Reflect on how medical social workers can impact social justice

Reflect on how medical social workers can impact social justice in healthcare. What factors do medical social workers need to consider to promote just experiences for their patients? Use an example from one of the case studies you examined previously in the course to support your perspective. What does anti oppressive practice look like in a system that is highly regulated and prescriptive? Use another example from case studies you examined previously in the course to support your perspective. How do you plan to apply your knowledge and skills to better serve vulnerable populations in your future work? What additional skills, knowledge, or resources do you need to achieve these goals? Description of the case and definition of client 1 Junior was a consumer in the IHSP and had been receiving home-delivered meals with occasional housekeeping services and occasional financial assistance with past due bills for three years. I met Junior prior to becoming his case manager and I supervised his previous case manager, so I was very familiar with his situation, having met him and reviewed his case file several times. I became his case manager when I was the Senior Supervisor of CIP’s Social Services Department. I supervised the six IHSP social workers, a supervisor for another program, and the social services department secretary. I reported directly to the Associate Director of Social Services and Housing who focused primarily on macro level social service and housing issues and center operations. This allowed me to oversee most of the general day-to-day department affairs. I had a small caseload of consumers who had complex issues that needed specialized attention, intensive case management, and multi-system coordination. At that time, Junior was a 72-year-old homebound African American man who suffered from non-insulin dependent diabetes (NIDDM), hypertension, mild short-term memory loss, arthritis, allergies, and lower extremity edema which was a direct result of congestive heart failure (CHF). He misused alcohol and identified himself as an alcoholic who had been in recovery for many years; he also smoked cigarettes. During our time together, he admitted that he also battled a crack addiction and, until recently, had been actively smoking it as he had done for years. Junior received Social Security income and lived by himself in a senior housing complex. His apartment was in a HUD 202 building which meant his rent would never exceed 30% of his income and most of his utilities were included. He was a retired sanitation worker and had been forced to leave his job due to a leg injury he sustained while working. Family was vitally important to Junior. He maintained contact with several family members. His older brother, Thomas, was in his eighties, wheelchair bound, and lived in a nursing home. Junior and Thomas spoke on the telephone daily and, until Thomas had several toes amputated due to complications from diabetes, he would stay with Junior on the weekends. Junior and Thomas had an older sister, Thelma, with whom Junior was also close. They spoke regularly and Junior was also in regular contact with some of her children, namely her son, John. Junior had been divorced for many years and his ex-wife died sometime after their divorce. He had five children but was only in contact with one of them. He had two children with his wife and three children from an extramarital affair. He had been close to his only son, but that son died of a drug overdose two years prior to my work with Junior. One of his daughters, Sandra, was the only one of his children with whom he kept in touch. He spoke to her regularly but had only been doing so for the past two or three years. She lived out of state, visited him monthly, and had often asked Junior to move in with her and her family so that she could better assist him with meal preparation, laundry, and other ADLs that were difficult for him. Junior continually declined her offer, preferring to maintain his independence. While she was willing to take him in to her home to provide for his needs, Sandra was unable to provide consistent support in his home due to the distance and her work and childcare responsibilities. Approximately 60% of caregivers are employed in the paid workforce: when they request reduced working hours, or “leave” time to accompany care recipients to doctors’ appointments, provide transportation, make arrangements with paid caregivers, or deal with emergencies, this can lead to hostile treatment by their employers (Wang & Wu, 2018). Sandra and John argued most about making sure he went to medical appointments. Junior needed this encouragement along with the emotional support and socialization that accompanied the visits. That said, Junior’s basic needs were not being met satisfactorily and this necessitated his referral to our program. During my work with Junior, I spoke with Sandra several times on the telephone and worked closely with his nephew, John. They were satisfied with the services Junior received from the IHSP and were grateful for any assistance we could provide. Both Sandra and John regularly confided in me about their frustrations with Junior. He was a proud man who relished his independence and was reluctant to accept help from anyone. Junior and I developed a strong bond and had an excellent rapport. His faith in me and trust in our relationship made it possible for me to have a significant impact on Junior’s life; I was able to convince him to make positive changes where his family and doctors had previously been unsuccessful. It is, of course, possible to work with a client without establishing rapport. But the hallmarks of a truly effective and successful working relationship are trust, mutual respect, and empathy. A