Please answer the following questions when creating your journal entry.  Feel free to use references, share links, media, pics, and other items that you feel would help your teammates.

• Do you belong to, or participate in interdisciplinary team meetings at your agency?  If so, what other professions make up your team (i.e.:  nurses, teachers, attorney, etc.)?  If you don’t have a team, what would a team look like at your agency (what other professions do your clients work with)?
• How can a social worker’s goals for care, differ from another profession’s goals (choose one from your agency/client)?  For example, how might a social worker’s goals differ from a nurse’s goals in patient care?
• How can the social worker work collectively and holistically with the team to provide continuity of care, rather than provide conflicting goals for the client?
• Discuss a time when you had to provide advocacy for a client.  Were you in-line with the team, or advocating against what the team wanted?  How did you include the client, to ensure you were voicing their needs?

Name:

Agency:

Name: Polly Smith

Agency: Seminole County Public Schools – Pine Crest Elementary

Client advocacy and teamwork are topics that my field supervisor and I talk about a LOT. In a school setting, there are so many different kinds of roles that we interact with, including: teachers, behavioral support staff, mental health counselors, guidance counselor, student support services coordinator, front desk admin, paraprofessionals, and parents/guardians. It takes a lot of effort to work collaboratively and foster healthy relationships, and I’m able to see how that effort pays off.

Due to my schedule, I’m not able to participate in these meetings, but the SSW (school social worker/my field supervisor) is the lead for truancy and she’s the one that runs attendance meetings. The SSW schedules these meetings strategically for the best chances that the parents/guardians will actually show up. I’ve seen interactions where other school staff wanted to schedule attendance meetings in one way, and the SSW advocated strongly for a different way of scheduling them so that it’s more convenient for the parents.

We communicate a lot with the front desk administrator, and I have a great appreciation for how important that relationship is for our students. The SSW has mentioned early on in my experience that the front desk staff sometimes get annoyed with her because of how much she advocates for the students and families, so she goes out of her way to help them out too. One time, a parent stopped by the school to do a couple things. The SSW and I were helping the parent, and as part of that we asked the front desk staff and one other school admin to provide us with some information right then. When we debriefed, I learned that the urgency was that this parent rarely shows up and is dealing with a potential truancy case, so the SSW wanted to jump on the opportunity to help the parent out.

The other week, I took a risk to advocate for a client and I think it paid off. We had a student that we met with individually to provide support after he had witnessed a violent incident the day before. As the SSW was talking, I could tell that the boy might have wanted to cry, or hug, or do something other than sit and listen. The SSW got a phone call, so when she stepped away I got up and brought the boy and I each a stress ball and walked him through a breathing exercise. He was so sweet and said thank you in the most genuine way, it melted my heart. A bit later on, I still felt like I needed to step in and advocate for this boy. I did so by asking a “hypothetical” question- “If a student has some big emotions and they want to ask for a hug or have a cry, can they ask one of us or their teacher?” I felt uncomfortable and like I was possibly overstepping my bounds, but I would rather take that risk than not. Because of my advocacy, we were able to help this client implement some tools (like having a stress ball in class and bringing a stuffed animal home for comfort) that we would not have done otherwise.

The SSW and I spend a lot of our supervision time talking about advocacy, so I’m grateful to be learning from her and witnessing examples of how she advocates for the students. This may not be relevant for everyone else, but I’ll share a YouTube video for another school social worker that talks about how SSWs can support teachers and staff. If we want a good relationship with others, we have to give as much as we take! That way we are helping one another and ultimately supporting our students. https://www.youtube.com/watch?v=dzn8sVAlY9o&ab_channel=SocialWorkScrapbook

Lauren Frank (Team 1): Hey Polly! I was wondering is it difficult to coordinate meetings with all of the different departments and groups that are included? Especially with everyone’s busy schedule, I would assume it would be hard to find a time that works for everyone.

Oh my gosh it is SO DIFFICULT to coordinate meetings! I think a lot of meetings with school staff and parents are held between 8am and 8:30am or for half an hour after school gets out. That’s generally the only time the school staff are able to meet, but it doesn’t always work out for parents. Thanks so much for asking, you always ask the most thoughtful questions! -Polly

Name: Elizabeth Prophete

Agency: Orlando Health REACH

• Currently at my agency, I do not belong to, or participate in interdisciplinary team meetings at your agency. Unfortunately, the SW’s at REACH do not interact a lot with the inpatient SW’s. I have heard from some REACH staff say things such as “inpatient and outpatient do not interact well as inpatient may feel that outpatient is unnecessary”. I remember when I was shadowing one of the staff members and we went to visit a patient at bedside. I noticed that the one I was shadowing was not interacting and or saying hello to the other staff (nurses or doctors) that were on the floor. I asked why, and she stated that she has not seen the other staff do that and the nurses are busy as well as those inpatient social workers. I then continued to tell her that she should still say hello, because at the end of the day, we are a team. If we are not able to get a hold of a patient, we can always speak to our fellow inpatient teammates to relay the information to the patient for us. Although I am not part of the interdisciplinary team in the hospital, I do believe that it would make up of the nurses, inpatient SW’s, doctors and any other medical staff working with that patient. Those are the ones who work with the patients as well as medical specialist for certain patients. Working in child investigations, we hold interdisciplinary and MDT staffing’s (multi-disciplinary team)quite frequently. Our MDT’s are specific to whom is running it. For example, if we have a medical neglect case, that MTD would consist of the investigators and the staff from the child advocacy center. When it comes to removing a child and placing them into care, that MDT consist of the child protection team, law enforcement, the parents, the caregivers, case management, guardian ad litem as well as the school liaison. I feel that having MDT staffing’s as well as interdisciplinary team staffing’s really helps everyone who is involved in a particular case get in the same page and or have an understanding as to what the other team members are doing. This helps with setting and accomplishing goals. 

