Data Summary and Analysis of Clinical Social Work and Rural Mental Health Services Program Implementation
Kurt D. LaRose first published this summary under the title of “Data Summary and Analysis of Clinical Social Work Program Implementation at The FAMU School of Nursing Gretna Wellness Center” in May 2005 with updated commentary in 2011, 2018 and 2019. The report/article highlighted implementation of mental health services in a rural community, later included as the basis of a Rural Community Health course for university students in S. Georgia and now a component of ongoing implementation services for onsite mental health.
Note: Power Point and Youtube Video information related to this article, along with various other program implementation models and platforms can be found throughout this page by clicking related links.
INTRODUCTION: The following graphs highlight various components and aspects of the social work program [that used to operate] at the FAMU School of Nursing Gretna Wellness Center. The Center is [was] a walk-in medical care center that provides primary care in a rural North Florida County. The Social Work program was added to the Center via a partnership 1between the Center and The Florida State University College of Social Work and the first Clinical Intern placed there created the mental health (and case management) services in conjunction with the medical team and onsite Advanced Nurse Practitioner. The partnership provided insight into how the medical model and the bio-psycho-social-spiritual model, once unified for the interests of patients, can have positive outcomes.
The Social Work program began in January of 2005 at the Center as a first time field placement opportunity through the Florida State University College of Social Work. There were no mental health services in the walkin center at the time, and the program that was there was not yet codified. In the first four months of the program’s implementation a multitude of administrative, program development and client-centered services were provided. In this summary the general client centered services are highlighted, dollar values are assigned to the services that were provided, and a segment of the report factors in limited administrative dollar values. The Wellness Center is [was] open two days per week for client services; many case management and administrative services were provided during days the clinic was closed. This report concludes with a summary, a discussion about cost/benefit analysis limitations, and a disclosure as to the data sources used to generate this report.
22% of the clients who were directly served during the social work (SOW) internship at the Center received mental health (MH) services. These clients were identified via in-house referrals from the on-site ARNP, with three referrals made from the rural North Florida communities of Gretna, Quincy, and Chattahoochee.
78% of the clients served at the Center received case management (CM) services, with a significant amount of time invested in finding and utilizing multiple medication patient assistance programs for patients who were previously dependent upon available sample medications. Multitudes of other CM services were provided (see “Service Provision” graph in this document).
“This analysis evaluates social work counseling and medical services—when offered together. It shows that onsite services can work! The value of mental health counseling cannot be measured in reducing symptoms only—not every life transformation requires a prescription. Sometimes a good bit of team work, coordination, and structure procedures with evaluations go a long way too. The value of onsite counseling services can be measured in dollars literally and by the lives that are rejuvenated into functional families, continued education, spiritual connectedness, and productive careers. This program implementation was a success, if nothing else were accomplished!” – K. LaRose
Mental health services were provided under the direction of multiple professionals and frequent supervision. Evidenced based practice methodologies were utilized on a case by case basis relying heavily on pre and posttest assessment instruments with known strong psychometric properties. “Children” is, of course, not a mental health typology. These cases are separately noted (but included in this graph) based upon the uniqueness of children’s issues. Two children presented to the social worker with mental health concerns and/or requests for medication, via parent and/or school identification, however neither child actually had mental health pathology. The third case presented with an apparent mental health concern requiring medication intervention (provided via referral). “Assessed” means the client was seen on no more than two occasions and a full written treatment plan was either not developed and/or not implemented, even as interventions were applied. Due to the brief nature of services a formal diagnostic impression was never made for these two cases.
It is important to note that there were multiple mental health consultations during the course of the Fall 05 SOW internship. Three Licensed Clinical Social Workers (LCSW) who were consulted in weekly “supervision” meetings provided consultation at their private practice office(s) in Tallahassee. In the normal operations of the private practice, it was routine for a Psychiatrist, Marriage & Family (M/F; Systems) professional and a Play Therapist (TX) to attend the supervision meetings (with each expert attending one meeting per month). Each expert was paid to provide case consultation (staffings) by the private practice LCSW’s. Other consultations occurred at random, as needed and often occurred via telephone.
