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Abstract

Purpose: This study protocol provides an overview of research that aims to integrate social workers into general practice teams to improve care coordination and reduce the burden of psychosocial issues presented to General Practitioners (GPs). Design/Methodology/Approach: This proof-of-concept study will be conducted in five overlapping phases to implement and evaluate three different models of social worker integration into general practice teams. The first phase will involve developing partnerships, contractual arrangements, co-design workshops, and an advisory group to establish the project. Phases two and three will focus on implementing the three models. The final phase is the evaluation and dissemination phase. Data collection will include co-design workshops, Qualtrics data capture surveys completed by social workers, wellness assessment surveys, patient feedback forms, and a stakeholder feedback survey. Data analysis will involve thematic and statistical analysis. Discussion: As an emerging area of practice for social work, the implementation of social work practice in general practice needs to be carefully planned and scaffolded. The findings of the evaluation of the models will show how they can address identified needs for primary health care and patient care in the primary health care setting. Co-designing the models at the implementation stage will ensure practice staff buy-in and provide a way to address anticipated challenges, such as referral pathways, role clarification, and resource availability. Originality/Value: This project will contribute to existing knowledge by testing the feasibility and effectiveness of different models of social worker integration into general practice teams in the Australian context, which is a major focus of the national ten-year primary health care plan and Strengthening Medicare reforms. The project will also identify the conditions and factors that influence the implementation and outcomes of social worker integration, such as role clarity, interdisciplinary communication, formal structures and processes, risk management, and funding.

Keywords

social work primary health care general practice integration evaluation care coordination multi-disciplinary teams

Background

The Australian Government (2022) 10-year Plan for Australian Healthcare objectives are to support equitable access to the best available primary health care services, reach parity in health outcomes for Aboriginal and Torres Strait Islander people, manage health and wellbeing in the community, support continuity of care across the health care system, support care system integration and sustainability, embrace new technologies and methods and support safety, and quality improvement. The plan embraces the Quadruple Aim framework for optimising health system performance that focuses on improving (1) people’s experience of care, (2) the health of populations, (3) the cost-efficiency of the health system, and (4) the work life of health care providers and health equity (Australian Government, 2022a citing Bodenheimer et al., 2014). It focuses on people being actively engaged in their own health care, funding reforms, and innovation, workforce reform, research, leadership and innovation (Australian Government, 2022a). The Strengthening Medicare Taskforce Report (Australian Government, 2022b) further recommends “coordinated multidisciplinary teams of health care professionals work to their full scope of practice to provide quality person-centred continuity of care” which calls out the need to add the fifth aim of equity.

The research discussed in this study protocol is based on the premise that social workers can contribute to cost-effective care that may improve health outcomes and increase patient satisfaction by addressing the social determinants of health (SDH), that account for between 30%–55% of health outcomes (Dahrouge et al., 2022; Dixon & Knapp, 2018; Fraser et al., 2018; Lotinga, 2015; McGregor et al., 2018; Reece et al., 2022; World Health Organisation [WHO], 2023), thus assisting patients in being engaged in their health care, improving outcomes for patients and the health of the population, which will have ripple effects on the health system and the work-life balance of health care providers (Australian Government, 2022). A recent report by the Canadian Association of Social Workers outlines the current practice and future vision for social work in primary care (Ashcroft, Adamson et al., 2024). The report highlights that ‘Social workers in primary care are enhancing the wellbeing of populations and the surrounding communities within which they work’, and emphasises the important contribution of social workers to interprofessional collaboration and patient-centred care (Ashcroft, Adamson et al., 2024, p. 9). However, while the potential of social work to improve health outcomes for patients is significant, the evidence base for the contribution of social work in regard to specific improved health outcomes is currently underdeveloped (Fraser et al., 2018; McGregor et al., 2018; Reece et al., 2022).

Social workers can perform a broad range of valuable roles that enable holistic patient care within general practice, such as behavioural health interventions, care management for behavioural and physical health, and community engagement or patient referral (Fraser et al., 2018). For example, Ashcroft and colleagues (2024a) highlight that social workers in primary health care provide patient care team support and community care. Direct patient care includes advanced care planning, advocacy, assessment and diagnosis, case management, clinical problemsolving, counselling/therapy, crisis management, psychoeducational groups, health promotion, and system navigation (Ashcroft, Adamson et al., 2024). These roles are especially relevant for complex and chronic health conditions, comorbidity, ageing, mental health, substance abuse, and other priority population groups (Fipps et al., 2022; Fraser et al., 2018; Mangan et al., 2015; Zuchowski et al., 2023). Social workers can reduce acute hospital admissions and emergency department presentations by helping people manage their health and wellbeing in the community, which offers both higher-quality and more cost-effective care (Bailey & Mutale, 2019).

