Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: http://www.tandfonline.com/loi/wshc20

Self-reported patient psychosocial needs in integrated primary health care: A role for social work in interdisciplinary teams Shelley Craig Ph.D., Rachel Frankford MSW, Kate Allan MSW, Charmaine Williams Ph.D., Celia Schwartz MSW, Andrea Yaworski MSW, Gwen Janz MD & Sara Malek-Saniee MSW To cite this article: Shelley Craig Ph.D., Rachel Frankford MSW, Kate Allan MSW, Charmaine Williams Ph.D., Celia Schwartz MSW, Andrea Yaworski MSW, Gwen Janz MD & Sara MalekSaniee MSW (2016) Self-reported patient psychosocial needs in integrated primary health care: A role for social work in interdisciplinary teams, Social Work in Health Care, 55:1, 41-60, DOI: 10.1080/00981389.2015.1085483 To link to this article: http://dx.doi.org/10.1080/00981389.2015.1085483

Published online: 04 Jan 2016.

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Date: 15 March 2016, At: 02:41

SOCIAL WORK IN HEALTH CARE 2016, VOL. 55, NO. 1, 41–60 http://dx.doi.org/10.1080/00981389.2015.1085483

Self-reported patient psychosocial needs in integrated primary health care: A role for social work in interdisciplinary teams

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Shelley Craig, Ph.D.a, Rachel Frankford, MSWb, Kate Allan, MSWa, Charmaine Williams, Ph.D.a, Celia Schwartz, MSWb, Andrea Yaworski, MSWa, Gwen Janz, MDb, and Sara Malek-Saniee, MSWa a Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; bSt. Michael’s Hospital, Toronto, Ontario, Canada

ABSTRACT

ARTICLE HISTORY

Despite being identified as significant determinants of health, depression and anxiety continue to be underdiagnosed and undertreated in primary care settings. This study examined the psychosocial health needs of patients at four urban interdisciplinary primary health teams. Quantitative analysis revealed that nearly 80% of patients reported anxiety and/or depression. Self-reported anxiety and depression was correlated with poor social relationships, compromised health status and underdeveloped problem-solving skills. These findings suggest that social workers have a vital role to play within interdisciplinary primary health teams in the amelioration of factors associated with anxiety and depression.

Received January 30, 2015 Accepted August 18, 2015 KEYWORDS

Health social work; interdisciplinary teams; mental health; patient care; primary care

Patients of interdisciplinary primary health care teams encounter psychosocial challenges. Globally, between 25–90% of primary care patients have unrecognized mental health symptoms (World Health Organization, 2008). When patients seek physician guidance for physical ailments, their psychosocial difficulties often go unreported or undetected (Craig & Boardman, 2007). Even when diagnosed, only between one and 40% of patients receive adequate mental health treatment in primary care settings (World Health Organization, 2008). As members of interdisciplinary primary health teams, social workers have the potential to detect and ameliorate psychosocial and mental health symptoms in primary care. This study develops and extends knowledge about the psychosocial needs of primary care patients and the role of social work in addressing patient needs. To that end, this article reviews critical factors in addressing mental health in primary care and the importance of interdisciplinary teams and patient self-reports in the provision of integrated care.

Shelley Craig [email protected] Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1V4. © 2016 Taylor & Francis

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Mental health in primary care Over 80% of patients seen by a family doctor experience emotional and social difficulties, in addition to physical health ailments (Bikson, McGuire, Blue-Howells, & Seldin-Sommer, 2009). Mental health comorbidities such as depression and anxiety along with chronic medical conditions such as hypertension, cardiac disease or diabetes (Ai, Rollman, & Berger, 2010; Culpepper, 2002) contribute to significantly more patient somatic complaints and impairment compared to chronic conditions without comorbid mental health symptoms (Katon et al., 2005; Parker, Wilson, Vandenberg, DeJoy, & Orpinas, 2009). Further, anxiety and depression increase awareness of physical symptoms (Waghorn, 2009). Depression puts people with physical health problems at risk for poor self-management and treatment non-adherence, poor quality of life, mortality, somatic and disability-related problems (De Ridder, Geenen, Kuijer, & Van Middendorp, 2008; Waghorn, 2009). For instance, elevated depressive symptoms have been linked to poor diabetes management (Culpepper, 2002) and heightened risk of stroke (Nishiyama et al., 2010). The presence of an anxiety disorder significantly predicted “cardiac disorders, gastrointestinal problems, genitourinary disorders, and migraine” (Harter, Conway, & Merikanges, 2003, p.317). Such comorbidities can complicate the delivery of health care. Vasiliadis, Tempier, Lesage, and Kates (2009) found that 30% of all patients had to make two visits, to both a family physician and another health care provider for psychological concerns. When questioned about the multiple visits, patients reported chronic physical illnesses, poor mental health, and “decreased ability to handle daily demands” (p. 470) were contributors to their poor health.