One-hour increments were estimated for all mental health clients who were seen weekly and one-hour increments were estimated for all case management clients. For clients who received both services, CM hours are reduced by one hour for each week MH services were also provided. During the course of the internship a total of 260 hours of direct client contact was recorded. The remaining 252 hours (of the total 512 internship requirement) were relegated to administrative and program development tasks. Dollar Value estimates for administrative social work tasks can be found in the latter pages of this report.
“Helping rural centers, school districts and onsite providers of social services improve existing programs is a real joy! In communities where formal onsite counseling programs have not existed being a part of the people who develop one – using digital technology that includes remote access and branded digitally time stamped documents – is amazing. In 2005 when this program was first conceptualized, and in the few years after it where other onsite services were implemented and consulted – the HIPAA encrypted technology was so new to “the little guy” – that the terms to describe digital private practice didn’t yet exist. Today, to see programs still working where I have been fortunate enough to help, and even with those that are now fully transitioned to their respective agencies and other professionals onsite – a breeze thanks to the technology of 2018 – it just means more communities, more professionals, more services, and more people are getting help.” K. LaRose
The various services that were provided to the clients during the internship span the gamut. Love at Work is a home repair program provided by a Tallahassee faith based community whereby the social work program agreed to provide home visits, interview potential recipients, and perform financial evaluations on clients who requested this free service. The goal was to use the medical model principle of triage to best utilize the freely (and limited) resources available through Love at Work. Many of the represented services were provided via referral and several cases required multiple services simultaneously. The case-by-case breakdown of SOW services provided include: Patient Assistance (22), Home Visits (12), Voc Rehab (2), School Staffings (2), Love at Work (21), Meals on Wheels (2), Food Assistance (3), CIL (1), Mental Health (17), We Care Network (5), Utility Assistance (1), and Lions Club (2). This list is not exhaustive. For full explanation of all service definitions, continue to the latter sections of this report (see “PROGRAM DEFINITIONS, SERVICE NETWORKING AND REFERRAL SOURCING”).
The dollar amount that is noted in the “Service Value – Mental Health” graph utilizes a flat hourly rate of $90.00 per hour for consumer purchased mental health counseling services (75 TL MH Hours x $90.00). The rate is likely more than the Gretna market could bear and it is an estimated amount based upon the rates of other known licensed practitioners in surrounding areas (NOTE: This rate is not the highest rate for counseling services).
The rate per hour ($19.80) that was utilized to estimate the “Service Value – Case Management” amount is derived from annual earnings of $38,000 for a practicing MSW (lower than the national average of $42,000), working 40 hours per week, based upon a 48 week work calendar. The “CM Cost Contribution” is tallied using $19.80 x 185 (TL CM HRS). The “TL Cost Contribution” is tallied by adding the “Cost Contribution – CM” and “Cost Contribution – MH.” Similar to the mental health hourly rate estimate, the Gretna market is probably unable to bear a $19.80 hourly pay rate for social work services. Based upon socio-economic factors the CM rate would likely drop significantly, and would require the services of a BSW practitioner – not an MSW.
The “Dollar Value Comparison” chart shows that the “cost” of mental health services would far exceed the cost of case management services – even when mental health services are provided to a much smaller percentage of the population. 65% of the dollar value was provided to only 22% of the clinic population; the remaining 78% of the clinic population consumed 35% of the dollar value. Even if the hourly rates for Mental Health services and Case Management services were adjusted related to the economic forces at play in the Gretna area, the cost dollar value share for mental health services, compared to case management services, would likely remain significantly higher. Case management services are generally more affordable to provide, thus more clients potentially could access them, while mental health services would remain harder to obtain in the commercial/private sector.