There are shortfalls in the provision of mental health services in Australia, and each Australian Primary Health Network [PHN] has a joint mental health plan to address these shortfalls and work towards mental well-being (Australian Government, 2022a). Social workers are one of the professionals “… that continue to provide a significant proportion of mental health care” (Australian Government, 2022a, p. 19). Social workers can reduce stigma and improve prevention and early intervention for patients with psychosocial issues by providing support through a general practice setting, where universal health systems and existing relationships facilitate access and engagement (Döbl, 2015; Fraser et al., 2018; Kloppe et al., 2022; McGregor et al., 2018; Reece et al., 2022). Overall, while social workers can assist patients through direct care provision, caring for patients' health needs and outcomes, they “….also directly addressed a broad range of social determinants of health such as issues related to gender-based violence, financial challenges, and insecure housing” (Ashcroft, Sheffield et al., 2024, p. 9).

Currently, the funding of social work in general practice is complex, and thus the call for funding reform by the Australian Government (2022a) is important. General practice is mainly funded through a fee-for-service system supported by MBS, with only 10% of Australian Government funding supporting quality improvement and outcomes through funding streams such as the Practice Incentives Program (PIP), the Workforce Incentive Program (WIP), and the Indigenous Australians Health Program (IAHP) (Australian Government, 2022a).

In this paper, the study protocol for the ‘Social Workers in General Practice Project’ is presented. This project builds on international and Australian research about social work practice in primary health care (see, for example, Ashcroft, Sheffield et al., 2024; Bailey & Mutale, 2022; Döbl et al., 2015; Fraser et al., 2018; Zuchowski & McLennan, 2023). This project is funded through the Commonwealth Department of Health and Aged Care PHN commissioning of multidisciplinary teams activity. The Brisbane South Primary Health Network [BSPHN] engaged the Community Services Industry Alliance [CSIA] to develop a model, financial tool, and information sheet to support general practices in using the Medicare Benefits Schedule (MBS) to embed social workers in general practice. However, while the report identified evidence that the integration of social work in general practice would be beneficial, the current MBS funding model was not conducive to sustainably funding the embedding of social work in general practice (CSIA, 2023). The report’s key recommendation was for BSPHN to commission different models to embed social work in general practice, evaluate these, and gain the required evidence to influence future health policy and funding strategies (CSIA, 2023).

Methods

Aims

The project aims to integrate social workers into general practice teams to improve care coordination and reduce the burden of psychosocial issues presented to GPs by providing stronger links to existing social support services. This proof-of-concept project will test three models of integrating social workers into general practice teams in catchments with different local needs. Access to social workers may be physical (through on-site service in a general practice) or virtual (by providing a direct link to general practice via a remote service). The project is funded for two years, from July 2024 to June 2026, and includes 12 months of service delivery by social workers who will be working in different models.

The overall goals of the inquiry are to explore

• the effectiveness of social worker integration in general practice;

• the impact of social work intervention on patient care coordination;

• whether there are indicators of reduction of psychosocial issues;

• the levels of patient satisfaction; and

• key stakeholder feedback on the usefulness and contribution of social work in the general practice.

Project Advisory Group

A Project Advisory Group (PAG) will support the project and provide expert input and advice. Following the commissioning of service providers, meetings will be held approximately monthly for the project’s duration. Members will include the PHN, the investigators (including academic social workers), the Australian Association of Social Workers [AASW], a PHN GP representative, the Australian Primary Health Care Nurses Association [APNA], a registered nurse with expertise in inclusive health, and representatives from state government health and community services departments. Participation in the PAG will be voluntary. The PAG will advise on the three demonstration models’ refinement, implementation and operation in selected sites within the BSPHN region; the formative and impact evaluations of the three models; and the dissemination of the project findings and learnings to internal and external stakeholders within agreed parameters.

Demonstration Models

The models being evaluated are:

Model 1: Vulnerable Populations With Unmet Social Needs

The model is focused on enabling a general practice to ensure patients are connected to the most appropriate support via a social worker. It must feature system navigation and service connection for patients with chronic conditions experiencing housing insecurity and other social determinants of health. The target group is patients of a clinic who are frequent users of hospital services and need social work support to overcome issues with housing instability that negatively affect their health and well-being outcomes. The facilitation of registration with MyMedicare is an essential element of this model.

