After experiencing such a life-changing event, a person with SCI has to deal not only with the arduous process of medical recovery and regaining of functioning, the person may also be confronted with ensuring financial coverage of medical and rehabilitation services, acquiring financial support for assistive products, personal care assistance, or modifications to car or home, or clarifying whether returning to work is possible given the new health and life situation. Having to handle all these and many other issues can be overwhelming if the person with SCI has to do it alone. Thus, providing social service support in rehabilitation, for example through a social worker-case manager (SW-CM), is essential, especially considering the myriad of insurances and regulations in healthcare.1
For persons with SCI, a key socioeconomic component of the rehabilitation and community reintegration process is insurance. The coverage and type of insurance can impact outcome. For example, the large-scale SCIRehab Project found that compared to private insurances, non-private payers with more limited insurance coverage like Medicaid, the social welfare program in the United States, was associated with lower social integration and mobility scores, higher likelihood of rehospitalisations, more time in psychology interventions, lower likelihood to be working or at school at 1 year post-SCI, and less life satisfaction in persons with SCI. The SCIRehab investigators suggest that the negative influence of more limited insurance coverage on outcome may be related more to social and other circumstances, such as lower socioeconomic status that may, in turn, influence educational and vocational opportunities, rather than the insurance coverage itself.23 Nevertheless, dealing with insurances is among the most important and time-consuming tasks of a SW-CM in the rehabilitation of persons with SCI, especially as part of discharge planning.134
Box 1 gives an overview of different types of insurances that are relevant for persons with SCI using the high-resource country example of Switzerland. Note that other countries, especially low-resource countries, may have different types of insurances as well as insurances with a different scope of coverage.5
In Switzerland, there are various types of insurances that are relevant for persons with SCI:6
These insurances, along with other insurance systems e.g. unemployment insurance, are embedded in the general social security system in Switzerland. One essential feature of the Swiss social security system is the three-pillar system:6
Beyond the support provided through the various insurances and Swiss social security system, there are also organisations in Switzerland that offer different types of assistance. For example, membership in the benefactors' association run by the Swiss Paraplegic Foundation (www.paraplegie.ch) provides a one-time benefit of 200'000 Swiss Francs in case the member experiences an accident resulting in a SCI and consequently requires a wheelchair to get around.
Acquiring insurance coverage for as many SCI-related expenses as possible is essential for preventing the person with SCI from experiencing financial hardship, especially considering the high financial burden associated with SCI. Despite the lack of comparable data on the cost of SCI, the existing evidence indicates that persons with SCI bear much of the costs. Expenses, such as the cost of assistive devices and long-term personal care assistance, tend to be high even after initial healthcare costs have decreased.5 In one study that examined the prevalence of medical debt in personal bankruptcy filings of persons with SCI or traumatic brain injury, the investigators concluded that medical debt played a major contributing role in the bankruptcies (filed within 5 years post-injury) of the 93 persons included in the study.7
Furthermore, given that the employment rate among persons with SCI is relatively low, particularly for those who are older,589 finding other means of maintaining financial security after SCI is essential.
In 2014, the profession of social work was broadly defined by the International Federation of Social Workers (IFSW) as “a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversities are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledge, social work engages people and structures to address life challenges and enhance well-being.”10
Drawing scientific and practical knowledge from diverse disciplines, the expertise of social workers is essentially interdisciplinary and transdisciplinary. Social workers recognise the dynamic interaction between a person with his or her environment, and implement measures to empower a person to take responsibility for actively addressing life challenges and for finding strategies to enrich his or her life.
These general principles of social work is universal. However, social work focus and practice may vary across countries and cultures. For example, in Switzerland the general aim of social work is to promote a person's independence and self-determination to enable the person to fully participate in life situations and in society as a whole.11
Social work practice encompasses a variety of interventions, such as “various forms of therapy and counselling, group work and community work; policy formulation and analysis; and advocacy and political interventions.”10
Within a rehabilitation context, specifically rehabilitation for persons living with SCI, social workers aim to achieve many of the same general goals as in other contexts. Box 2 outlines the role of social work-case management in SCI rehabilitation.
Since social workers (includes case managers, but will not refer to case managers explicitly from now on) in various healthcare settings gather and employ functioning information, as well as conduct ongoing functioning assessments in clinical settings, it is important that social workers are familiar with the World Health Organization's (WHO) International Classification of Functioning, Disability, and Health (ICF).1213 Furthermore, the biopsychosocial model of the ICF is closely related to the principals of social work, especially in emphasising the impact of a person's environmental factors on functioning and disability and in promoting a person's participation in life situations. In support of the interdisciplinary and transdisciplinary nature of social work, the ICF also facilitates the communication and collaboration among diverse health professionals.131415 Lastly, the ICF provides social workers with a standardised terminology to describe a person's functioning status, strengths and weaknesses, and informs the planning of social work interventions.14
The use of the ICF in rehabilitation management, that also includes social work services, is illustrated in this case study of Conrad. Conrad's case also shows the role of the social worker in addressing issues that persons with SCI face in planning for community integration, specifically in navigating the landscape of the social security and insurance systems.
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