections for the ACA. The take-away message from the take-up literature is that states will face a formidable challenge in enrolling eligible populations.

A recent report by the Kaiser Commission on Medicaid and the Uninsured about the experiences of uninsured adults who could gain Medicaid coverage underscores the enrollment challenge before us (Perry, Mulligan, Artiga, & Stephens, 2012). In focus groups conducted across the country, participants were largely unaware of the new law. Their knowledge of "Obamacare" was confined to the individual mandate. It is important to note that they were unaware of the new health coverage options or programs to make care affordable. Some expressed skepticism that they would qualify for Medicaid and some were skeptical that coverage would ever be affordable. Others who reported having previous experiences enrolling in Medicaid (for themselves or on behalf of their children) said that the enrollment process is complicated. Lack of awareness about coverage options, doubts about eligibility and affordability, and the complexity of enrollment are all barriers that must be overcome if we are to achieve the ACA's coverage goals.

The ACA provides two key avenues to help people enroll in health insurance programs and in the premium tax credits and cost-sharing reductions. Social workers can have a positive impact on rates of participation in health plans by becoming integral players in these programs.

The first is a new "navigator program" that the state health insurance exchanges are required to establish. Within a broad federal framework, states have considerable discretion in designing navigator programs, setting goals, selecting the types of entities to serve as navigators, and determining the resources that can be leveraged. The ACA specifies that states consult with various stakeholders, including "advocates for enrolling hard to reach populations?' Social workers can play a consultative role in helping states design and implement navigator programs that engage disenfranchised populations. This consultative role ought to be imagined as an ongoing dialogue between states and the social work community because social workers will be in preferred positions to know about populations being left behind. Toward this end, social workers might wish to join formal advisory groups designed to solicit input from consumer advocates and consumer representatives, which are now established in at least 12 states (Boag-Munroe & Evangelou, 2012; Zemel, Arons, Miller, & Gauthier, 2012). There is a clear advocacy role for social workers to play in states lacking such a venue or in cases where there is a formal committee but no consumer representation.

Hard-to-reach populations include people who are unaware of services; are discouraged from participating for various reasons, such as program complexity, stigma, lack of trust, or diminished access to services; refuse to participate; fail to comply at desired levels; or drop out (Boag-Munroe & Evangelou, 2012; Watson, 2005). Evidence has shown that social workers are attracted to serving the most economically disadvantaged populations (Abell & McDonell, 1990; Limb & Organista, 2003, 2006). This commitment to serve vulnerable populations makes social workers a particularly cost-effective resource: Nothing boosts productivity like motivation.

The ACA specifies that the navigator duties include conducting public education activities to raise awareness about available health insurance plans; distributing fair and impartial information that is both culturally and linguistically appropriate; facilitating selection of plans; and providing referrals to offices charged with handling grievances, complaints, or questions about coverage. Social workers are well positioned to be able to do these sorts of things effectively, but there is no escaping the fact that there will be a steep learning curve. Consider that every state will be different. There will be different qualified health plans. Some states will operate their own exchanges and others will have federally facilitated exchanges. And the Supreme Court decision makes it likely that Medicaid eligibility will vary from state to state. But once this learning curve has passed, there is every reason to believe that social workers will be at the vanguard of navigation, poised to help the hardest to reach.

What is needed now is for social workers to be explicitly recognized as navigators. This will set the stage for social workers becoming trained as navigators. The Centers for Medicare and Medicaid Services' (CMS's) Center for Consumer Information and Insurance Oversight (CCIIO) could facilitate such recognition by issuing guidance about the appropriate role of social workers as navigators.

Social workers have a role to play across the continuum of navigation. Because ensuring access to care requires more than having an insurance card, it will be important for states to ensure that the navigation continuum extends beyond outreach and initial enrollment and includes post-enrollment activities, including referral to nonhealth social service resources, retention of coverage, and effective use of coverage (Morales, Vasquez, & Galloway-Gilliam, 2012). The Kaiser Commission study showed that those who stand to gain coverage have been accustomed to going without needed care, including preventive care, prescription drugs, care for chronic illnesses, and mental health services. As a result, this group reports suffering from physical and mental health conditions that interfere with their work and daily lives (Perry et al., 2012). Therefore, we can expect that newly enrolled adults will have great pent-up demand to address a myriad of unmet physical and mental health needs. They will need guidance on how to make effective use of their new coverage and linkage to community resources to ensure appropriate and timely use of health care services. The social work case management paradigm provides a clear road map for intervention.

ASSISTERS

In addition to the insurance exchange navigator programs, the ACA also provides grants to states to develop or expand consumer assistance programs. These somewhat lesser known programs, currently offered in 38 states plus the District of Columbia, support several important activities that can be successfully carried out by social workers. These activities include in-person case management, education, and referral. The one-on-one nature of the relationship may be especially appealing to social workers.

