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
Insurance – A Key Socioeconomic Component
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. 2 3 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.1 3 4
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
Box 1 | Insurance Systems in Switzerland
In Switzerland, there are various types of insurances that are relevant for persons with SCI: 6
- Health insurance – All residents in Switzerland must have health insurance. The insured person pays a premium for coverage for basic healthcare for illness, pregnancy or accidents (if not covered by accident insurance). The premium rate depends on the person's choice of health insurance company, insurance policy, and place of residence, and is generally not income-dependent. However, a reduced premium rate is available for selected low-income insurers.
- Accident and occupational diseases insurance – Paying into this insurance fund is compulsory for all employed and unemployed persons. The employer is responsible for paying the premium for workplace accidents and occupational diseases, while the employee is responsible for paying the premium for non-occupational accidents. However, the employer pays the insurer the whole premium and deducts the employee's part from the salary. For persons not gainfully employed (housewives or househusbands, children, students, retired persons) and self-employed persons, this type of insurance can be taken up on a voluntary basis. Accident and occupational diseases insurance covers medical treatment in- and outpatient, medical tests, medication, rescue and transport costs, and some medical devices.
- Invalidity (disability) insurance – This insurance is compulsory for anyone who is living and working in Switzerland. This insurance aims to eliminate or reduce the impact of long-term (more than 1 year) physical, psychological, or mental disability first and foremost through the provision of rehabilitation measures, and as a last resort cash benefits. Cash benefits are granted when the insured person, after receiving rehabilitation, is still unable to work or complete daily tasks at full capacity. Benefits are determined by the degree of disability (or invalidity). The invalidity (disability) insurance also offers a so-called “helplessness allowance” that pays for personal assistance required by persons with disability to complete day-to-day tasks, such as self-care.
- Old-age and survivor's insurance – Starting with 17 years of age until the statutory retirement age (currently 64 years of age for women and 65 years of age for men) persons in gainful employment are required to pay into the old-age and survivor's insurance. This insurance is a sort of fund from which the person's retirement benefits (or old-age pension) is derived. This insurance also offers subsidies to cover the cost of certain assistive technologies and devices, such as hearing aids or wheelchairs, for retired persons with disability.
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
- The 1st pillar, a state-run programme, is the old-age, survivors and invalidity insurance (AHV), and aims to cover basic living costs. Contributions from employers, employees, and self-employed into the system is compulsory; public authorities contribute to the AHV as well.
- The 2nd pillar is the so-called “occupational benefit plan”. Contributions to this pension plan is compulsory for employees earning at least 21'150 Swiss Francs (status 2016) annually and is financed equally by employees and employers. The 2nd pillar together with the 1st pillar aim to ensure that the person is able to maintain their standard of living as much as possible.
- The 3rd pillar is a voluntary system in which the person pays into a fund at a selected occupational benefit institution such as a bank or private insurance company. The aim of the 3rd pillar is to supplement other pensions so that the person is able to maintain their usual lifestyle after retirement.
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.
Impact of SCI on Financial Status
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, 5 8 9 finding other means of maintaining financial security after SCI is essential.
Defining Social Work
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.
Box 2 | Social Work-Case Management in SCI Rehabilitation
- Financial assessment and planning: Social workers-case managers (SW-CMs) provide information and assistance in dealing with various insurances and in optimising available benefits through the social service system.
- Discharge planning: SW-CMs review the feasibility of returning to the preferred discharge location, and assist the person and his or her family with identifying possible safety and accessibility issues, the need for caregiver support, and any barriers, such as financial barriers, to returning to the preferred discharge location. SW-CMs also provide assistance in finding a suitable discharge location if the preferred location is ill-suited.
- Discharge services: SW-CMs identify and coordinate necessary services to ensure that the person's discharge from inpatient rehabilitation and community transition is successful. Examples of services include personal care assistance, home health nursing services, and day rehabilitation programme. SW-CMs also provide assistance in getting required assistive devices, e.g. wheelchair, and medical supplies, e.g. bowel and bladder management supplies. The outcome of discharge planning informs the decision about the necessary services.
- Rehabilitation team and patient/family conferences: SW-CMs participate in regular conferences with the interdisciplinary rehabilitation team to review and discuss the person's progress and goal achievement status, and possible modifications to the rehabilitation activities and goals. Additionally, the team discusses any issues and exchange information about dealing with these issues. The person with SCI and his or her family are also invited to selected conferences.
- Supportive counselling: In consultation with psychologists or other clinical team members, SW-CMs also provide counselling to address psychosocial issues, such as alcohol or drug abuse, coping and adjustment problems, sexuality, etc...
- Peer/Advocacy groups: SW-CMs provide information about peer and advocacy groups that, in turn, provide persons with SCI and their families with support, education, and resources on various topics, such as community resources, disability legislation, new products and technologies.
- Education: Persons with SCI and families are provided education about, among other things, available support services and resources, and about the person's rights, such as those related to medical decisions. In addition, SW-CMs assist the person and families in completing all required documentation.
- Community/In-house services: SW-CM makes referrals for various other services not included in the other tasks, such as pastoral (chaplain) services, lifeline telephone services that calls the police or local hospital in case of emergency, etc.
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). 12 13 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. 13 14 15 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.