For spinal cord injury (SCI) patients, there are issues beyond the physical disability that can impact quality of life and community reintegration. A range of socio-economic and environmental factors often needs to be addressed by patients, their families and rehabilitation teams for successful rehabilitation and community reintegration. Financial and insurance issues, occupational and accommodation issues all present challenges for SCI patients.

Much support is dependent upon broad health care systems that can be difficult for a patient - who may have just suffered a life-changing injury - to navigate. Social workers are essential members of the rehabilitation team, there to assist patients with the overarching social aspects of a patient’s recovery and return to independent living.

Social Supports and Other Factors

Figure 1 illustrates the wide range of social supports and other factors that can impact a patient’s life situation. While some of these are personal and environmental factors that may be difficult or not possible to address (e.g. intellectual ability, state of the job market), many of these factors can offer points for interventions and social worker interaction.

Figure 1: Integrated Rehabilitation according to the life situation

Figure 1: Integrated Rehabilitation according to the life situation (Adapted from: Mühlum, A., Gödecker-Geenen, N., Soziale Arbeit in der Rehabilitation, p.37)

For persons with SCI, a key socioeconomic component of the rehabilitation and reintegration process is insurance. The coverage and types of insurance can impact a number of factors from Figure 1, including a patient’s economic and social situation, and also the workplace/vocational situation. In the event of an unanticipated injury, various types of insurance can come into play.

Box 1 describes a number of classes of insurance that are important in Switzerland; other countries’ insurance systems may differ, but this case example presents one industrialized nation’s perspective.

Box 1 | Social services and insurance: the Swiss example

Each country’s system of social and/or disability insurance differs and Switzerland offers just one example of many. In Switzerland, there are five different insurance classes that play a role in the event of a spinal cord injury and subsequent disability2:

  • Health insurance mandatory coverage with each insured person paying a premium; issues benefits in the case of sickness, maternity or accident; for those on low incomes, there may be government assistance to reduce premiums
  • Accident insurance – all employed and unemployed persons must carry accident insurance; covers both occupational and non-occupational accidents and occupational disease, including medical treatment, rescue and transport costs, and some medical devices.
  • Pension and invalidity insurance – covers permanent or long-term invalidity that reduces or eliminates earnings. Benefits include early intervention/rehabilitation measures, daily cash benefits and “helplessness allowances”; benefits are determined by the degree of invalidity (40%, 50%, 60% or 70%).
  • Occupational benefit insurance – these are retirement benefits that can be drawn on by men at age 65 and women at age 64; there is also an option for early retirement at age 58. This insurance must ensure a person can maintain his or her previous standard of living in an appropriate way.
  • Additional private insurances, if applicable
  • Here there are both public and private insurances that can cover sickness, death or disability. In the case of spinal cord injury, the broad aim of Swiss public insurance (known as “social security”) is to protect against the risks of disability and cover the financial consequences of such an unlikely event. This Swiss social security system is divided into five areas that are financed through income taxes:Old-age, survivors’ and invalidity insurance (three-pillar system)
  • 1st pillar: Old-age, survivors and invalidity, income compensation allowances and supplementary benefits
  • 2nd pillar: Occupational benefit plans concerning old-age, survivors and invalidity
  • 3rd pillar: Linked individual provident measure
  • Protection against the consequences of illness and accidents
  • Income compensation allowances in case of service and in case of maternity
  • Unemployment insurance
  • Family allowances

To support financial security and independence, there are a number of additional opportunities in the Swiss and other national systems for funding:

  • If a minimum standard of living is not achievable, a person living with a disability may apply for municipal assistance within the township where he or she resides.
  • Organization/foundation assistance (e.g. Swiss Paraplegic Foundation 3, Caritas, etc.) – assistance may depend upon membership, available funding, and/or determined on a case-by-case basis.

With low employment rates for persons living with SCI (particularly for those who are older)4 and, according to one study, five-fold higher rates of medical debt5, having a minimum degree of financial security is essential for independence and higher quality of life. Various insurance plans provide the most common path to post-injury income for patients. However, regardless of a country’s insurance system, there are always limitations that can result in problems for SCI patients:

  • Health insurance may not cover (or only partially cover) invalidity and benefits from accident insurance may vary.
  • Many have difficulty having assistive devices covered – a particular challenge if a person is also unemployed and has limited financial resources
  • Combined benefits may not be equivalent to pre-injury earnings, requiring a reduction in standard of living.
  • Household assistance is not covered by accident insurance and only to a very limited degree with health insurance
  • Compensation for transportation is limited or non-existant
  • For those self-employed, private health insurance may be expensive and many choose only minimal coverage
  • There may be long waiting times for benefits, necessitating alternative financing options temporarily.

