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PracticePerspectives

Challenges and Opportunities forSocial Workers in Hospice and Palliative Care

FallI S S U E

N O V E M B E R2 0 1 2

IntroductionSocial work in hospice and palliativecare requires a high level of professionalknowledge and skill. NASW has longadvocated for professional social workqualifications in hospice and palliativecare. In recent years, however, thefederal government has downgraded thequalifications needed to practice socialwork in hospice settings. This change ispart of a deprofessionalization trendaffecting social workers and clients in avariety of practice settings. Social workpractitioners can promote the professionby enhancing their palliative andhospice expertise, educating consumersand their colleagues about the socialwork role within interdisciplinarypalliative and hospice teams, conductingand promoting research to demonstratethe value of social work education andtraining within hospice and palliativecare, and advocating on organizationaland state levels.

Hospice and Palliative SocialWork Knowledge and Skills Hospice and palliative social work requirespecialized knowledge and skills, as describedin the NASW Standards for Palliative & Endof Life Care (2004). Practitioners must beattuned to and able to intervene in situationsinvolving complex ethical concerns, such asend-of-life decision making. Personal andprofessional self-awareness is needed to ensurecompassionate, person-centered responses toindividuals and families participating inhospice and palliative care. Moreover, socialworkers must recognize that individual andfamily perceptions of and responses to illness,disability, dying, death, grief, and bereavementvary greatly and, consequently, strive to serve each client system in a culturally andlinguistically appropriate manner.

Hospice and palliative social workersfrequently deal with nuanced situations and,therefore, must possess strong skills in clientengagement and biopsychosocial assessment.Practitioners may implement a wide variety ofinterventions used to support individuals andfamilies. Clear, concise, timely documentationof social work assessments and interventions is

Chris Herman, MSW, L ICSW

Senior Prac t i ce Assoc ia te

[email protected]

Occupational Profiles: Available athttp://workforce.socialworkers.org/studies/other.asp• Social Work Salaries by Gender• Social Work Salaries by Race/Ethnicity• Social Workers in Colleges and Universities• Social Workers in Government Agencies• Social Workers in Health Clinics & Outpatient Health

Care Settings• Social Workers in Hospice and Palliative Care• Social Workers in Hospitals and Medical Centers• Social Workers in Mental Health Clinics & Outpatient Facilities• Social Workers in Private Practice• Social Workers in Psychiatric Hospitals• Social Workers in Schools• Social Workers in Social Service Agencies

Social Work Practice Perspectives: Available atwww.socialworkers.org/practice/default.asp• 2011 Medicare Changes for Clinical Social Workers• Accountable Care Organizations (ACOs): Opportunities for

the Social Work Profession• Adolescent Depression and Suicide Risk: How Social

Workers Can Make a Difference• Advocating for Clinical Social Workers: Highlights of 2010• Creativity and Aging• Dangerous Rites of Passage: Trends in College Alcohol

Consumption• Domestic Violence and Human Trafficking: Double Jeopardy

for Immigrant Women in the United States• Domestic Violence and Women of Color: Complex Dynamics• Engaging Young People in Their Transition Planning• Healthy People 2020: Social Work Values in a Public

Health Roadmap

• Opting Out of Medicare as a Clinical Social Worker• Results of 2010 Psychotherapy Survey• Support for Family Caregivers: The National Landscape

and the Social Work Role• Supporting the Child Welfare Workforce to Reduce

Child Maltreatment• The Medical Home Model: What Is It and How Do

Social Workers Fit In?

Leadership Ladders: Steps to a Great Career in Social WorkAvailable at http://careers.socialworkers.org/professionaldev/default.asp• From the Front Line to the Corner Office• Letting Your Voice be Heard• Managing Stress• Navigating Large Service Systems• Opening a New Private Practice• Outside the Lines: Maximizing the Flexibility of a

Social Work Degree• Presenting Your Work to Others• Publishing as a Practitioner• Risk Management in Clinical Practice• Strengthening Your Writing Skills: An Essential Task for

Every Social Worker• The Tech-Savvy Social Worker: Prepared for the

Challenges of 21st Century Practice• The Value of Dual Degrees

New Practice StandardsFor a complete list of practice standards, visitwww.socialworkers.org/practice/default.asp• NASW Standards for Social Work Practice with Family

Caregivers of Older Adults (2010)

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Practice Perspectives Fall November 2012

Center for Workforce Studies & Social Work Practice Recent Publications

critical to ensure continuous, coordinated care.Furthermore, because self-determination is integralto both the social work profession and thehospice and palliative philosophy, social workersneed to advocate for the rights, decisions, andneeds of individuals and families.

Hospice and palliative social workers must becomfortable working autonomously and able toexercise strong individual judgment, often in crisissituations. At the same time, they work closelywith other members of the interdisciplinary team,communicating during and between teammeetings and sometimes conducting joint visits orfacilitating family meetings with their colleagues.Such collaboration necessitates not only a strongsocial work knowledge base, but also anunderstanding of how to support the work ofother disciplines while maintaining a social workscope of practice. Thus, palliative and hospicesocial workers need to engage in ongoingprofessional development to ensure their practicereflects ongoing advances in the field.

