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Abstract
Objectives Maximising social workers’ contributions to primary care requires clarity about their scope of practice in this context. This scoping review sought to clarify what is known about social work’s scope of practice in primary care settings.
Design A scoping review design guided by the five-stage scoping review framework developed by Arksey and O’Malley and the updated JBI Manual for Evidence Synthesis.
Data sources 204 articles, published between 2013 and 2023 and obtained from the following seven databases, were reviewed: MEDLINE, CINAHL, Social Work Abstracts, Social Services Abstracts, Applied Social Sciences Index and Abstracts and Scopus.
Eligibility criteria Peer-reviewed articles that included a focus on social work and primary care, written in English, published between 2013 and 2023 and not restricted by geographical location.
Data extraction and synthesis Social workers’ scope of practice in primary care was assessed in terms of role; health conditions, patient populations, social issues addressed; location of practice and modality for care delivery; range of providers that social workers collaborate and methods of collaboration.
Results Results indicate that primary care social workers advance comprehensive, patient-centred, continuity of care and benefit both patients and other providers within primary care teams. Social workers undertake a range of roles, activities and functions in primary care settings—spanning direct patient care, team processes and community engagement. Social workers in primary care are involved in supporting patients with a robust range of mental, behavioural and neurodevelopmental conditions, as well as other acute and chronic health conditions. Most social workers are physically co-located within a team and are collaborating with a wide range of providers within and outside of the team.
Conclusions This scoping review contributes clarity about social work’s capacity for enhancing the delivery of primary care. Social work’s role in primary care facilitates comprehensive, continuous and patient-centred care that improves the experiences of both patients and teams. Social work clinicians, leaders and scholars are encouraged to seek out opportunities to participate in and undertake research identifying these contributions to primary care.
- Primary Care
- Health Services
- Primary Health Care
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study’s methodological strengths included the involvement of an interdisciplinary team comprised of clinical and content expertise spanning social work, primary care and health systems research.
The search strategy was developed with the involvement of a social sciences librarian which is a strength of this study.
Another strength is the inclusion of literature from across all geographical locations, resulting in 27 countries represented among the sample.
A weakness of this study is that the inclusion criteria were limited to English.
There was no formal assessment of quality applied to articles included in this study which results in descriptive findings.
Introduction
There has been an increased focus on the expansion of interprofessional primary care teams over the last several years in Canada, the USA and other international settings.1–3 With new growth in interprofessional teams, it is anticipated that the number of social workers in healthcare settings, such as primary care, is expected to increase by 20%.4 5 In addition, the number of social workers in primary care is anticipated to increase in response to the growing demands for patient care related to mental health, behavioural health, and the social determinants of health.5 6
Social work is a practice-based profession that responds to a range of needs of individuals, families, communities and groups, with a focus on improving health, mental health and social well-being.7 8 Social work education for clinical practice mainly includes training at the Bachelor’s and/or Master’s level, with social work one of the largest health, mental health and social service professions in Canada, the USA and elsewhere.8–13 For example, the Canadian Institute for Health Information14 reports there are approximately 52 823 registered social workers across Canada, and the Bureau of Labour Statistics reports more than 715 000 social workers across the USA.12 Social workers are employed across various types of settings, including healthcare, mental health and addictions, child welfare, education and many other areas of specialisation.8 15–17 There are a range of modalities used in social work practice, including individual, family and group therapy or counselling, case management, crisis services, support services, system navigation and resource allocation, community organisation, policy development and advocacy.7–10 Since the early 2000s, greater numbers of social workers have been integrated into primary care in response to policy reforms driving interprofessional team-based models of care in Canada, the USA, New Zealand and elsewhere.6 18–20 New initiatives are currently underway in Canada, the USA and elsewhere to further strengthen interprofessional team-based primary care as a strategy to combat the current human resourcing crisis resulting from a shortage of family physicians.1 21
Primary care is the first point of access and the cornerstone of most healthcare systems worldwide.22–24 Team-based primary care expands the scope of comprehensive health and mental health services by integrating providers from various disciplinary backgrounds, including social workers, to work in tandem with family physicians and/or nurse practitioners.18 23 While family physicians, nurse practitioners, nurses, social workers, pharmacists, physiotherapists, dietitians and psychologists are among the most common types of providers found in primary care teams, other types of providers may be included depending on the health needs of the immediate community population.18 22–24 The composition in terms of the types and numbers of providers, however, varies from team to team.22 25–27 A benefit of team-based approaches to primary care teams is that teams enhance comprehensiveness—a foundational attribute which refers to the breadth of services made available to patients.24