client should feel understood, supported, respected, and should feel that the social worker is sensitive to their issues, understands their situation, and is willing to invest in them and work with them to establish and meet their identified goals. Nevertheless, certain natural barriers exist in the client-social worker relationship that must be overcome in order to establish good rapport with a client and these barriers were initially present for Junior and me as well. Junior was an older African American man, and I was a white woman who was young enough to be his grandchild. To be successful in working with special populations it is incumbent upon a social worker to learn about the history, cultures, values, and norms of the population. In order to work effectively with African American older adults, it is necessary to have an understanding of and sensitivity to the effects of oppression, discrimination, the impact of the Civil Rights Movement and what preexisted it. It is also important to recognize the role of family, family dynamics, and the importance of kinship; religiosity, an affiliation with a particular house of worship and congregation if one exists, and the pastoral relationship; and the health disparities, both physical and mental health, that exist for African American older adults, particularly men. All of these circumstances impact a client’s life and affect their decision-making processes. The other key to establishing a positive relationship with a consumer is authenticity and, with a sincere desire to help, a social worker can overcome almost any barrier. Junior trusted me because he knew I was invested in his health and well-being, that I believed he could overcome his challenges, and that I would do whatever I could to help him. We worked together, and our partnership was equal and friendly: we discussed things of mutual interest to us, like sports and music, and my use of self-disclosure helped him to feel less like a client and more like a partner. My role as Junior’s advocate was another central part of our work together and my advocacy efforts on his behalf helped to strengthen the trust in our relationship. Advocacy is, of course, a basic tenet of social work. In Junior’s case, I often advocated for him: with doctors, family members, institutions, and even within the IHSP. Although Junior often made poor decisions and neglected his own health and environment, he was competent to make those choices. I agreed with his family and doctors that Junior would be better off, and perhaps even thrive, in a more structured environment, such as living with his daughter, where someone could prompt him to take his medicine, eat properly, attend to hygiene and other issues he sometimes neglected. But the key point to be understood is that, just because a client makes a bad decision, it doesn’t mean they lack the capacity to make a “good” one. Even though the decisions he made often had deleterious effects on other aspects of his life and were, at times, in direct conflict with his overall objectives and goal, Junior had the right to choose how he wanted to live. I believed it very much my role to advocate for his right to do just that. Though I did not agree with some of the decisions he made, it was important for me to respect his right to make them and to defend that right whenever it was threatened. I also strongly felt it was my responsibility to point out to Junior when his decisions conflicted with his objectives and how they jeopardized his ability to live independently. I used his trust in me and respect for my position to try to convince him to make better choices. Goals, objectives, outcome measures, and contracting The goal that was most important to Junior was maintaining his independence. All the objectives that were set forth by his family, physicians, and me needed to adhere to this goal. My goal as his social worker, however, was conditional in that, while I tried to help Junior to maintain his independence in the community, I could only continue to do so if it was safe for him to live independently. When a client’s safety and well-being conflict with their stated goals, it is my role to help them to see the necessity to reframe or change their goals based on their current circumstances. This was true of my work with Junior and, as his health and circumstances deteriorated, it was necessary to amend his goal. All of the consumer’s goals and objectives are logged on a Service Plan form and both the consumer and Case Manager sign the form. Junior’s other stated goals were to stay in the IHSP and retain me as his case manager. As is often the case, clients whose cases are open for a long period of time inevitably work with several case managers as there is often turn-over in entry level positions. Junior worked with three IHSP case managers prior to our work together. I was careful to make sure Junior understood the parameters of the IHSP and that he knew that he would be in the program as long as he continued to be eligible. I assured him that, if his circumstances necessitated his transfer to another program, I would maintain our relationship and would always do whatever I could to advocate for him and assist him in any way possible. My response to this latter goal showed not only a disregard, but a lack of understanding, of the importance of proper disengagement at the end of the client relationship. At the time, however, I justified this response with two reasons: first, I was not only Junior’s case manager, I was also the supervisor for the program and, as such, frankly speaking, I had more latitude. The other reason showed both my humanity and need for continued training: I felt genuine feelings of friendship toward Junior and wanted to do whatever I could for him, whether inside or outside the confines of the