Social support, relationships, and mental health The relationship between mental and physical health can be impacted by interpersonal relationships and stressors in work and home domains. Social support protects against depression, especially for women (Uebelacker et al., 2013). In a British survey, Pevalin and Goldberg (2003) found that mental health deteriorated in the face of social deficits such as the death of a spouse, and low levels of social support protracted the recovery process. Low social support increased anxious affect among female cancer patients (Hipkins, Whitworth, Tarrier, & Jayson, 2004) and among breast cancer patients specifically, a reduction in social support was an independent risk factor for depression post diagnosis (Hill et al., 2011). Li, Morrow-Howell, Proctor, and Rubin (2013) explain that the presence of good quality social support can enable recovery from depression among the elderly population. Receiving support from positive relationships at work is linked to less clinical depression (Blackmore et al., 2007), and improved overall self-rated health (Falkenberg, Nyfjäll, Hellgren, & Vingård, 2012) beyond the impact of

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having a paid job (van Woerden, Poortinga, Bronstering, Garrib, & Hegazi, 2011). Working in stressful environments characterized by high psychological demands (e.g., workload pressures) may lead to symptoms of fatigue, difficulty sleeping, poor concentration, and distress (Watson, Gardiner, Hogston, Gibson, & Stimpson, 2009) and might result in an inability to maintain strong social networks (Berkman & Glass, 2000; Melchior et al., 2007). Those reporting high levels of work stress, particularly with diminished social support were 75% or 80% more likely to develop a mood or anxiety disorder respectively, even in the absence of previous mental illness history (Melchior et al., 2007). Mental health and interdisciplinary teams in primary care Given the increased stress on both the health care system and patients (American Psychological Association, 2014) caused by fee structures that shorten appointments that would otherwise allow for thorough assessment of patients’ mental health issues and referral to necessary services (Vagholkar, Hare, Hasan, Zwar, & Perkins, 2006); increased utilization of allied health professionals within interprofessional teams has been recommended for effective disease management (Rosser, Colwill, Kasperski, & Wilson, 2011). This approach has also been credited with saving health care dollars (Bonadonna, 2003; Hemmings, 2000; Rothman & Wagner, 2003). For the past decade, interdisciplinary teams have promoted holistic patient-centered care within many urban primary care settings (Wynn & Moore, 2012). Team members include physicians, social workers, nurse practitioners, pharmacists, and dieticians that together provide comprehensive care to patients (Moulding et al., 2009; Oandasan et al., 2009; Wynn & Moore, 2012). These teams of health care professionals work together in a single physical location or through a hub to ensure that patients receive the care they need while in their own communities (Ministry of Health and Long Term Care, 2012). Compared to traditional primary care, interdisciplinary primary health teams result in better outcomes for patients with complex medical issues (Health Force Ontario, 2013) due to the integration of multiple professional perspectives and influences on health (Conference Board of Canada; 2014). Social workers in primary care

Utilizing allied health professionals, such as social workers, within primary health care teams allows for the exploration, assessment and support of a patient’s psychological, social, and medical needs, as social workers are trained to address the various facets of a patient’s life that impact health (Ayalon et al., 2008; Loveland Cook, Freedman, Freedman, Arick, & Miller, 1996; Bikson, McGuire, Blue-Howells, & Seldin-Sommer, 2009; Schneider, Hyer, & Luptak, 2000). There is growing evidence that the treatment of mental health concerns