Model 2: Place-Based Service Extension

This model is based on a hub-and-spoke approach that integrates with existing PHN and other related programs. It aims to increase service access and engagement for patients residing in a location with service access issues, low trust in authority, and whose need for social support negatively affect their health and well-being outcomes. The access to social workers may be physical (through on-site provision of service in one or more general practices) or virtual (by providing a direct link to general practice via a remote service). The intent of this model is not to provide a frequent physical outreach service. This will require a focus on community connection and awareness raising as part of the model.

Model 3: Culturally Diverse Populations

This model targets clients from culturally and linguistically diverse (CALD) backgrounds with complex needs who experience poorer health outcomes compared to the general population because of unmet social support needs. The access to social workers may be physical (through on-site provision of service in general practices clustered near a major transport corridor) or virtual (by providing a direct link to general practice via a remote service). The intent of this model is not to provide a frequent physical outreach service to geographically dispersed patients but to utilise existing transport corridors and telehealth capability. This will require a focus on community connection and awareness raising as part of the model. The social worker will work in the general practices but will be employed by an organisation that currently delivers social work services and can provide clinical supervision to all social workers.

The research does not target specific groups. However, Model 3 may capture people from culturally and linguistically diverse backgrounds. To ensure research participants provide informed consent, all practices have access to free translation and interpreting services. The research will be undertaken in a culturally sensitive manner and steps will be taken to ensure participants understand their participation is voluntary.

All three models will require the employment of generalist qualified social workers who are eligible for membership of the AASW (2015). Although social workers may be accredited mental health social workers, a singular focus on mental health counselling is outside this project’s scope. All models will support patients 18 years and over.

Timeline

This research will be conducted in five overlapping phases, implementing three models of practice delivery of social work in general practice staggered and commencing in November 2024. Data collection will occur throughout all phases. The models outline the different approaches to implementing social work in general practice settings; however, they do not alter the data collection or methods.

Phase 1- Project establishment

• Co-design workshop. Use of outputs to draft design models and data collection.

• First advisory group meeting held to discuss the project aims and to confirm the suitability of data collection tools

• Development of data collection tools

• Confirm general practices and social work provider organisation that will be involved for each model

• Establish contracts with participating clinics.

• Ethics application submitted to James Cook University Human Ethics Committee for consideration.

Phase 2-Project implementation: Model 1

Implementation of Model 1:

• Social worker employed in general practice to assist people with unmet needs.

• Advertised social work position filled by first practice to go live

• Collect data on social work practice via reporting tools

• Data collection via Patient feedback forms

• Data collection via the wellbeing scale Promis-10 Global

• Monthly Project Advisory Group meeting

Phase 3- Project implementation: Model 3

• Social worker employed by a third party provider to assist culturally and linguistically diverse populations

• Social worker position advertised and filled by organisation for model 3

• Practices contracted

• Collect data on social work practice via reporting tools

• Data collection via patient feedback forms

• Data collection via wellbeing scale

• Monthly Project Advisory Group meeting

Phase 4 -Project implementation: Model 2, commencing May 2025.

• Social worker employed to support place-based service extension

• Social worker position advertised and filled by practices for model 2

• Collect data on social work practice via reporting tools

• Data collection via patient feedback forms

• Data collection via wellbeing scale

• Monthly Project Advisory Group meeting

Phase 5- Evaluation & reporting, commencing December 2025

• Reviewing and finalising key stakeholder survey

• January - May 2026 Data collection via online survey

• January - May 2026 Data analysis

• June - August 2026 – Dissemination of findings to project funding body and key social work and medical journals

Data Collection

Sampling and recruitment will be as follows: After conducting market analysis and determining which practices met the eligibility criteria, a closed tender process was attempted. When that was unsuccessful, a direct procurement approach was used for practices that met the eligibility criteria and were interested and engaged with the PHN. Funding differs for each model.

Model 1 - funding to employ the social worker

Model 2 - funding to employ the social worker

Model 3 - funding to a third party to employ the social worker and funding to the general practices to offset the room costs

General practice employees (GPs, nurses, practice managers, and other allied health professionals) of the participating organisations will be invited to complete surveys to consider the outcomes of having a social worker employed in the clinic. Staff will be asked to consider the contributions to the patients and the clinic staff as a whole. Social Work employees supporting the participating general practices will be recruited through standard employment processes and will be selected based on their suitability for the position. During the job interview stage, social workers will be informed of the research being undertaken, the requirements included in their employment contract, and the invitation to participate in the staff feedback survey.