Social work’s biopsychosocial philosophy and commitment to equity and social justice complement primary care.19 28 Social workers contribute to whole-person care by providing comprehensive psychosocial assessments and interventions for a range of reasons; offering therapy and counselling; doing case management; engaging in systems navigation activities, including community referrals and communicating with external organisations and providers; conducting prevention and health promotion activities and training other providers, including medical residents, about the psychosocial aspects of health and illness.18 29 30 Although the extent to which social workers are involved in chronic disease management in some jurisdictions is unclear,30 it has been suggested that social workers in primary care can improve patient health outcomes by addressing the complex psychosocial and environmental aspects of chronic conditions such as diabetes, cancer, hypertension, infectious diseases and depression.31 Patients with complex health and social needs, including those living with multimorbidities, derive benefits from social work interventions in primary care.31
Despite the range of range of contributions to patient care, recent research has shown that members of primary care teams experience some confusion and ambiguity about the role of social workers.5 32 For example, in a recent study only 38% social workers in primary care reported that members of their team had an in-depth understanding of their roles and functions.32 Role clarification and negotiation is a core competency for successful collaboration within interprofessional team settings and requires there to be an adequate level of understanding and negotiation of individual and team members’ roles.33 Scope of practice refers to the range of roles, functions, activities and responsibilities that professionals are educated, trained and authorised to perform.34 According to the Ontario College of Social Workers and Social Service Workers, scope of practice for social workers refers to the ‘assessment, diagnosis, treatment and evaluation of individual, inter-personal and societal problems through the use of social work knowledge, skills, interventions and strategies, to assist individuals, dyads, families, groups, organisations and communities to achieve optimum psychosocial and social functioning’ 35 (,p. 8). Having a clear understanding of social workers’ roles, functions and patient care activities would enable newly emerging primary care teams to optimise social workers’ contributions and enhance clarity for existing teams.5 A challenge for achieving such clarity, however, is in part because professional roles of social workers in primary care vary due to differing scopes of practice legislation across and within countries,8 aligning social work roles to the unique needs of the patients they are working with and communities within which they are embedded,5 30 and also because of variations in the availability of resourcing.5 18 30
Conducting a scoping review of the literature helps identify the current state of knowledge regarding social work’s role, functions in relation to patient care in primary care. This scoping review was inspired by Team Primary Care, a national Canadian project launched in 2022, which aims to accelerate transformational expansion and uptake of interprofessional primary care teams by enhancing the capacity of each disciplinary profession involved in team-based primary care.36 Evidence synthesis is considered critical to inform evidence-based healthcare and facilitate improvements and advancements in healthcare.37 By articulating the various roles, activities and areas that social workers can contribute to patient care and interprofessional teams, findings from this scoping review may be useful to future primary care leaders who are establishing new primary care teams that include social workers.
Methods
A scoping review was used to map a broad range of information on the role and scope of practice of social workers in primary care. As a form of knowledge synthesis, scoping reviews provide valuable insight to inform practice, policy and service delivery, and provide a method to map key concepts, research evidence and research gaps on a topic.36–38
This scoping review was guided by the five-stage scoping review framework developed by Arksey and O’Malley39 in addition to the updated JBI Manual for Evidence Synthesis.37 The five stages of the scoping review outlined by Arksey and O’Malley39 are (1) identify the research question, (2) identify relevant studies, (3) study selection, (4) charting the data and (5) data summary and synthesis of results. This research followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR) checklist in the reporting of the methodology of this scoping review40 (see online supplemental table 1). No protocol was previously published.
Supplemental material
Stage 1: identify the research question
The scoping review was guided by the following research question: What is the professional role of social workers in primary care?
Stage 2: identify relevant studies
A search strategy was developed to identify literature examining the role and scope of social work practice in primary healthcare contexts. As a core member of the research team, a social sciences librarian (BW) developed a pilot MEDLINE (Ovid) search. The goal of this search was to locate articles with relevant text words appearing in title, abstract and author-supplied keyword fields. Relevant controlled vocabulary was also used to increase search sensitivity. All text words and subject headings were determined collaboratively with the research team.
The resulting pilot search shown in table 1 was evaluated by an independent health science librarian using the Peer Review of Electronic Search Strategies framework41 and all required revisions were implemented. The syntax of this MEDLINE search was then translated for use in five additional databases including CINAHL, Social Work Abstracts, Social Services Abstracts, Applied Social Sciences Index and Abstracts and Scopus. A date limit was applied to each search limiting results to work published in or after 2013. The rationale for limiting to the last 10 years of publications was to capture the most current roles, activities and functions of social work in primary care. Results were limited to work published in English, although there were no restrictions on geographical location to capture a broad understanding of social work in primary care without geographical restriction.
Full pilot search strategy for MEDLINE (Ovid)
A search in each database was conducted on 13 July and 14 July 2023, and results were exported to the literature review management software Covidence for deduplication and screening. On 11 December 2023, each database search was rerun to identify additional sources indexed after 13–14 July 2023 in order to capture the complete 10-year range of literature from 2013 to 2023. While a total of 13 013 citations were exported from six databases, deduplication left 3945 unique sources to be screened. Full search strategies across all six databases are available on request.