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in physically ill populations improves coping abilities, psychological distress and disability-related limitations (Waghorn, 2009), and positively impacts adjustment to illness (De Ridder, Geenen, Kuijer, & Middendorp, 2008). Vagholkar et al. (2006) found that the integration of mental health services in primary health care reduced patient distress following treatment. Including social work services within primary health care settings through interdisciplinary teams allows for patients’ psychosocial issues to be addressed within a holistic team approach (Craig, Betancourt, & Muskat, 2015; Conference Board of Canada, 2014; Stanhope, Videka,, Thorning, & McKay, 2015). Health social workers in primary care are also able to help patients identify their needs and provide information about the relationship between physical and mental health, which can reduce ineffective use of the health care system (Hine, Howell, & Yonkers, 2008; Loveland et al., 1996). Further, research indicates that patients will often share information related to the social determinants of health (e.g., income, housing, food, and working conditions) with a social worker, including the inability to afford medications, which they would otherwise not openly share with their doctor (Craig, Bejan, & Muskat, 2013; McGuire et al., 2005). Consequently, when agreement exists between physicians and patients about the identification of their health, social and basic needs, including housing and food, patients’ mental health outcomes improve (Lasalvia, Bonetto, Tansella, Stefani, & Ruggeri, 2008). Gabbay et al. (2003) found that patients who agreed with their providers about their main presenting problem had lower average depression scores after 12 months. This approach of enabling patients to identify their needs and exert some control over influences on their health can lead to improvements in patient health outcomes (Raphael, 2012). A meta-analysis conducted by Coulter and Ellins (2007) found that patient engagement contributed to improved health outcomes across a wide range of health concerns. It was noted that involving patients in their own care, including facilitating the identification of their own health needs, is a promising strategy for improving patient health and well-being. Patient needs and self-reports

Patient self-report is the most frequently utilized approach to collect individual health information (Bhandari & Wagner, 2006). In primary care, patient self-reports are critical to the identification of mental health symptoms by family physicians (Kerr & Kerr, 2001; Yigletu, Tucker, Harris, & Hatlevig, 2004). Health professionals depend on verbal and written patient reports of symptoms, behavior, and treatment (McDowell, 2006). Studies that compare self-report and conventional data collection suggest that self-report measures are more sensitive and accurate than diagnostic tools (Bourgeois et al., 2007; Short et al., 2009). Further, patient self-reports are non-invasive, inexpensive and fairly quick to administer (McDowell, 2006).

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Patient self-reports have particular benefits that can inform diagnostic or assessment data and ultimately impact treatment effectiveness. For example, social determinants such as housing quality or income, symptomatic details regarding impact on functioning and psychosocial issues such as depression or anxiety are crucial elements of health that can be captured in patient selfreports (Reeve et al., 2013; Craig, Bejan, & Muskat, 2013). Such self-reports highlight the unencumbered voice of the patient and capture the complexities of personal health that are so critical to patient-centered care (McDowell, 2006, Craig, Bejan, & Muskat, 2015). Reeves and colleagues (2013) suggests that self-report measures provide critical information about patients’ reported needs, beliefs, and feelings about health and care that could improve service quality. As many presenting psychosocial issues or comorbid complaints do not end up in diagnostic resolution, the ability to “link services” to specific patient concerns can illuminate care pathways and improve processes (Steinwachs & Hughes, 2008). Increasingly, patient selfreports are considered a key component of integrated health practice and policy that is responsive to patients’ needs (Bourgeois et al., 2007; Hansen, Draborg, & Kristensen, 2011; Stanhorpe et al, 2015). With the increased focus on the patient experience of comorbid health and mental health issues in primary care and the importance of integrated interdisciplinary teams in care provision, understanding self-reported patient mental health needs can better inform the work of allied health professionals such as social workers. The potential for social workers to address patient mental health needs as part of interdisciplinary teams in primary care is supported by qualitative research findings (Gocan, Laplante, & Woodend, 2014); however, quantitative evaluation research is needed to strengthen the existing evidence. The primary aim of this pilot study was to develop and extend knowledge about the psychosocial needs of a sample of patients receiving services from interdisciplinary primary health care teams and the opportunities for social work to address those needs. A second aim of this study was to identify correlates of anxiety and/or depression in patients of interdisciplinary primary health teams. It is hypothesized that the endorsement of anxiety and/or depression symptoms will be positively associated with: (a) poor physical health status; (b) conflict in family and work relationships; (c) impaired task cognition; and (d) low levels of social support and self-efficacy.

