Laura Shea, MSW, LICSW, clinical social worker, Phyllis Jen Center for Primary Care


Laura Shea and Rose Kakoza

As a clinical social worker in the Phyllis Jen Center for Primary Care, I see firsthand how challenging it is for patients with multiple life stressors to manage their physical and mental health. Managing a chronic disease, such as diabetes or chronic obstructive pulmonary disease, may feel impossible when also facing poverty, unstable housing, untreated psychiatric disease, substance use disorder and other challenges.

To provide more intensive support and care management for vulnerable patients, Brigham Health joined other Partners HealthCare institutions in launching the MassHealth Medicaid Accountable Care Organization (ACO) pilot last December. As a Medicaid ACO, we are making a commitment to providing more comprehensive, coordinated high-quality care to Medicaid patients.

The goal of the pilot phase, which concludes in December, is to better understand what our Medicaid patients need and how we can best support them. The pilot covers the entire care continuum, with a special focus on three of our primary care practices: the Jen Center, Southern Jamaica Plain Health Center and Brookside Community Health Center. At these pilot sites, community health workers and social workers are working closely with Medicaid patients to increase primary care engagement and care coordination.

An innovative new role, called Social Work as Lead, was established at the primary care practices participating in the pilot. Dedicated to a select group of high-risk Medicaid patients, these social workers support Medicaid patients who have significant psychosocial and behavioral health challenges that make it difficult for them to access medical and psychiatric care.

Many of my patients have been marginalized because of their race, class, gender, sexual orientation and other parts of their identity, so establishing a therapeutic alliance that empowers them to advocate for themselves and engage actively in their care is a key component of my work. One example of how social workers help patients achieve these goals – and ultimately improve their health – is a technique I use called motivational interviewing. This approach allows patients to explore their own reasons for wanting to change and identify ways to move toward their goals.

“What is so exciting about this pilot is that it recognizes the need to leverage the unique skills and expertise of our social work colleagues in the coordination of care and management for a unique and vulnerable patient population,” noted Rose Kakoza, MD, MPH, medical director of the Medicaid ACO pilot and assistant medical director of BWH’s integrated Care Management Program. “We believe these types of innovative solutions in health care will be necessary to not only improve quality and reduce costs, but also achieve health equity in our health care system.”

It is a privilege to work on a dedicated interdisciplinary team to provide compassionate, evidence-based care to a remarkably resilient group of patients. My hope is to continue to develop new ways of providing care to these vulnerable patients.