These assister programs share many features with navigator programs. Grantees help consumers enroll in and renew health insurance coverage by providing information, referral, and assistance; educating consumers about their rights and responsibilities; collecting, tracking, and

quantifying problems; and resolving problems. The requirement to capture data about problems gives social workers important information to use in their advocacy efforts to improve programs.

The ACA gives the assister programs more flexibility in determining both what type of organizations carry out assistance programs and the specific duties to be performed by assisters (Fish-Parcham, 2012). As suggested before in the context of navigators, CMS's CCIIO could facilitate having social workers play an explicit role in consumer assistance programs by issuing guidance about the appropriate role of social workers as assisters.

MORE RESEARCH DEMONSTRATING SOCIAL WORK'S ADDED VALUE IS NEEDED

What research we have suggests that there is strong potential for social work case management to help achieve success in meeting the important milestones of the ACA. Social work case management has been shown to improve a range of outcomes for a diverse array of populations (Adler, Lipkin, Cooper, Agolino, & Jones, 2009; Dzyacky, 1998; Ell et al., 2002; Gardner et al., 2005; Polinsky, Fred, & Ganz, 1991; Shannon, Wilber, & Allen, 2006; Vourlekis & Ell, 2007; Vourlekis & Greene, 1992), but the evidence to date does not present a definitive conclusion about social work case management's effectiveness in improving health outcomes or reducing costs (Boult, Rassen, Rassen, Moore, & Robison, 2000). The lack of a definitive conclusion, however, should not lead us to abandon the model but should instead stimulate further experimentation.

With an eye toward measuring social work's contribution toward reaching the ACA's third milestone of controlling costs, social workers ought to design studies that isolate the value added by social work case management services or social workers. This can be methodologically challenging because social work case management services are often part of a larger array of services that clients receive, and social workers are often part of interdisciplinary teams. Fortunately, there are instructive examples from the job training and employment literature (Lechner & Smith, 2007) that can serve as models for research design. We must be careful not to frame the question as "Who should provide case management?" because there is real potential for social workers to align with (rather than separate themselves from) community health workers (Spencer, Gunter, & Palmisano, 2010) and nurses (Dzyacky, 1998) to carry out case management in a way that is compatible with social work's knowledge, skills, and values.

Two new grant programs could be used to formally test the effectiveness of social work case management. The first is offered by the CMS's Center for Medicare and Medicaid Innovation. The second is the Patient-Centered Outcomes Research Institute (PCORI). PCORI is particularly well suited for testing social work interventions and recently funded a grant to study one often overlooked component of social work case management: patient advocacy (Lindberg, 2012).

With the coverage expansions set to go into effect in January 2014 and the goal of having navigator programs in place by October 1, 2013, social workers need to assert themselves into roles that can help to ensure the success of the ACA. This means that they must work now to set the stage to be recognized as future navigators and assisters.

doi: 10.1093/hsw/hlt003

REFERENCES

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Adler, A., Lipkin, C., Cooper, L., Agolino, M., & Jones, V. (2009). Effect of social work intervention on hospital discharge transition planning in a special needs population. Managed Care, 18(11), 50-53.

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Polinsky, M. L., Fred, C., & Ganz, P. A. (1991). Quantitative and qualitative assessment of a case management program for cancer patients. Health & Social Work, 16, 176-183.

Shannon, G. R., Wilber, K. H., & Allen, D. (2006). Reductions in costly healthcare services utilization findings from the care advocate program. Journal of the American Geriatrics Society, 54, 1102-1107.

Sommers, B., Kronick, R., Finegold, K., Po, R., Schwartz, K., & Glied, S. (2012). Understanding participation rates in Medicaid: Implications for the Affordable Care Act. Washington, DC: U.S. Department of Health & Human Services.

Spencer, M. S., Gunter, K. E., & Palmisano, G. (2010). Community health workers and their value to social work. Social Work, 55, 169-180.

Vargas, R. B., Ryan, G. W., Jackson, C. A., Rodriguez, R., & Freeman, H. P. (2008). Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer, 113, 426-433.

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Julie S. Darnell, PhD, is assistant professor, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Room 758, Chicago, IL, 60612; e-mail: jdarnell@uic. edu.

Original manuscript received January 28, 2013

Accepted January 30, 2013

Advance Access Publication May 5, 2013
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Title Annotation:VIEWPOINT
Author:Darnell, Julie S.
Publication:Health and Social Work
Article Type:Report
Geographic Code:1USA
Date:May 1, 2013
Words:2897
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