Methods Procedures

This study was conducted in a Canadian urban city between September 2011 and May 2012 and developed through a collaboration of an advisory group consisting of two social work academics and three members of Integrated

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Interdisciplinary Primary Health Teams (two social workers and a family physician). The team met five times at two hour meetings to design the study and craft the survey. Participants were recruited through four interdisciplinary primary health teams located in three community hospitals and clinics. Study inclusion criteria consisted of: (a) all new patients that had been scheduled to visit with the health social worker after being referred by a primary care physician; (b) patients willing and able to complete a 15-minute survey in English about their health care needs; (c) over 18 years of age. To facilitate recruitment, the researchers trained reception staff to provide information and questionnaires to new patients which were completed in the waiting room before their first meeting with the health social worker. The survey took 10–15 minutes to complete. Participants completed a written informed consent that fully described the study procedures and were assured that their participation had no bearing on their medical services. This study was covered under Institutional Research Board protocols from the University of Toronto and St. Michael's Hospital. Measures

A survey was developed by the advisory group to further understand the psychosocial needs of patients in interdisciplinary teams. Items were determined iteratively through enhanced discussion and survey refinements. The patient survey had three sections including demographics, psychosocial needs, and health and quality of life. Demographics: Age, race, ethnicity, immigration status, employment status and income information was elicited from participants (Table 1). Patient Needs: Following meetings with health social workers and a review of the literature, a list of common patient psychosocial complaints in primary care was generated by the advisory team. These items were refined and added to the survey along with an open-ended question in a non-mutually exclusive format (Table 2). For example, “Are you dealing with anxiety and/or depression today (yes/no)?” was used to assess the presence of anxious and/or depressive symptoms. A subsequent question asked patients to indicate, in order of importance, the two psychosocial issues that they would like help with today (Table 2). A final question asked patients to either choose or write in the type of service they required from social work today. All open-ended responses were discussed and collapsed into categories during a meeting of the advisory team. Health and quality of life

The advisory group generated a list of domains that influence patient psychosocial needs in primary health. Questions were then located in the literature or created that mapped onto those areas. Response options

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Table 1. Summary of participants’ demographic characteristics. Demographic Gender identity (n = 100) Male Female Transgender Race & ethnicity (n = 97) White European South Asian Mixed heritage Black Caribbean Black African Middle Eastern East Asian Aboriginal African American Latin American Other Prefer not to answer Sexual orientation (n = 98) Heterosexual Gay Bisexual Lesbian Queer Prefer not to answer Age (n = 100) 19–29 30–39 40–49 50–59 60–69 70 + (Above 70) Education (n = 98) Less than high school Completed high school Graduated college, trade/tech school Bachelor’s degree Postgraduate degree Prefer not to answer Employment status (n = 99) Work full time Work part time Volunteer for no pay Work in the home On temporary disability On permanent disability Unemployed seeking work Retired Something else Prefer not to say Income (n = 98) Less than $10,000 $10,000–$19,000 $20,000–$39,000 $40,000–$59,000 $60,000–$79,000

n

%

59 40 1

59 40 1

53 11 10 4 6 4 3 2 2 2 1 1

54.7 11.3 10.3 4.1 6.2 4.1 3.1 2.1 2.1 2.1 1 1

75 10 4 3 3 3

76.5 10.2 8.6 3.8 3.8 3.8

18 18 32 20 11 1

18 18 32 20 11 1

4 23 25 28 17 1

4.1 23.5 25.5 28.6 17.3 1

30 11 1 3 8 13 19 6 5 3

30.3 11.1 1 3 8 13.1 19.2 6 5 3

12 18 25 14 4

12.2 18.4 25.5 14.3 4.1

(Continued )

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Table 1. (Continued). Demographic $80,000 or more Prefer not to answer Country of birth (n = 100) Canadian born Non-Canadian born

n 19 6

% 19.4 6.1

64 36

64 36

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Not every participant answered each question and therefore, the actual number (n) is reported for clarification purposes.

