Key concepts

• "Integrated health care," often referred to as interdisciplinary health care, is characterized by a high degree of collaboration and communication among health professionals.
• Chronic diseases like hepatitis and cirrhosis are best managed by interdisciplinary teams in which health care workers from different specialties independently treat the patient's issues in a coordinated effort with shared goals.
• For patients with advanced liver disease who often have complex psychosocial needs, social work and mental health providers are integral members of the team.

Background

Research has consistently demonstrated that for chronic diseases, addressing a patient's individualized needs with an interdisciplinary approach reduces overall healthcare costs and mortality. Interdisciplinary care teams comprehensively address a patient's biological, psychological, and social needs with a shared goal or set of goals in mind.

Team members can include physicians, nurses, pharmacists, psychologists, social workers, and occupational and physical therapists.

Addressing Psychosocial Needs

Patients should be screened for psychosocial readiness to begin treatment with a systematic approach based on clear guidelines and standardized criteria. According to a theory of human behavior, Maslow's Hierarchy of Needs, patients need their safety, security, and stability needs met before they can achieve the health behaviors necessary for optimal management of advanced liver disease.

Patients living with psychosocial co-morbidities such as substance use, mental illness, and financial or logistical barriers benefit from social work or mental health involvement if they require ongoing care for advanced liver disease. Social workers and mental health providers utilize case management strategies such as screening, assessment, risk stratification, follow-up, and transition of care.

By identifying and addressing psychosocial factors that can potentially interfere with treatment adherence, social workers and mental health providers have the opportunity to improve a patient's engagement in care and self-management skills prior to starting treatment.

Social work and mental health providers can also address motivation for treatment, education about disease processes, self-efficacy (a person's belief in their ability to manage their illness), and lack of social support. Once these barriers are identified, social workers can connect Veterans with internal and external resources, including financial, transportation, housing, and disease specific support.

Finally, social workers and mental health providers can play a pivotal role in addressing risk factors for exacerbation of cirrhosis through referrals to VA- and community-based substance use disorder (SUD) and mental health services.