When considering the dollar value of all services provided, compared to the total number of clients assisted via social work at the Center the “cost” per client equals $135.23 (77 clients / $10,413 TL Dollar Value). When comparing the total number of client hours to the total dollar value of all SOW services provided, the dollar value per client – per hour equals $40.05 (10,413 TL Dollar Value / 260 TL CM & MH Hours). On average, each client received 3.4 hours of social work services (mental health and case management hours combined) in a four-month period (260 TL CM & MH Hours / TL SOW Clients). These dollar value estimates are based upon direct client service provision and do not reflect estimated administrative cost/dollar value factors.
The “Combined Direct Client Service Value and Administrative Service Value” graph highlights the cost factors that were/are relevant to the total dollar value contribution – administrative dollars and direct client dollars. Administrative dollar values are reported separate from the CM and MH dollar value contribution amounts, which are direct client dollar values. The Administrative (Admin) Service Value amount ($4,989.60) was tallied using the annual $38,000 MSW salary estimate that was previously referenced in this report (see “Service Value – Case Management” graph) by multiplying $19.80 (hourly pay rate) x 252 (total administrative and program development hours). The “Total Service Value” ($15,402.60) dollar amount is the combination of Admin, CM, and MH dollar values.
Program Implementation Data Analysis Summary: What it all Means…
Social Work services were key in meeting the needs of the people of Gretna and surrounding areas, who utilized the Center as a primary care service center (the center closed several years after this program was implemented, and after this 2005 report was completed). While the population of the city of Gretna is rural (1,700 people; 2000 Census) other communities were/are impacted – Quincy and Chattahoochee. [NOTE: with the 2011-2012 casino developments in the community the need for rural mental health services is likely to be increasingly necessary].
“Whenever a Clinical Social Worker is able to provide onsite mental health counseling services in cooperation with an onsite prescriber and a number of other professionals in the agency and in the community — and here in this onsite program where the prescriber saw value in the bio-psyco-social-sexual-spiritual model—it is (and was) the client who benefits the most. This data analysis gives credence to that fact. Too, the other programs that have been implemented, evaluated, and successfully set up for to account for provider transitions, administration transitions, using digital onsite services – tells me that more onsite programs – existing or new ones – are fertile ground for increased professionalization. It’s so cool to be apart of the changing face in digital mental health services! Today in 2018, after nearly 14 years of working in the office, onsite, and most recently now online – allot has changed since this presentation was first completed!” K LaRose
The introduction of onsite mental health and social work services into Gretna was an important factor in addressing gaps in services that were previously identified in Gadsden County, such as mental health counseling. Even as the community was more aware of the mental health component, the nature of the internship task of program implementation (and continuity of care) at one point necessitated a mid-term moratorium on new clients. Patient demand would have increased, provided the services could have been continued. The small number of mental health clients (n=17) does not accurately identify the needs of the community or address the dollar value of those same services. Case management services, according to the numbers presented herein, appear to be in greater demand, but those services were provided without moratorium, up to the last day of the internship.
Most patients who were enrolled into PAP’s benefited from the patient assistance programs by getting free medications via pharmaceutical manufacturers. Prior to the implementation of the social work program at the Gretna Wellness Center, patients received manufacturer medications when/if the onsite ARNP had time to enroll the patient; and because the ARNP treated an average of 45 clients per week without the assistance of a social worker, PAP’s were uncommon prior to the introduction of Clinical Social Work services. To date, only one patient has been denied PAP approval.
Dollar value numbers included in this summary do not factor cost savings for free medications that patients received due to PAP enrollment. These numbers were not included in this report due to the prohibitive nature of obtaining the prices of every medication for each client, which varies according to milligrams, daily dosage, treatment timelines, retail versus manufacturer cost variability, and formulary factors. Similarly, the dollar values do not reflect cost benefits from mental health counseling outcomes, such as improved employability, reduced medication usage, fewer sick days, etc. The administrative dollar values that are included in this report are limited only to those hours that were utilized by the MSW intern during the course of the semester. Administrative dollar values do not include cost factors for mental health consultations (psychiatrists, play therapists, marriage and family therapists) and/or any other indirect administrative factors (building, office equipment, supplies, utilities) or other partner/personnel involvement (AHEC, PAEC, GCHD, FSU, FAMU, CMO, or the City). These numbers, medication cost savings, cost benefit factors, professional consultations, operations costs, and extraneous partner costs could be quantified, but in general, they are outside the scope of this report. A more thorough assessment should be considered as it would more accurately place a dollar value contribution to the Gretna and Gadsden County community as it relates to the newly formed Social Work program at the Gretna Wellness Center.