Table 2. Current psychosocial issues and priority psychosocial issue today (n = 100). Psychosocial issue Anxiety and/or depression Family or relationship issues Stress management Adjusting to health condition Social isolation Coping with trauma Mental health issues Workplace issues Housing Legal issues Problems with disability or other benefits

% 78 57 51 28 23 22 22 19 17 11 9

Priority psychosocial issue 31% 21% 16% — — 9% — — — — —

Items are not mutually exclusive.

ranged from poor/poorly (1) to excellent/well (10). Definitions were also provided to anchor the concepts (e.g., “Social support can be defined as having people to rely upon for emotional and practical help when you need it”). Measures with more than one item were total scored for each group of sub-items. Self-reported health and mental health status were measured by: “In general, would you say your physical health is? In general, would you say your mental health is?” Social support was measured by two questions such as: “How much social support do you have in your life?” Impaired thinking was measured by two items such as: “How well are you able to think your way through these daily tasks? (e.g. managing money, shopping, using public transportation).” Self-efficacy was measured using three questions from the General Self Efficacy Scale (Schwarzer & Jerusalem, 1995) such as: “I can always manage to solve difficult problems if I try hard enough.” Family conflict was measured by two questions such as: “Thinking about your relationships with family, how well do you get along with each other?” Work conflict was measured by two questions such as: “Thinking about your relationships with work colleagues, how well do you get along with each other?” Finally, housing

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satisfaction was measured using two questions such as: “How would you rate your satisfaction with your current living arrangements and housing?”

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Data analysis

Descriptive statistics were calculated. Missing data ranged from 0 to 5% for retained variables. Missing data was examined using the missing values analysis in SPSS. Data ranged from 0–2% missing from the T1 and T2 measures. To preserve the sample size, an expectation-maximization (EM) multiple imputation method in a maximum likelihood estimates was applied because it retains the advantages of imputation and overcomes its limitations (Little & Rubin, 1989). To enhance interpretation, several questions were reversescored. Biserial correlations were calculated between the major constructs of interest. An initial logistic regression was conducted to identify the contribution of the variables to self-reported anxiety and/or depression (Aiken & West, 1991). Anxiety and depression were chosen as the focal variables in consultation with the advisory team because of their frequent manifestation in practice and research. Additionally, this study found that anxiety and/or depression were the most frequently cited patient concern. The independent variables were selected for inclusion in the logistic regression because of their contribution to self-reported anxiety and depression from the literature and the experience of the advisory team. To that end, poor self-reported health was not included in the logistic regression because of the high correlation of with anxiety and/or depression. Results SPSS 22 was utilized for all analyses. Descriptive analysis including frequencies (Table 1) was conducted. Participant (n = 100) ages ranged from 19–71 (M = 16.87, SD = 1.57). As a result of the demographic composition of the city where the research was undertaken, participants primarily identified as white European (54.7%); Asian (combined South Asian, East Asian) (14.4%); Black African/African-American/Caribbean (12.4%); Aboriginal (2.1%); Latin American (2.1%); and Middle Eastern (4.1%). Participants identified as female (40%), male (59%) and transgender (1%). Due to small sample size, those who identified as other were removed from analyses. Frequencies were generated to identify patients’ current psychosocial issues. Participants reported high levels of anxiety and/or depression (80%), followed by family relationship issues (57%) and stress (51%). When participants were asked to indicate their two priorities for social work intervention that day, anxiety and depression (31%) and family relationship issues (21%) emerged as the most frequently reported issues (Table 2).

