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Identifying Client Goals and Barriers

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An Interview with our Medical Social Worker, Kristy Gerschefske. Visit our teams screen to read more about her.


1. Question: What do you do in your role as Medical Social Worker at PCIC?
Answer: In my role as Medical Social Worker, I wear several hats! There is my “case management hat” where I directly help clients to identify their health and personal goals and then begin to work towards them. This often includes connecting to community resources, helping to obtain appropriate physical and mental health providers, and providing the connection between home and the clinic. In combination with my wonderful case manager, Andy, and Nurse Practitioner, Janick, we do home visits, clinic visits, hospital visits, and connect with clients over the phone. While wearing my case management hat, I am often seen as an advocate, a listener, and/or a problem-solver. My ultimate goal is always to empower my clients to be able to do what I do for themselves. I always say that I am really trying to “work myself out of a job”!
2. Question: What goals and or approach do you employ with clients?
Answer: My approach is always to “start where the client is at”…a pretty basic social work concept, but one that is important to ensure accurate communication on all sides. It is also important to not make assumptions about client needs or desired outcomes as sometimes what “I” think is best, may not be what the client wants. Ultimately the client is the one that drives our intervention and what goals we want to accomplish.
3. Question: In working with High-Need, High-Cost clients, what are some of the INDIVIDUAL barriers you see, and how are they identified?
Answer: Many of our clients face individual barriers such as lack of transportation, low income levels, difficulty understanding how to navigate the health care system, and difficulty with medication compliance/not understanding their medications, to name a few. Many times these individual barriers are part of larger systemic barriers, but oftentimes, there is education PCIC can provide to aid clients in overcoming their piece of the puzzle. These barriers are identified through the use of our Values Tool which aids PCIC in identifying client values and then understanding what gets in the way of clients being able to live their life as they would like.
4. Question: In working with High-Need, High-Cost clients, what are some of the SYSTEM barriers you see, and how are they identified?
Answer: System barriers include an intricate health care system that is inherently difficult to navigate: long wait times for appointments, difficulty accessing/finding reputable providers, minimal education on physical and mental health diagnoses and what they mean, and a paternalistic and fragmented health care system. Other systemic barriers include access to public transportation, and a complicated SSI/SSDI process. They are also identified through the use of our Values Tool.
5. Question: Are there specific tools or strategies you utilize to overcome these barriers?
Answer: Some of these barriers are easier to overcome than others. For example, with medication adherence, we often aid clients in beginning to utilize a pill box. We have found that by using stickers to color code and provide texture for each day of the week can be very helpful in maintaining medication compliance. We try to tailor the stickers to things the client enjoys. An example of this is a pill box where we used color-coded flipflops to designate days of the week and sheep stickers to designate night from morning medications. On Mondays, a blue flipflop was placed on both the morning and evening medication slots and then a sheep added to the evening slot. This can trigger a client to remember “oh, I took the blue flipflop this morning, so now I take the blue flipflop before I go to bed”. Being creative and thinking outside the box is often the best way to overcome barriers!
6. Question: Are there barriers that can’t be overcome?
Answer: Many of the systemic issues within the health care system are very difficult to overcome. In these cases, we work with clients to become better advocates for themselves in order to obtain the outcomes they are desiring.
7. Question: What are your hopes regarding High-Need, High-Cost patients from a community perspective?
Answer: My hope is that ultimately the system begins to collaborate and communicate on a more integrative level in order to provide the care that these clients need. They are often high utilizers because they have many co-morbid conditions and are difficult to treat. Rather than providers looking at their history and becoming overwhelmed, my hope is that they begin to embrace these clients to gain a greater understanding as to the root causes of how they got to the place they are in and then be able to work with other community members to provide wraparound supports, beginning to truly integrate health care and the Social Determinants of Health (SDOH).
Last modified on Monday, 13 November 2017 23:17

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