Stage 3: study selection
Two steps of screening were conducted to appropriately identify relevant literature for this review. The first step involved the title and abstract review, and the second step involved a review of the full text of the article. The first step of screening was conducted by the lead investigator (RA) and a graduate research assistant (PS) while the study coordinator (SL) supervised and reviewed all screening decisions. These three team members met biweekly to review and discuss any disagreements. This stage of screening was an iterative process in which team members met to review articles that were unclear, reviewed the full texts for further information, refined the inclusion terms and reviewed all the screened material to ensure there was agreement and consistency in the screening process. The second step of screening involved the full-text review of the selected articles. At this step, articles were only included if social workers were included, and there was some connection between social work and primary care. For instance, if the article mentioned youth worker, caseworker, healthcare worker, link worker or any other service provider who was not specifically identified as a social worker, the article was excluded. If the term ‘social work’ was included but was not referenced in a manner that demonstrated a substantive link with primary care, the article was excluded at this stage. The authors used Covidence—an online systematic review software—to complete the screening process.
Stage 4: charting the data
A data extraction tool was developed and piloted by the research team to extract and chart the data. Data extraction categories included author(s), journal, abstract, location of the corresponding author, if the article was published in a social work journal, type of article, study methods, study participants, if social work was a primary focus of the article, specified role of social work in primary care, patient health and mental health conditions social workers or identified as addressing, social issues addressed by primary care social workers, methods of team collaboration, location of social work practice, type of collaborators and modality used for delivery of patient care (see box 1). The charting was completed by a graduate research assistant (PS) and further reviewed by the lead investigator (RA). The RA met with the lead investigator (RA) to discuss the grouping and naming of the themes. This stage of review was iterative, wherein charted material was reviewed by other team members (KA/FP/GW/L-FD/DS/CK/JR/JBB) at virtual team meetings, broadened to ensure inclusivity and synthesised to support the conciseness of findings. All decisions made at this stage were made in consultation with team members to ensure there was uniformity in the charting process.
Charting framework.
Author(s).
Year.
Location of the corresponding author.
Journal title.
Is this a social work journal (Y/N)?
Is social work the primary focus of the article (Y/N)?
Article type (ie, empirical, literature review, etc).
If empirical: methods (qualitative, quantitative, mixed methods).
Study participants (social work clinicians, social work educators, interdisciplinary healthcare providers other than social workers, patients, other).
Specified role of social work in primary care (assessment, counselling and therapy, education and training, patient groups, system navigation, referrals to community resources, case management, leadership, research, programme development, community development, communicating with providers in other sectors, other).
Patient health and mental health conditions social work addresses in primary care (addictions and substance use, anxiety, depression, suicide, personality disorder, eating disorder, general mental health conditions, serious mental illness, diabetes, memory and cognition, heart disease, chronic disease, COVID-19, sexual health, ‘complexity’, not applicable, other).
Social issues social work addresses in primary care (social determinants of health—general, financial, housing, insurance issues, legal issues, accessing community resources, not applicable, other).
Ways social workers collaborate with team in primary care (formal collaboration in team meetings, informal consultations, formal consultations, external referrals, internal referrals, collaboration but not specified, no mention of collaboration, other).
Location of social workers in primary care (co-location, multisite (offsite), multisite (not stated), not applicable, other).
Type of provider that social work collaborates with in primary care (family physician, nurse practitioner, nurse, physical therapist, occupational therapist, dietitian, pharmacist, psychiatrist, paediatrician, psychologist, not stated, other).
Modalities for direct patient care by primary care social workers (in person and in office, home care, synchronous virtual care, asynchronous virtual care, not applicable, other).
Stage 5: data summary and synthesis of results
Tables and charts were generated for all extraction items, summarising the number of articles addressing each subitem. Thematic grouping was used to synthesise and explain some of the findings of data extracted from identified articles.
Patient and public involvement
No patients or public were involved in the design, conduct, reporting or dissemination of this study.
Results
Description of sample
The search strategy retrieved a total of 13 013 article citations. After the removal of duplicates, 3945 articles remained for the first stage of title and abstract review while a total of 971 articles were accepted for full-text review. Based on a full-text review, a total of 204 articles were included in the final stage of the scoping review (see online supplemental table 2). Online supplemental table 2 provides descriptive information for the 204 publications identified through our systematic search. Figure 1 presents the PRISMA flowchart of the screening and search process.
Supplemental material
Preferred Reporting Items for Systematic Reviews and Meta-Analyses charting diagram.
