POLEK: I don't think so, because I think that our leadership realizes that even though we don't bring in money, we save the institution a great deal of money in a variety of ways. We find solutions for families and patients with complex problems, thereby freeing up other staff time. We help people leave the hospital at the appropriate time. We help people adjust and cope with news that isn't what they want to hear, again freeing other staff to perform other tasks. We are, frankly, often frontline prevention against lawsuits that could evolve from patients who perceived a lack of service. Although there are economic rationales for what we do, I'm proudest, of the intrinsic benefits we provide to patients, families, our co-workers and physicians.

HEIDECK: We also help patients and families adjust to intense treatment plans and assist the entire team when compliance issues arise.

BARR: By helping patients understand and follow long-term treatment plans, we can prevent readmissions.

POLEK: When self-pay or cash account patients come in, the social worker takes a large role in helping to access or find funding for them, whether it's linkage to MediCal or some other payment resource.

Q: Has it ever been suggested that you in fact do send bills?

POLEK: Actually, until about three years ago we did bill for services, but the cost didn't justify the return. Now there is a bit of a trend in the outpatient setting for social workers to bill as ancillary providers. Group therapy sessions in the Complementary Medicine Clinic are billable, and the Positive Care Clinic is looking at billing for certain activities, but overall, we are definitely not a revenue-producing department.

Q: What can physicians do to help you do your job most effectively?

BARR: Ask for assistance early, before problems have a chance to escalate.

POLEK: Physicians can help by not promising things to patients when they are uncertain what resources are available. Promises to patients such as "we'll provide housing if you need it," set unrealistically high expectations and make it harder for the social workers or the case managers to present "reality." A statement such as "you can stay as long as you need to" is open to a varied interpretation. It would be most helpful if the physician would just say, "I'm not really sure, but we do have resource people in the hospital who can assist you, and I'll be sure to make a referral."

Q: Do you work with both inpatients and outpatients?

BARR: Most social workers function almost entirely in one setting or the other, but Anne and myself are a bit unusual, because we work with the full spectrum of inpatient and outpatient activity.

Q: Can you describe your clients?

HEIDECK: I work a lot with leukemia patients, generally young people who are suddenly faced with a major illness without the ability to do much planning. At a time in their lives when they are expected to work hard, be independent, care for loved ones, they are suddenly vulnerable and dependent - emotionally and usually financially as well. Unless they are given treatment, they will die within weeks or months. And they face a pretty intensive treatment plan that can last two and a half years.

Q: Can you describe a case?

HEIDECK: I had a young man in his 20s, working part-time jobs, going to college. I worked with him to get him rapidly on MediCal, then obtained social security benefits so that he could pay for living expenses and wouldn't become homeless. We worked to make sure he could follow through on an intensive treatment plan that required him to come in two to four times per week initially. We made sure his family could deal with their shock and then understand what support was needed to help him.

BARR: In my world, the first person that a new patient meets in bone marrow transplantation is a social worker - usually me. We begin the assessment of coping skills, suitability for transplant, as well as making the new patient aware of the requirements for family participation. Part of what we do is help the patient get all the pieces in place to be able to come to transplant and be able to be discharged. We also troubleshoot problems that might exist within the family structure that could interfere with the treatment process. We try to head those off before we ever get started.

Q: For example?

BARR: Every bone marrow transplant patient is required to have a caregiver at discharge. The patients are so restricted that they must have someone who can drive a car with them 24 hours a day. By talking about this up front, you give patients a chance to get over the shock and start doing some planning. And if they get into difficulty, we sit down and work them through that. We troubleshoot by offering them an opportunity to explore their own environments, their friends, their families, their church groups. We've had people come up with all kinds of interesting alternatives to the standard "my retired mother can come and take care of me."

Q: Are there organized groups that can jump in to help when people can't find ready resources within their own network of family, friends and associates?

POLEK: There isn't a community agency that provides such a service free of charge. Someone who has no access to a caretaker of his or her own is typically someone who is relatively isolated and without a lot of resources either emotionally or financially. There are agencies through which people can hire a caretaker but it's very expensive and isn't covered by insurance. Remember, we're talking about 24-hour coverage and that can cost more than $3,000 a month for someone with no medical training and $5,000 to $7,000 per month for round-the-clock coverage by LVNs or RNs. So the social workers can get very creative and very persuasive with extended family members, neighbors, everyone trying to help a potential patient access caregiving resources.

BARR: Churches often provide tangible support to their own members.