The Center did not have a social work program prior to this internship. Multiple policies and procedures had to be developed and codified. Assessment and treatment interventions were researched, developed and utilized. Another task was to formalize and codify an agency specific policy and procedure manual with the addition of policies and procedures geared to case management social work duties and mental health social work duties.
In the final analysis of the implementation of the Social Work program at the Gretna Wellness Center the medical model and the bio-psycho-social-spiritual model partnered to meet the needs of an impoverished population. Quality healthcare, as it is generally defined, is often perceived as a biological hard science. At the FAMU School of Nursing Gretna Wellness Center, in large part because of the insight and broad knowledge base of the nurse practitioner—the terms “quality healthcare” are misnomers. The union of the medical model and the bio-psycho-social model provides the Gretna community with premium healthcare.”
The social work program that was implemented at the FAMU School of Nursing Gretna Wellness Center was made possible in part, due to a stipend that was paid by the Big Bend Area Health Education Center. Other community partners enabled the SOW program implementation to occur: Florida A & M School of Nursing, Big Bend Area Health Education Center, FSU College of Social Work, FSU Community Medical Outreach, FSU College of Medicine, the City of Gretna, and the Gadsden County Health Department. The dynamic role of each partner (both formal and informal) was addressed in a Power Point® presentation (and since that first presentation, a number of other onsite programs and professional development implementation services have evolved)! None of the day-to-day roles fulfilled by clinical social work could have been possible without the support, trust, encouragement, and enthusiasm of Debra Danforth, MS, ARNP (the onsite practitioner).
Additional information about the internship, including copies of the Policies, Procedures, Referrals, Originals (PRO) Manual, and documents that explicate evidence based practice methodologies can be obtained by contacting the author of this report, Kurt LaRose. The PRO manual later was used as a component at Thomas University Division of Social Work, where LaRose was a professor, educating up and coming social work professionals in the implementation and design of behavioral health and case management programming in under served and gaps in services agencies (either by volunteer or by agency design/creation).
PROGRAM DEFINITIONS, SERVICE NETWORKING AND REFERRAL SOURCING
Program Definitions – Onsite Program Implementation Services
The following terms and links are part of an article / presentation that was originally published by LaRose in May 2005 (with some revisions in 2011 and 2018) titled: “Data Summary and Analysis of Clinical Social Work Program Implementation at The FAMU School of Nursing Gretna Wellness Center.” Information about the article, the associated training presentations and other onsite professional development aspects can be found throughout this report and via the links provided.
What is Patient Assistance?
Patient Assistance, in the context of the medical setting, refers to obtaining free medications from pharmaceutical manufacturers. The process required financial evaluations completed by the social worker, supporting tax documents, a doctor’s prescription, and the patient had to be without any kind of public or private health insurance. The requirements vary between various companies, however most pharmaceutical companies offer patient assistance programs. Narcotics and addictive medications are not covered under patient assistance programs. If you’d like information on whether or not a medication you are taking is covered under patient assistance programs, please see your drug manufacturers website.
What are Onsite Counseling Services and Program Implementation Services? They’re customized to bring mental healthcare to clients just about every where! Where supplemental behavioral health services are not provided in house (or when in-house professional development services are desired), program implementation, secure server data management and digital overlay services technology, staff training and school related onsite services, mental health counselor training, consultation, and where permitted by law, supervision services can be included in the onsite counseling services offered. Just as it was at the Gretna Wellness Center program implementation in 2005 (just as grad school was wrapping up) to a 14 year schools program that was effectively moved from sub-contract to in-house, there’s nothing quite as exciting as seeing the onsite service model take shape! My hope is to bring more and more standardized protocols and training options to onsite providers anywhere and everywhere possible!