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Table 3. Table of correlations. Anxiety and/or depression Poor self-rated mental health Impaired thinking Self-efficacy Social support Work conflict Housing satisfaction Income Family conflict Poor self-rated physical health

1 __

2

.302**

__

3

4

5

6

.213* .507** __ −.197* −.387** −-.365** __ −.225* .458** −-.294** .395** __ .239* .389** .359** −.319** −-.319** __ −.239* .086 −.223* −.271** −-.331** −.273* −.202* −.281** .230* .116 .060* .176

.158 .049 .288**

7

8

9

10

__

.291** .327** −.266** .243** __ −.096 −-.330** .154 −.327** −.236* __ −.275** .151 .217* .064 −.231* .056 __

**Correlation is significant at the .01 level (2-tailed). *Correlation is significant at the .05 level (2-tailed).

Finally, in response to a question about the type of service that would be the most beneficial to meet their needs, counseling (64%), emotional support (59%), and problem solving (42%) were the most frequently indicated. A correlational analysis found relationships among the variables as detailed in Table 3. The direction of the correlations were generally as expected, with the presence of anxiety and/or depression strongly and positively correlated with poor mental health (p = < .01) as well as physical health, impaired thinking, work conflict and family conflict (p ≤ .05). Self-efficacy, social support, housing satisfaction and income all had significant negative correlations with anxiety and/or depression (p ≤ .05). Logistic regression: A test of the full model against a constant only model was statistically significant, indicating that associations between the factors influencing anxiety and/or depression were significant (χ2 = 32.299/ 11, p < .001), reflecting a fairly strong relationship (Nagelkerke’s R2 = .451). Table 4 presents the detailed results of the regression analysis. Using the EXP (B) value, the odds of anxiety and depression were over five times higher for each unit increase in impaired thinking, (OR = 5.5); four times higher for the presence of work conflict, (OR = 4.3); almost four times higher for family stressors, (OR = 3.9); almost three times higher for poor health, (OR = 2.8); and low social support (OR = 2.6) and low self-efficacy (OR = 1.2). Table 4. Regression analysis for factors associated with anxiety/depression in a sample of primary care patients (n = 100). Variable Impaired thinking Work conflict Family conflict Poor physical health Low social support Low self-efficacy Δ 2

B 1.897 2.536 1.410 .985 1.048 .220

SE B .955 .818 .657 .427 .536 .109

β 5.544* 4.301* 3.945* 2.878* 2.653* 1.290*

CI 1.03–8.34 1.73–11.70 1.13–9.83 1.16–8.15 .99–7.15 .02–1.44

R = .860 (Hosmer & Lemshow) .29 (Cox and Snell) .44 (Nagelkerke) *p < .05, **p < .01.

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Discussion This study provides meaningful information about about the needs of patients in interdisciplinary primary care teams. Similar to the findings of Hemmings (2000), this study found that a high percentage of patients of primary health care teams struggle with anxiety and/or depression. Anxiety and depression have been identified as significant health determinants. This study found that significant contributors to patients’ self-reported anxiety and/or depression included challenges in family and work relationships, low levels of social support and self-efficacy, poor health status, and impaired task cognition. As a profession that specializes in the assessment and treatment of such psychosocial comorbidities, social work is well-positioned to address these needs through interdisciplinary teams. Given their ability to execute biopsychosocial assessments, mobilize tangible resources and provide treatment using evidence-based modalities, social workers have the potential to alleviate the burden of suffering associated with psychosocial and mental health symptoms in primary care patients (Craig, Betancourt, & Muskat, 2015; Stanhope et al., 2015). There is a range of severity in patients’ anxiety and/or depression in primary care and a commensurate variety of mental health services and psychosocial support provided by health social workers. For example, social workers often provide supportive counseling and psychoeducation for patient adjustment to illness which, if left untreated, could manifest as anxiety or depression, or other psychosocial issues. Without intervention, these psychosocial comorbidities could deepen and lead to further problems in health and well-being. To be effective, interdisciplinary teams need to be aware of patient perspectives on their own functioning. Eliciting patients’ psychosocial needs, often through selfreport, leads to timelier treatment and more appropriate referrals (Udedi, Swartz, Stewart, & Kauye, 2014) and is increasingly important in patient-centered care (Asadi-Lari, Tamburini, & Gray, 2004). Craig and Boardman (2007) suggest specifically asking patients open-ended questions about their anxiety, depression, and adjustment to illness as well as paying attention to cues such as a patient’s emotions during appointments, frequency of visits, and difficulties surrounding the social determinants of health. Although it is recognized that the self-reported needs of the patient do not drive the provision of primary health care, this study suggests their concerns should be elicited and integrated into care.