program. Various objectives were established and addressed in the years Junior had an active IHSP case at CIP. The main objectives were to keep his apartment clean, better maintain his health, ensure he received proper nutrition, and make sure his bills were paid in a timely fashion. All these objectives, if met, would ensure the achievement of his goal to maintain his independence. Many significant crises and challenges presented themselves as critical barriers that stood between Junior and his goal and objectives. Each time a crisis arose that would threaten the achievement and maintenance of his primary goal, he and I would contract, though only verbally, and assign specific tasks and responsibilities to get back on track. For example, I would agree to negotiate a payment arrangement for a past due bill and he would agree to make a doctor’s appointment. This was done on an “as needed” basis. In the time his case was active, Junior was able meet many objectives that in turn helped him to meet this overall goal. When we first opened his case, we ordered home-delivered meals because he was unable to cook for himself. We purchased furniture for his apartment because he was sleeping on a mattress on the floor and had only milk crates to sit on, and one time, when he had been mugged while walking to purchase money orders, we paid his rent and utilities using the Discretionary Fund. Junior’s health and functional ability began to deteriorate and his ability to remain safely in the community was in question. Junior often visited me in the office, which certainly would have jeopardized his eligibility for the IHSP had his case been reviewed by PCA. On one particular day, Junior arrived nearly breathless, his vision was blurry, and his legs were swollen such that he could not get his socks on and had to leave his shoes untied. He told me that he had two doctor’s appointments on this day (cardiologist and optometrist). He walked several blocks after taking the bus to ask my opinion about which appointment he should keep. Junior was reluctant to go to the cardiologist because he was worried he would be admitted to the hospital. He was adamant that he did not want to be admitted and had signed himself out against medical advice (AMA) on previous occasions. Furthermore, Junior was afraid that, if he was admitted, he would be forced to go into a nursing home. Junior had been told by doctors during previous hospital stays that they were concerned about his capacity to make decisions and that they felt he was unable to continue living on his own. His nephew, John, threatened to “put him away” in a nursing home. I was able to convince Junior to go to the cardiologist but had to promise that I would advocate for him, should anyone call his competency into question. Afraid that he was too ill to make it to his appointment independently, I drove him to the cardiologist and informed them of his current state, noting that I was afraid he had CHF. The doctor determined that Junior was in severe congestive heart failure. He was not, however, admitted to the hospital and was sent home with a very complicated regimen of medications, mostly diuretics. Given his state when he arrived at the cardiologist, his complex medical conditions and new diagnosis, I was incredulous that he was not admitted. When he arrived home, he called and said that he could not read the medication bottles he was given because his vision was still very blurry, likely a sign that his blood sugar was unstable. I contacted a colleague, Carla, who was a Community Liaison from the VNA, for consultation, support, and to try to get an emergency home care visit to assist him in setting up his medications. Carla agreed with me that Junior should have been admitted and contacted the cardiologist to get an order for home care so that she could go to Junior’s home, check his vitals, and set up his medications. The cardiologist refused to approve the order, stating that she “went against her better judgment by allowing him to leave and not admitting him.” The doctor said that Junior needed to be in the hospital, and she advised that he go to the emergency room. In over 15 years as a home visiting nurse, Carla reported that this was the first time she had ever experienced a doctor refusing to approve home care. I attempted to convince Junior to go the emergency room and, given the urgency, advised that he take an ambulance. He refused, wanting to protect his privacy, and not wanting the people who lived in the building to think he was frail. Carla and I both tried unsuccessfully to reach Junior’s primary care physician to approve the home care. Junior was not speaking to his nephew John and would not give me permission to call him, vaguely mentioning that they were having “problems.” His daughter was also unavailable. I called Junior’s neighbor, Ernestine, and asked her to read me the medication bottles and I instructed her as to which pills to give him immediately and which pills to set out on the counter for the evening. Junior said he felt okay and promised he would call 911 if needed. Ernestine promised she would look in on him. When I called him the next day, there was a woman yelling in the background. When I asked him who it was, he indicated that it was “the woman who cleans the apartment” and that she wanted money and drugs. I told Junior to tell her to leave, he did, and I could hear her refuse. I told him I was on my way to the apartment. I don’t know what I thought I was going to do when I got there, but she left before I had to find out. When I arrived, Junior and I talked about his deteriorating health and need for immediate medical treatment. I spoke candidly to him and told him that if he did not go to the hospital, he may die. He agreed to go, but only if I took him. On our ride to the emergency