Q: Much of your contact is face to face. Could some of that be streamlined by using telephones and other aids?

POLEK: Probably no physician who has utilized a social worker would ever think our services could be done by telephone. Even if practicing physicians don't know exactly what social workers do, they have come to rely on social workers in those cases in which they are near their wit's end. They clearly appreciate the fact that a family or patient has needs well beyond the scope of what they are able to provide.

Q: Trilla, you have worked in the Emergency Department as well as in transplantation. Is the work quite different?

BARR: Yes. The two different environments require completely different sets of skills. In the emergency room, the skills needed are very rapid, very concrete and solution oriented. It involves quick assessments and immediate responses. In bone marrow transplant the scenarios are long-term and I have time to plan. I think I have more time than Anne, who must deal with patients who are suddenly diagnosed with a rapidly progressing disease.

Q: How does your professional training relate to finding solutions?

BARR: You don't stop when it looks like the end of the road. Part of what we learn professionally is the skill to explore resources and to take resources and follow them to their logical conclusions. Then we look further. For instance, just because you have someone who might be eligible for assistance from a state or federal program, doesn't mean there aren't other programs available. Within specialized areas you get to know what those programs are.

HEIDECK: The orientation of social work has always been person and environment, different from psychology which focuses on internal happenings. We try to look at the person in a context of his or her physical, social, psychological and cultural environment. We look at what patients' roles are in the family, what their roles are in society, how they see themselves. We believe in self-determination and are careful not to superimpose a decision.

BARR: Social work is an enabling process. You show people how to do things for themselves.

POLEK: Managing group and family dynamics is a big part of what we do. We need to be able to negotiate in a hostile group or an enmeshed family situation. These are skills that are taught to social workers within their professional training. Psychologists and psychiatrists tend to focus on what is going on internally with the patient, while social workers are trained to think about the system and help the patient find the best possible solution.

Q: Has the financial pressures of recent years changed how you operate?

BARR: For me, no. Bone marrow transplantation has always been very focused on the issue of making sure that we could continue the program. Consistently, we have looked at what coverage the patient had, how we could expand that coverage if necessary and then proceed to get authorization. We don't hesitate to suggest that patients become advocates, political and otherwise, to seek changes.

Q: Can you be specific?

HEIDECK: We're pretty active advocates ourselves. I had a young woman who went through leukemia treatment, then got a massive infection, ended up in an intensive care unit and then needed a lot of rehabilitation. She was 27 years old and basically had to learn how to live her life again. She needed to relearn such basics as standing and walking. The insurance company was telling us we had to send her to a nursing home, and they wouldn't qualify her for intensive rehabilitation. So I wrote a letter advocating for her that putting her in a nursing home with people who were 70 and 80 years old and demented wasn't going to give her the program she needed to become a functioning, working, independent adult in this society. I said she deserved the chance to get back on her feet, but it took a couple of letters to actually get that approved. I have to say, she's now out working again and has had a baby and is functioning well.

POLEK: Social workers are in a unique position to help advocate for patients because, in addition to their advocacy skills and understanding, they also have access to the medical data that third-party payers need to make informed decisions.

Q: As a tertiary referral center are you called upon to understand community resources over a wide area?

POLEK: Yes. We need a knowledge of community resources throughout the nation.

Q: What are some major issues you are facing?

POLEK: Housing for patients and families. I can't explain what a huge issue this is. Some patients are impoverished in another state, and when they come to California, you have to tell them the economy motel costs $85 a night when their income is $500 a month.

Q: So what can you do?

POLEK: We have developed within the department different low-income housing resources. We use the Santa Clara County Assistance League's HOME apartments on Welch Road, but that meets only a fraction of our needs. We've developed relationships with local hotels to provide patients with hardship rates of about $50 per night. We've leased some rooms in apartment houses, which we rent out for $25 per night. We are asking community volunteers to open their homes for, say, $10 to $15 a night for patients or families. Trying to meet the temporary housing needs for financially challenged individuals is a mission for our department.

Q: How many housing units do you have?

POLEK: About 50, including 38 at the HOME apartment, with the rest in apartment buildings and about five units a day at hardship rates at several local motels.

Q: Is that meeting the need?

POLEK: We're close. At the end of the day, the people who need housing are housed. But it's a scramble and occasionally people have to remain in the hospital or have to take a unit that is too expensive.

Q: Elizabeth, the other component of your department is case management. How should physicians know which of the specialties to contact when they need assistance?