Implications for practice The results of this study have relevance for social work practice in integrated primary health care and will be discussed through enhancing patient problem solving, quality of social relationships and communicating the importance of their health status.

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Problem solving

A clear message from patients is that they need practical guidance and emotional support to assist them in managing health-related and social challenges. Social workers are particularly skilled in engaging patients (removed for review) and enabling them to develop solutions to their daily challenges (removed for review). This means that social work efforts within interdisciplinary teams should consider providing tangible resources to manage problems and specific strategies to reduce levels of anxiety and enhance coping. Some interprofessional teams are embracing this approach. In the United Kingdom, financial or benefits navigators have been implemented in hospitals (Bloch, Rozmovits, & Giambrone, 2011). Additionally, social work can play a central role in the identification and treatment of patients’ needs by assessing psychological well-being and implementing individualized and collaborative treatment plans guided by patient lifestyle, preferences and informed decision making (Waghorn, 2009). These efforts demonstrate promise in improving self-efficacy and modifying perception of illness and limitations. In this way, social workers can enhance patients’ abilities to manage problems and increase their self-efficacy. Allied health professionals can play a critical role in delivering education and training to patients using self-care strategies that are both cost-effective and efficient (Bonadonna, 2003). The benefits of a combination of generic skills-building programs with disease-specific approaches for self-management of chronic illnesses have been noted in the literature (Newman, Steed, & Mulligan, 2004). The delivery of psychoeducation (Culpepper, 2002; Waghorn, 2009), pain management strategies (Waghorn, 2009) and approaches that address barriers to compliance (Culpepper, 2002) are further tasks suitably completed by health social workers. Rothman and Wagner (2003) highlight the need for clinical case management of chronic illness by a large multidisciplinary team with an emphasis on self-management, coordination of supports/care, collaboration and agreement on treatment goals, close monitoring and education, and a focus on improving health behaviors. Helping patients with self-management can improve self-reported health status (Lorig, Sobel., Ritter, Laurent, & Hobbs, 2001), which can, in turn, influence anxiety and depression. This suggests that a cyclical relationship exists, where having poor health, perceived or otherwise, contributes to the development of anxiety and depression, which then can contribute to poor physical health. To effectively influence the high prevalence of anxiety and/or depression found among patients of interdisciplinary teams, it is important for social workers to address cognitive issues that impact daily decision making. These study findings highlight existing evidence of a relationship between poor problem solving (e.g., seeing the problem as a threat; doubting one’s abilities;

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anticipating bad resolutions; being easily frustrated) and depressive and anxious affective patterns (Chang, D’Zurilla, & Sanna, 2004; Ciarrochi & Scott, 2006; Haugh, 2006; Kant, D’Zurilla, & Maydeu-Olivares, 1997). Use of cognitive behavioral strategies in health care settings and within integrated care has been suggested to address thinking errors, reframing of perceived limitations and to promote engagement in desired activities and goals (Khoury & Ammar, 2014). De Ridder et al. (2008) and Waghorn (2009) stress the importance of therapeutic strategies—such as cognitive behavioral therapy (CBT), therapeutic writing, solution-orientation approaches, and supportive emotional counseling—to help physically ill patients gain awareness of their affective experience, improve coping and redefine values and goals, which in turn can decrease anxiety and depression. Moreover, evidence is growing in favour of the feasibility of employing such therapeutic approaches using brief techniques within health care. A review of the literature on counseling services in primary health teams showed some evidence for the cost-effectiveness of therapy by reducing physician visits, the number of external referrals and the amount of psychiatric medication use (Hemmings, 2000). Social relationships