• As a REACH SW, our goals are similar yet different for inpatient social workers. Inpatient and outpatient both work with the patients and provide resources for them that will better suite their needs. What I see differently and have been told, is that while REACH SW’s work with patients who are at times still admitted in the hospital, they also work with clients who have been discharged and they continue to work with them 4/5 weeks after discharge. Inpatient on the other hand have goals to discharge the patients successfully out of the hospital withing a certain time frame.

• When it comes to a social worker working collectively and holistically with the team to provide continuity of care, rather than provide conflicting goals for the client. The one and only thing that I feel is most important is communication. Communication with one another as well as with the clients that they are serving. While communicating, making sure that the focus is on the client what is in tehri best interest. 

• While working as a Dependency Case Manager, one of my sole jobs was advocating for the families I worked with. I had one particular case where a couple children were removed from their parents due to domestic violence. The incident was so egregious, that although the mother was the victim of domestic violence, she too had her children removed from her. That mother and father were both given separate case plans. The mother faithfully worked on her case plan, to the point case management felt as if she could be starting the reunification process with her children. Of course, guardian ad litem did not agree. This lead to a hearing in the presence of the judge. I am happy to say that I advocated for the mother so well, that the judge ruled it in my favor to have the mother start the reunification process as soon as possible while the mother continued to complete her case plan. In the end, she did gain full custody of her children.

Polly – I like how you took that risk to advocate for the student. I don’t think you were overstepping at all. I honestly think that was a learning experience for you and by asking, you learned what can be done. 

I wanted to share this video with you guys. Yes, we need to advocate for others, but most importantly, we need to advocate for ourselves….

The Secret to Self-Advocacy | Bhavana Bartholf | TEDxWaterStreet – YouTube

Lauren Frank (Team 1): Elizabeth! I loved the youtube video! Super helpful and thank you for sharing!

Elizabeth- That’s so interesting to hear your experience in the hospital. I have the impression that hospitals aren’t really collaborative in the way that I’d expect. It’s good to have your fresh perspective to ask those important questions! And wow what a great story about advocating for your client so that she could have custody of her kids again. In my experience, advocacy is sometimes hard when it feels like we’re going against the norm, but it’s always worth it! -Polly

Name Alicia Henry

Agency: Orlando Health: Heatlh Central Hospital

I work as an inpatient SW at my agency. I engage in MDS (Multidisciplinary Staffing), which occurs every morning at 10 a.m. and again at 1:30 p.m. The goal of this staffing is to allow all parties involved in the patient’s care to work alongside one another on the best plan of action for the patient’s care. The SW’s job at these meetings is to identify a safe discharge for the patient, ensuring that all of their needs are met before discharge. The team consists of doctors, nurses, social workers, case managers, physical and occupational therapist, the financial officer, and feedback from the patient and family. I appreciate that Orlando Health gives patients and family members a say in their treatment plan and discharge planning decisions.

As an inpatient social worker, you must be familiar with the various insurance plans and what they cover. As an inpatient social worker, you must also be up to date on any changes to regulations and procedures that may have an impact on transportation, medical equipment, and service providers. The discharge plan is determined by the patient’s insurance coverage. Other involved parties’ goals may differ from those of the social worker, who is educated about what the patient qualifies for based on their insurance plan.

When it comes to continuity of care, the social worker is crucial since they are able to inform patients, family members, and other relevant parties about the discharge planning process. I recall a doctor at an MDS wanting to discharge a dialysis patient who had been medically cleared. The SW intervened and informed the doctor that the patient’s insurance does not cover outpatient dialysis and that the patient would need to stay in the hospital or have an order for the patient to return to the hospital for treatment until a plan for continuous outpatient dialysis treatment could be established.

I was recently doing a patient assessment for discharge planning. The patient was told by the doctor that he would be leaving today, which greatly devastated him and his wife. The patient was not happy that the necessary medical equipment would not be delivered until the following day. The patient required a bedside commode and a bariatric walker. The doctor informed the patient that his wife should be able to assist him until the medical equipment arrived. The patient was a large man, and his wife was a small lady. There was no way that his wife could assist him. I contacted my supervisor and informed her of the situation. I suggested that the discharge be delayed until the necessary equipment was delivered in order to ensure a safe discharge. My supervisor agreed. I called the doctor and informed him of my concerns regarding the unsafe discharge. Despite his reservations, he delayed discharge until it was established when the medical equipment would be delivered.

I have to say that the team at Health Central works really well together, with a shared goal of doing what is best for the patients.

Working in the Healthcare Industry has opened my eyes to how our healthcare is dictated by insurance companies. It is so important for us to understand how this process works. I have attached a video that explains the process. 

Polly- You shared this with me in class. I applaud you for not just advocating for him, but also reading his body language and recognizing what he needed at the time.

Elizabeth- thank you for sharing this video. I found it to be quite self-reflective. I used to feel uncomfortable standing up for myself because I didn’t want to be known as the angry black woman. I’ve come to realize that I have to speak up and stand up for myself regardless of stigmas or prejudices.

Alicia- Thank you for sharing that video, it was very helpful! I still find it so wild that patients’ care and discharge is based on their insurance coverage. It must be hard caring for patients when you’re at the will of insurance companies. That makes advocating for clients even more important! -Polly