POLEK: The short answer is if physicians call, we can easily figure out who can help them. Generally, the case managers, who are RNs, are primarily responsible for utilization management - interfacing with the insurance companies and doing medical discharge planning, such as arranging home care, transfers to other hospitals, skilled nursing facilities or subacute rehab. If doctors have a question about insurance coverage, or the discharge disposition, that would go to a case manager. If they are in need of community resources, if the family is in crisis emotionally, if there are some real concerns about the patient's finances, these would go to social workers. Of course there is overlap. For example, both case managers and social workers may handle referrals to hospices. If there is a really difficult family, and the difficulty hinges on where the patient will ultimately go after the hospital, there may be a family conference involving both the case manager and social worker, as well as others. The case manager is primarily responsible for the discharge plan, but if that process has become so complicated because of psychosocial issues, then the social worker may also help.

Q: Can you give an example of social workers and case managers working closely together?

HEIDECK: We had a discharge recently - a man with advanced prostate cancer, new wife, a lot of family issues around caring for him at home, the rapid progression of the disease and adult children coming in from another state. We needed to set him up for IV pain medication, oxygen and to help his wife understand and cope with the dynamics of what was clearly a terminal illness. The wife needed to get ready to become the primary, 24-hour-a-day caregiver at home. It was helpful to have both a case manager and social worker with two perspectives. In very general terms, the nurse case manager can discuss the medical details, third-party payer rules, and the regimen, while I can help the family understand, accept and adjust to the plan that needs to happen - what does this mean to you and family members, emotionally, socially, financially? Both the nurse case manager and myself can go over the wide ranging differences of such things as custodial vs. skilled nursing care. Having the case manager/social worker team available to talk about hospice care is useful. Again, the nurse can talk about pain control measures - how the pump is going to work. I may talk about how the family members can take care of themselves as caregivers. I can help explore how extra help can be brought in, how adult children can be mobilized and also ask such frank questions as "Would you feel comfortable with a loved one dying at home?"

Q: How do you plan your day? Do you make appointments or wait to get beeped?

BARR: We prioritize our day's activities according to need and patient availability.

HEIDECK: If you walk in in the morning and someone is in crisis, that's where you start. In the outpatient setting, I look at the daily schedule to see if there are patients I need to check in with about ongoing issues. On inpatient units, I look at the census, then check with the physician teams, case manager and unit nursing staff. Today, for example, three or four consults were referred by nurses, and the father and mother of a patient who has been here a long time came to me to talk about some arrangements we need to make over the next few days.

Q: Where do you see patients?

HEIDECK: Usually in the patient's room. If it's a group or large family we may use a consultation room.

Q: On an average day, how many patients would you typically see?

HEIDECK: Obviously it varies, but thinking back to a typical day - maybe 10 patients on the unit and three or four outpatients.

Q: How have cuts affected your operations specifically?

POLEK: We were already leanly staffed, but we did take about a 15 percent cut. One step we decided to take was to limit ED coverage in the morning, using social workers from other units as needed during that traditionally slower time in the ED. We also cut back on support staff. Many of the social workers now have a larger caseload, such as an additional nursing unit assigned to them.

HEIDECK: I think that we are going to try to do business as usual, but I think there is an impact on the caseload. We are going to be busier, and we have a challenge to meet.

POLEK: We've made some adjustments that have pushed everyone to work with maximum efficiency. Everyone must carefully prioritize their referrals and interventions based on intensity and immediacy. Additionally, I think that the social workers are impacted by cutbacks in other departments. For example, for budgetary reasons, security will no longer transport patients to local hotels, a service we traditionally arranged. For us, that's turned what used to be a one- minute solution into a problem that requires an hour to solve for patients.

Q: Do you have funds for patients?

POLEK: We have restricted funds from donations from such sources as the hospital auxiliary and some small foundations that social workers are able to access for highly specific services. We use this money primarily for subsidizing housing, subsidizing pharmacy, transportation, meal vouchers.

Q: How much money is available?

POLEK: We have about $150,000, but that is misleading. This is restricted money. For example, we have about $63,000 earmarked by an endowment for "hospital room charges." Well, these days that much money could easily be depleted by one patient. We've not been able to gain flexibility for the fund. It is too little to go far enough for hospital charges, and yet $63,000 could be of enormous value to help with medications, durable medical equipment, home care visits, or a couple of days in a skilled nursing facility.

Q: Why did you get into the profession?

POLEK: I think we want to spend the hours that we spend working doing something that positively impacts individual families.

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