Data sources for the evaluation are guided by Australian Government reporting requirements associated with project funding and by an ethics application approved by the James Cook University [JCU] Human Research Ethics Committee [HREC] (granted on 29.11.2024, approval number H9611). Each funded provider will capture and report a minimum, de-identified dataset via Qualtrics to enable the PHN to meet contracted Australian Government funding requirements. Additional data will be captured and considered in alignment with the JCU HREC approval for the project.

Several data collection methods will be employed throughout the project, using a combination of qualitative and quantitative tools. Researchers and advisory group members reviewed the data collection methods to ensure that the patient surveys are appropriate for delivery in the general practice settings. There will be six key sources of data to inform the evaluation of the project:

Output From Research Co-Design Workshops

In March 2024, Brisbane South PHN invited a broad range of stakeholders to participate in a co-design workshop for overall project implementation. All participants were informed that de-identified outputs from this workshop would be captured and would be used to inform further project development. Additional co-design workshops will be held with participating clinics prior to implementation each model.

Intervention Records

Qualtrics data capture surveys are completed by social workers using a QR code after each patient contact. Data captured for all patients will include the source of referral, consistency of referral with presenting issues, principal mode of engagement, and alignment with relevant Medicare and Medicare items. Additional data will be captured for those who consent to participate including demographic data such as gender, marital status, employment status, ethnicity, language, age, and presenting issues, areas of concern, and type of intervention.

Wellness Assessment

Pre- and post-intervention wellness self-assessment of patients will be conducted in Qualtrics and capturing PROMIS Global 10 questions and patients’ self-reported health care visits, attendance at an emergency department, or unplanned hospital admission in the previous three months. Thes assessments will be completed by social workers with patients as part of the intervention.

Post-Intervention Satisfaction Survey of Patients

Practice staff will distribute a voluntary, anonymous post-intervention satisfaction survey to patients via hard copy or QR code. The patient feedback forms will seek feedback on the value and impact of the social work consultation. Hard copies will be scanned and returned to the research team by the practice without any identifying information.

Stakeholder Feedback Survey

Key practice stakeholders, including social workers, GPs, nurses and allied health professionals, and other general practice or social work provider staff will be invited to complete a voluntary, anonymous survey. The survey will seek feedback about the model implementation and the usefulness and contribution of a social worker within the practice. The principal investigator will distribute the survey to key stakeholders are they are not involved on the ground or engaging with provider stakeholders in other capacities.

Data Analysis

Responses to the qualitative survey questions will be analysed thematically (Braun & Clarke, 2019; Grazino & Raulin, 2013). At least two of the four researchers will review the data for common themes, initially independently and then refine them collaboratively. The draft themes will be presented to the Project Advisory Group, which includes all investigators, for further insights. The quantitative data will be entered in SPSS for descriptive and other analyses (Grazino & Raulin, 2013; Kim, 2017; Walker, 2016).

This proof-of-concept study is designed to ensure methodological rigour through a multi-phase, mixed-methods approach that integrates co-design, implementation, and evaluation of three models of social worker integration into general practice teams. Rigour is achieved through the implementation of five overlapping, structured phased and stakeholder co-design that allows contextually relevant and iterative refinement (Morley et al., 2024). Data triangulation through multiple data sources, analytical transparency through thematic analysis guided by established frameworks and ethical and reflexive practice and the oversight of an interdisciplinary advisory group combine into a rigorous research approach (Berger, 2015; Braun & Clarke, 2019; Grazino & Raulin, 2013). This supports the generation of credible and transferable findings and insights.

Quality assurance measures will include regular reviews of data collection processes, validation of survey instruments and ongoing feedback from the Project Advisory Group. Table 1 outlines the monitoring and evaluation matrix that shows how data collection relates to the overall goals of the project and the frequency of that application.

Table 1.