It is critical to address problems in family and work relationships, and increase social support in order to reduce symptoms of anxiety and depression. Similar to this study, previous research has determined that social relationships contribute to anxiety and depression, which impact heath (Seeman, 2000; Umberson & Montez, 2010). Social workers in primary care settings can identify these social deficits and support patients by creating linkages to community programs or online services in order to foster a sense of belongingness, address barriers to increasing social networks (e.g., transportation, access to Internet, interpersonal skills development), and improve coping with unmet needs. Health social workers can also help patients to reduce social isolation and receive validation within their social networks (Li et al., 2013). In addition, social work is uniquely positioned to assess community needs and advocate for the implementation of recreational and support group programs to help individuals extend their social support networks. For social work, facilitating communication in family and work relationships by mediating conflict, providing family interventions, education, and strategies to reduce the impact of stress may positively influence high rates of anxiety and depression. Health status

With the increasing awareness of eliciting patient perspectives and knowledge regarding health and well-being and the social work expertise in

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assessing and addressing psychosocial comorbidities, there is an opportunity for social work to undertake health promotion, prevention, and quality of life improvement within the health care sector. Previous research indicates that social workers operating within interdisciplinary teams are capable of effecting significant and meaningful change in patients’ quality of life, despite the presence of significant physical health diagnoses (Miller et al., 2007). Within integrated care, social workers are well-suited to address both mental health issues and the social determinants of health (Craig, Bejan, & Muskat, 2013). Given the profound impact of the social determinants of health on health status, social workers practicing in primary care settings are well-equipped to influence patient health status through psychosocial interventions. Implications for research and policy The results of this study indicate implications for research and policy. Future research should clearly articulate the early interventions undertaken by social workers in primary care teams. Marshall et al. (2011) states a need for more evidence-based prevention literature in order to increase visibility of the need for early interventions. Longitudinal research is needed to examine the long-term cost-effectiveness of interdisciplinary primary care teams which include social workers, in order to inform policy. By addressing concurrent mental and physical health needs through interdisciplinary primary care, it may be possible to avoid more costly hospitalizations or work absences. It is currently estimated that 21.4% of workers in Canada experience mental health issues, resulting in an estimated productivity loss valued a $6.4 billion in 2011 (Mental Health Commission of Canada, 2013). A recent policy change in Ontario has led to a reduction in the growth of interdisciplinary primary care teams except in remote areas (Grant, 2015). Longitudinal research may be able to demonstrate the value of interdisciplinary teams using long-term indicators, leading to policy changes that would support the growth of interdisciplinary care teams in which allied health care providers are able to address medical and psychosocial needs concurrently. Limitations This study utilized a convenience sample of new patients scheduled to see the social worker working in primary health teams located in clinic and community-based hospital primary care settings. For this reason, findings are not generalizable to all patients presenting to primary care settings. Despite the clear differences in scope of practice between many health and mental health social workers, this study did not strive to illuminate those differences because of small sample size and the desire of the advisory

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group to focus on interdisciplinary teams more broadly. This study used cross-sectional data so causality cannot be inferred. Anxiety and depression were not measured separately in the survey instrument and as a result, findings related to the correlates of anxiety and depression must be interpreted together. The study instrument was provided in English and required participants to have the ability to complete the questionnaire in English. Given this condition, the results of this study do not reflect the correlates of anxiety and depression for newcomer populations to Canada who lack English proficiency. In addition, participants were required to be at least 18 years of age at the time of participation in the study. Therefore, the results of this study do not reflect the psychosocial concerns of children and adolescents within a primary health care setting. Despite these challenges, there is some value in understanding patient needs within interdisciplinary teams.

Conclusion This study provides further evidence that primary care patients frequently present with significant mental health, relational and stress-related challenges. This study found that anxiety and depression were associated with poor social relationships, compromised health status and underdeveloped problem-solving skills, which are all issues that are within the scope of practice of health social work. These findings suggest that social workers have a vital role to play within interdisciplinary teams in the amelioration of psychosocial needs and risk factors associated with poor mental health outcomes.

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