What are Home Visits?
Home visits included going into the houses of residents who were seeking home repair assistance through the Love at Work program. Home visits included informal assessments of the degree and severity of deteriorating properties. Homes with more extensive damage were prioritized over those with less damage.
What is Voc Rehab?
Vocational Rehabilitation is a state sponsored program where career counselors assist unemployed person’s obtain work. Voc Rehab is utilized by people who have been out of work due to medical reasons, when recovery enables them to return to work and/or find different employment.
What Are School Staffings?
A School Staffing occurred in cases where consultations with teachers, coaches, and/or school administrators were needed in order to assist youth experiencing academic difficulty. By meeting with school personnel, parental and child reports could be validated or supported. The school setting provided multiple informants so that academic, behavioral, social, and psychological factors were thoroughly assessed. Staffings also allow the school to ask questions related to methods that might enable them to better assist problematic youth. (See School Counseling Programs Here)
What is Love at Work?
Love at Work is a faith based home improvement initiative whereby youth groups spend parts of their summers rehabilitating dilapidated homes. Because of the financial constraints that often exist for families living in poverty, an ever increasing problem in rural communities with limited economic growth, access or development, many families live in homes that are in need of repair. Love at Work is an outreach of the Killearn United Methodist Church in Tallahassee, Florida. The missions based program focuses its community assistance services to the Gretna and Gadsden County area providing roof repair, painting, and other services free of charge. The social work program at the Center provided the home inspections and financial evaluations in an effort to triage the more critical cases in which homes were exposed to the elements.
What is Meals on Wheels?
Meals on Wheels is a volunteer based feeding program ran by Elder Care Services, providing warm and diabetic meals for the Big Bend area (several North Florida Counties make up the “big bend area”). Elder Care is supported, in part, by various federal, state (FL. Elder Affairs) and local funding authorities. The Gretna Wellness Center social work program made referrals to Elder Care Services and its Meals on Wheels program, for geriatric clients who were in need of meal and/or food assistance.
What is the We Care Network?
The We Care Network is a medically based organization that facilitated (and still provides) referrals for medical procedures. Clients were referred to the We Care Network from the Center based upon medical need, and the We Care services were available to those patients who were in need of medical procedures, and who did not have health insurance and who could not afford to pay for the procedures. The ‘Network’ was (and is) comprised of medical professionals who have agreed to donate their time and services dependent upon their ability to do so.
What are Lyons Eye Glasses?
The Lyon’s Club has an eye glass program where clients can access eye care services free of charge. The services were (and are) provided only by referral, and in order for clients to access the program the social worker provided initial financial assessment and intake information to the Lyon’s Club. If approved, clients would receive one free pair of eye glasses.
DATA SOURCE: All data are taken from SOW Center records as of 4/21/05. Hours were extrapolated and tallied using the data located at the Center. It is important to note that while the hourly estimates are not exact, they are conservative estimates. Clients seen by the social work intern were recorded in the Excel® spreadsheet when services required a formal interview and/or when documentation was necessary to adequately meet the needs of the client. Every client who was assisted by the intern was not recorded as a SOW client receiving services in the spreadsheet where data was maintained; therefore this analysis reflects practical intern roles and services at the Wellness Center. The date range of program implementation and service provision begins January 6, 2005 and ends April 29, 2005. Graphs were created using MS Excel®.
NOTE: Article was originally published by LaRose in May 2005, titled as: “Data Summary and Analysis of Clinical Social Work Program Implementation at The FAMU School of Nursing Gretna Wellness Center”. | Rev 2011 | Rev. 2018 | Rev. 2019 |
OTHER ONSITE PROGRAM EXAMPLES
| School Programming | Professional Development and Implementation Options | Teacher / Professional Development Example | Digital Services Overlay and Data Management Example | Digital Server Overlay Set Up Support Services | Other Program Implementation Services Examples