room, he confessed to me that he smoked crack and that his nephew, John, was the person who gave it to him. John allegedly gave crack to both Junior and “the woman who cleaned the apartment” so that she would “look after” him. We spent the entire day in the emergency room, and he was admitted. After his stay in the hospital, Junior required oxygen and a higher level of care than could be provided by the IHSP. I facilitated his transfer to a long-term care program through PCA. I continued to work with Junior and his new social worker informally and, shortly after his transfer, it became clear that Junior was no longer able to live safely on his own. I discussed nursing home placement with him, and he agreed to enter a facility, provided he could be with his brother, Thomas. Description of the case and definition of client 2 Phyllis Robinson (a pseudonym) was a 78-year-old Black female who was born and raised in a middle-class, Christian family in New York City. She was a retired educator with a master’s degree in educational leadership who spent her career teaching at an independent day school in the city. She maintained a home in NY but was visiting her daughter in Delaware for the Thanksgiving holiday when she experienced shortness of breath and shooting pain around her rib cage. Her daughter Janice rushed her to the hospital emergency department where a comprehensive workup revealed metastatic cancer of unknown primary origin with evident lung lesions. When her mother had arrived for the holiday visit, Janice noticed that Phyllis seemed thinner and weaker, however she attributed this to the isolation and resultant depression imposed by COVID-19 lockdowns. Phyllis was admitted to the hospital for management of dyspnea (shortness of breath) and further workup, and ultimately was given a terminal prognosis of “days to weeks” and referred to the hospital’s inpatient hospice center for ongoing symptom stabilization. Phyllis had divorced Janice’s father when their daughter was in junior high school. Phyllis had remained single since then which suited her fiercely independent personality. Janice had been born into a lineage of family caregivers and watched as Phyllis cared for her own mother at the end of life. Having grown up with this experience helped Janice to embrace being both a daughter and a caregiver, though not without some hesitation. One major source of anxiety for Janice was the heavy responsibility of healthcare decision-making for her mother during times when Phyllis was too consumed by pain or foggy from dyspnea. Under Title 16 of the Delaware Code, important healthcare decisions default to a surrogate decision maker when a patient is deemed to lack capacity. Prior to this hospitalization, Phyllis had not discussed her care wishes with her daughter and had not completed an advanced healthcare directive. Thus, Janice was forced to make important decisions in a crisis situation which added to her apprehension. Upon learning about the hospice inpatient unit and feeling overwhelmed by the enormity of responsibility heaped upon her, Janice consented to having her mother admitted into the care of the hospice agency. This was the family’s first experience with hospice care and the fact that Phyllis was being transferred to an inpatient unit reinforced the misconception that hospice care is only delivered in a placed-based setting. Given all of the other information Janice was trying to wrap her mind around, she did not immediately understand that her mother might have to be discharged home at some point with home-based hospice care. A clinical liaison from the team informed Janice that the IPU was for “short-term symptom management” only, but she still did not realize what this meant. Janice thought of hospice as a place you go to die, and she had just signed her mother “into a hospice.” This decision also created a sense of guilt as she felt she was going against her fundamental values by turning her mother’s care over to a group of strangers. To be admitted to the hospice IPU, a patient must agree to “being a DNR,” (i.e., they must agree to a physician order instructing that if the patient’s heart stops, they do not desire resuscitation, and CPR will not be administered). Phyllis and Janice felt pressured to make this decision in the midst of adjusting to the recent terminal prognosis. Phyllis was faced with two choices: leave from the hospital with little support because there was “nothing more that could be done,” or approve admission to the hospice IPU for short-term symptom management and stabilization. Goals The primary goal of hospice is to provide each patient with their conception of a good death experience. Collectively, we hoped to support Phyllis’ autonomy to define a good death for herself, then to collaborate with the interdisciplinary team to help curate a plan of care that met with her definition. This “goals of care” conversation is usually facilitated by the HSW, and it centers each patient’s identity and helps them bridge the divide between who they were and who they can still be. Together, we considered Phyllis’ life experiences, skepticism about the healthcare system, and the multiple losses she had faced throughout her life. We explored what she understood about her prognosis and the implications of that prognosis on her care needs for the remainder of her life. Phyllis desperately longed to return home to New York. However, the acuity of her medical needs coupled with her extreme weakness and increasing disorientation rendered this impossible since she did not have a stable caregiving system in New York. With all her assumptions shattered, we collaborated with Phyllis and Janice to build a new hope for compassionate care and support during this time of agonizing loss.

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