Box 1 also examines some alternatives for funding sources within the national insurance systems.

To successfully navigate to secure benefits is a challenge for many persons in societies. A patient and his or her caregivers may not have sufficient knowledge of a given health and insurance system and its eligibility criteria. While insurance may be seemingly comprehensive, it nevertheless presents a further complication that must be addressed by or for patients and can add to anxiety. It is one example of a key issue where a social worker can offer expertise and support.

The definition of the social work profession

The broadest definition of the profession of social work was outlined by the International Federation of Social Workers (IFSW)6 in 2000 (replacing an older definition from 1982). They defined the responsibilities of the social work profession as:

“[promoting] social change, problem solving in human relationships and the empowerment and liberation of people to enhance well being. Utilizing theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.”

Furthermore, the IFSW states that a social worker’s mission centers on enabling “people to develop to their full potential, enrich their lives and prevent dysfunction” by focusing on “problem-solving and change”. Social work methodology should always be based on a “systematic body of evidence-based practice” and also “recognize the complexity of interactions between human beings and their environment”. In Switzerland, further aims are outlined by a national body representing social workers. Here they define the general goal of social work as seeking a patient’s “greatest autonomy”. Within health care services, they are responsible for the prevention and solving of social problems and work to “promote the recovery process, social integration and to protect the patients by providing attention to the social aspects of health”.7

The actual practice of social work will include a variety of interventions that may be patient-focused or even involve social policy and planning. This includes “counseling, clinical social work, group work, social pedagogical work, and family treatment and therapy as well as efforts to help people obtain services and resources in the community”.6

These definitions are broadly applicable and the IFSW emphasizes the holistic aspects of social work, while recognizing that implementation priorities may vary with geography and depend upon cultural, socioeconomic and historical conditions.

Social work and rehabilitation

While there are some rehabilitation-specific issues, social work within a SCI rehabilitation context aims to achieve many of the same general goals of non-rehabilitation health care contexts: namely, helping a patient cope with personal, social and financial problems that arise following the injury (Box 2).

Box 2 | Social work in rehabilitation

Organizational and administrative tasks - organization of meetings, structuring of external care, provision of interpreters; maintaining patient files (case management).

  • Legal issues - assist legal services in matters such as liability claims, accident insurance claims, job loss and housing termination; clarify guardianship (if necessary); clarify rights under the Victim Support Act (in Switzerland, if applicable)
  • Financial and insurance issues - clarification of a patient’s financial status and available insurance; registering for applicable insurances; requests for financial assistance to appropriate foundations or funds; applications for rent reductions or other disabled benefits if available
  • Housing and support services - clarification of a patient’s living situations (Will the patient require assisted living or live independently? In his or her own residence or in a nursing home?); responsible for registration for the intended housing; organization of post-discharge services such as transportation
  • Employment - together with other team members (doctor, occupational therapist, etc), determine, support and assist patient’s in reintegrating into an acceptable vocation;

Psychosocial support - support patient in dealing with his or her new situation; support families and caregivers; link to additional care institutions; support and monitoring of patients in other institutions post-discharge (schools, residence homes, etc.) Activities and daily routines - establish a regular and appropriate daily routine for a patient following discharge.

Given the holistic nature of both a patient’s needs following a devastating injury such as an SCI and a social workers responsibilities, there have been some efforts to acknowledge and promote social work in health care settings. From the Swiss example, there has been legal anchoring of the social work profession within hospitals, as well as steps being taken at a policy level to encode social services performed in health care settings for improved remuneration.

Furthermore, there have been recent considerations for establishing and promoting core functions of social work based upon the International Classification of Functioning, Disability and Health (ICF).8

The content of the ICF is closely related to the goals of social work, emphasizing a patient’s personal, social and environmental factors contributions to health and life quality9. Thus, the combination of the ICF with social work helps to provide a systematic method of identifying intervention targets and developing interventions that promote individual capabilities, while also recognizing relevant facilitating factors and barriers.10

Using an example from Switzerland, this case study aims to illustrate how the lives of persons with SCI can be impacted by finance and the social security and health insurance systems of the societies in which they live, and emphasize the importance of social work in helping a patient to navigate through these systems.