Monitoring and Evaluation Matrix

Evaluation question	Indicator	Data source	Method	Frequency
Effectiveness of social worker integration	Number of interventions	Qualtrics surveys	Quantitative analysis	Monthly
Potential for Medicare funding	MBS items shadow billing	Qualtrics survey	Quantitative analysis	Monthly
Reduction of psychosocial issues	Wellness assessments	PROMIS global 10 surveys	Quantitative analysis	Pre- and post-intervention
Patient satisfaction	Satisfaction survey results	Patient feedback forms	Qualitative and quantitative analysis	Post-intervention
Stakeholder feedback	Survey results	Stakeholder surveys	Qualitative and quantitative analysis	Mid and end of project

Discussion

General practitioners are currently faced with increased complexity and co-morbidity in patient presentations, and may lack the time, resources, and skills to address particularly the psychosocial aspects of the patient’s care for which they are not specifically funded. Social work practitioners are qualified and skilled to respond to a range of health needs related to psychosocial aspects of health conditions and social determinants of health. Social work professionals are qualified to ensure comprehensive and holistic analysis of a patient’s situation to support health professionals in providing effective health care services. They are also well placed to provide connection to community services that can ensure continuity of patient care. Social work in general practice is well established in countries such as Canada, where the professional social work association argues that social workers are a natural fit for primary care, due to their generalist training and given the breadth of concerns it addresses (Ashcroft, Adamson et al., 2024). As Ashcroft and colleagues highlight, “Social workers work with complex issues often reported as the most challenging for family physicians to manage” (2024a, p. 13).

The current research will contribute to existing knowledge by testing the feasibility and effectiveness of different models of social worker integration into general practice teams, a significant focus of Australia’s Primary Health Care 10 Year Plan 2022–2032 (Australian Government, Department of Health, 2022a). It will also identify the conditions and factors that influence the implementation and outcomes of social worker integration, such as role clarity, interdisciplinary communication, formal structures and processes, risk management, and funding (Bailey & Mutale, 2022; Kharicha et al., 2005; Kloppe et al., 2022; Lotinga, 2015; Mangan et al., 2015; Reece et al., 2022; Zuchowski et al., 2023). Co-design will ensure alignment of the healthcare research with practice and patient needs (Morley et al., 2024).

The study will provide insights into the various ways of embedding social work into general practice. The value of co-locating social workers within practices can include the development of multidisciplinary teams. However, to achieve the development of the multidisciplinary teams investment into “… adequate facilities, local systems that facilitate information sharing, continuity of personnel and the promotion of organisational development activities” is needed (Lalani & Marshall, 2022, p. e394). This would need active engagement and commitment to break siloed thinking and approaches between practice staff (Lalani & Marshall, 2022). The study will consider what supports the multidisciplinary work, how co-location, hub and outreach implementation impact and how joint understandings of social care provision can facilitate holistic health care (Lalani & Marshall, 2022).

Conclusion

There are three main motivations for embedding social workers in general practice settings; person-centred care, better health outcomes and a more sustainable primary health care workforce, where professionals are enabled to make the best and highest value use of their scope of practice and expertise. While indicators highlight that embedding social workers in general practice is of value, with benefits across a range of health and quality of life outcomes, current Australian Government funding models do not adequately support the integration of social work in General Practice. Although some funding pathways are available, they do not sustainably cover the costs. In this proof-of-concept project, three different models of embedding social work in general practice will be implemented and evaluated to develop the required evidence to inform health policy and funding reforms.

Footnotes

Acknowledgements

A reference group supports the research project.

ORCID iD

Ines Zuchowski

Ethical Considerations

Ethics application approved by the James Cook University [JCU] Human Research Ethics Committee [HREC] (granted 29.11.2024, approval number H9611), based on the National Statement on Ethical Conduct in Human Research 2023 .

Consent to Participate

Consent to participate will be sought for all data collection a per ethics approval.

Author Contributions

The research study was designed by the first author with support an input from the co-authors. Author two drafted the manuscript, all authors revised and edited the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded by the Brisbane South Primary Health Network.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data is stored in a data management system and de-identified data might be available upon request.*

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Social Work Practice Models in General Practice in Australia: Protocol of an Intervention Study

Abstract

Keywords

Background

Methods

Aims

Project Advisory Group

Demonstration Models

Model 1: Vulnerable Populations With Unmet Social Needs

Model 2: Place-Based Service Extension

Model 3: Culturally Diverse Populations

Timeline

Data Collection

Output From Research Co-Design Workshops

Intervention Records

Wellness Assessment

Post-Intervention Satisfaction Survey of Patients

Stakeholder Feedback Survey

Data Analysis

Discussion

Conclusion

Footnotes

Acknowledgements

ORCID iD

Ethical Considerations

Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References