Personnel Requirements for Hospiceand Palliative Social WorkThe Centers for Medicare & Medicaid Services(CMS) sets Conditions of Participation (CoP) forhospices that participate in the Medicare and

Medicaid programs. These requirements, firstimplemented in 1983, were revised to somedegree in 1990 and underwent major revisionbetween 2005 and 2008. The latest CoP,which took effect on December 2, 2008,include significant changes to the personnelrequirements for hospice social work:

• Whereas the previous CoP required abachelor’s or master’s degree in social work(BSW or MSW) to perform hospice socialwork, the current CoP require an MSW,BSW, or “a baccalaureate degree inpsychology, sociology, or other field relatedto social work” (Medicare and MedicaidPrograms, 2008, pp. 228–229).

• Whereas the previous CoP did not requireMSW supervision of BSWs, the new CoPrequire all baccalaureate-level staffperforming medical social services withinhospice programs to be supervised by anMSW. This requirement applies to bothBSWs and individuals with baccalaureatedegrees in other disciplines. CMS exemptsonly one subgroup from the supervisionrequirement: BSWs who work for the samehospice organization that employed thembefore the CoP took effect (Medicare andMedicaid Programs, 2008).

In addition to the educational and supervisionrequirements specified above, the 2008 CoPrequire “one year of social work experience in ahealth care setting” (Medicare and MedicaidPrograms, 2008, p. 229). This requirementmatches that of previous CoP for hospiceprograms participating in Medicare and Medicaid.

Though states and employers may implementmore stringent personnel qualifications than thoseset by CMS, changes in the federal requirementshave garnered concern among hospice socialworkers of all educational levels. MSWs mayfind their direct practice opportunities limitedbecause some hospice programs now employbaccalaureate-level staff for jobs previously heldby MSWs. On the other hand, the newsupervision requirement may limit employmentopportunities and mobility for BSWs.

Of greatest concern to NASW and many socialworkers is that both MSWs and BSWs must nowcompete for hospice social work jobs withindividuals who lack social work education andtraining. This change parallels both thedeprofessionalization affecting multiple socialwork practice settings (NASW, 2012) and thedowngrading of CMS personnel requirements forcertain other health care settings, such as nursingand skilled nursing facilities (Requirements forLong-Term Care Facilities, 1992). In bothinstances, social workers have raised concernthat lack of social work education and trainingmay compromise the quality of services providedto individuals and families (Bern-Klug et al., 2009;Social Work Policy Institute, 2010a, 2010b).

The revised CMS personnel requirements forhospice social work have implications far beyondhospices participating in Medicare and Medicaid.The Joint Commission’s accreditation standards forhospice defer to CMS’s personnel qualifications(The Joint Commission, 2012, StandardHR.01.02.01, EP3). Similarly, the JointCommission’s advanced certification for palliativecare programs defines social worker as “anindividual who either has met the requirements ofa graduate curriculum (leading to a master’sdegree) in a school of social work accredited bythe Council on Social Work Education, or whohas the documented equivalent in education,

training, or experience [emphasis added]” (C. Mooney, personal communication, May 10,2012).i These broad requirements for hospiceand palliative social work in Joint Commission–accredited and certified programs are but oneexample of the ripple effect triggered by the2008 Hospice Conditions of Participation forMedicare and Medicaid Programs.

What Social Workers Can DoCountering the deprofessionalization of palliativeand hospice social work requires a multiprongedapproach. NASW consistently strives to promotethe professional social work role in hospice andpalliative care on a national level. Social workpractitioners can further this goal by taking actionin their individual practice and within theirorganizations, communities, and states:

• STRIVING FOR INDIVIDUAL EXCELLENCE.Reading professional literature andparticipating in continuing education specificto palliative and hospice care helps socialworkers keep up with the latestdevelopments in practice and research.

• CONSIDERING CERTIFICATION.The NASW-NHPCO credentials for hospiceand palliative social work allow socialworkers to demonstrate their commitment topalliative and hospice care.

• EDUCATING COLLEAGUES.Social workers can help their interdisciplinarycolleagues understand both the psychosocialchallenges associated with serious orlife-threatening illness and the social workrole in palliative and hospice care.

• RAISING CONSUMER AWARENESS.Effective social work intervention not onlyenhances client coping but also conveys apositive impression of the social workprofession.

• CONDUCTING RESEARCH.Research linking social work education withbeneficial client and program outcomes isneeded to make the case for hiring BSWsand MSWs in palliative and hospice care.

The revised

CMS personnel

requirements for

hospice social work

have garnered

concern among both

BSWs and MSWs.

Hospice and

palliative social

work require

specialized

knowledge and

skills, as described

in NASW’s

Standards for

Palliative & End of

Life Care (2004).