27 countries were represented among the selected articles, including the USA (n=126, 61.8%), Canada (n=22, 10.8%), the UK (n=8, 3.9%), Spain (n=7, 3.4%) and Australia (n=6, 2.9%). Most of the identified articles were empirical studies (n=170, 83.3%), followed by commentaries (n=21, 10.3%), literature reviews (n=9, 4.4%), as well as n=2 protocols (0.98%) and n=2 case studies (0.98%). Empirical studies included quantitative (n=69, 40.5%), qualitative (n=64, 37.6%) and mixed-methods studies (n=37, 21.8%). Participants in empirical studies included social work clinicians (n=110, 53.9%), social work educators (n=7, 3.43%) and social work trainees (n=6, 2.94%); interdisciplinary healthcare providers other than social workers (n=95, 46.6%), trainees from non-social work professions (n=2, 0.98%) and patients (n=68, 33.3%). Of the identified articles, only 26.0% (n=53) were published in a social work-specific journal while 32.4% (n=66) had a first author who was identified as a social worker. Online supplemental table 3 stratifies our findings by country to provide insight into the patients, collaborators and work settings of social workers internationally.
Supplemental material
Role
Of the 204 articles included in our review, 87% (n=178) explicitly addressed social workers’ roles in primary care. In terms of direct patient care-focused activities, most articles highlighted counselling/therapy (n=123, 60.3%), assessment (n=121, 59.3%), systems navigation (n=104, 51%), case management (n=98, 48%) and health promotion activities (n=85, 41.7%). Other direct patient care clinical responsibilities included clinical problem solving (n=31, 15.2%), patient advocacy (n=30, 14.7%), crisis management (n=25, 12.3%), facilitating psychoeducational patient groups (n=27, 13.2%), advanced care planning (n=13, 6.4%) and diagnosis (n=6, 2.9%). In terms of team-focused activities, many articles highlighted team coordination (n=101, 49.5%), clinical education (n=44, 21.6%), leadership (n=31, 15.2%), research and evaluation (n=19, 9.3%) and programme development (n=16, 7.8%). In terms of community-focused activities, some articles highlighted community development (n=20, 9.8%) as a social work role. Table 2 provides an overview of social workers’ roles in primary care distinguished by patient care, team and community activities.
Social workers’ roles in primary care distinguished by patient care, team and community activities
Discrepancies were noted between articles with social workers as first authors and those written by non-social workers, describing the social work role. Articles whose first authors were social workers (n=66, 32.4%) more frequently reported multiple activities than articles with first authors who were not social workers (n=138, 67.6%). Activities that were noted more frequently in articles with a social worker as first author (compared with articles with a non-social worker as first author) included systems navigation (mentioned in 47.0% of papers first-authored by social workers, but in only 28.3% of papers first-authored by non-social workers), case management (59.1% vs 42.0%), patient advocacy (25.8% vs 9.4%), counselling/therapy (69.7% vs 54.3%) and communicating with providers in other sectors (15.2% vs 7.2%).
Patient care
Social workers in primary care are working with patients related to a range of reasons spanning mental, behavioural and neurodevelopmental concerns, and acute/chronic health conditions. Mental, behavioural and neurodevelopmental conditions had the most mentions across the sample whereby many articles mentioned mental health (generally) (n=98, 48%), depression (n=79, 38.7%), addictions and/or substance use (n=56, 27.5%), anxiety (n=54, 26.5%), trauma (including post-traumatic stress disorder) (n=24, 11.8%), memory/cognition (n=20, 9.8%), serious mental illness (generally) (n=13, 6.4%), suicidality (n=12, 5.9%), autism spectrum disorder and attention-deficit/hyperactivity disorder (n=6, 2.9%), eating disorders (n=2, 1%), insomnia and sleep disorders (n=2, 1%) and personality disorders (n=1, 0.5%). The articles also mentioned various types of chronic disease care in which social workers in primary care were involved including chronic disease (generally) (n=70, 34.3%), diabetes (n=29, 14.2%), heart disease (n=11, 5.4%), hypertension and stroke (n=8, 3.9%), chronic pain (n=8, 3.9%) and HIV prevention and harm reduction activities (n=5, 2.5%). Providing sexual health counselling, in the service of STI prevention, health promotion and sexual education about contraception, was also indicated (n=7, 3.4%). Other types of health issues mentioned in the sample related to ageing (ie, frailty) (n=15, 7.4%), COVID-19 (n=10, 4.9%) and cancer (n=2, 1.0%). There were four articles (n=4, 2%) classified as other spanning topics of adverse medical outcomes (n=1, 0.5%), general medical conditions not otherwise specified (n=1, 0.5%), non-suicidal self-injury (n=1, 0.5%) and urgent psychosocial needs (n=1, 0.5%) (see figure 2).
Types of patient concerns addressed by social workers in primary care (n=204). ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder; NOS, not otherwise specified; PTSD, post-traumatic stress disorder.
In terms of specified patient populations served by social workers in primary care, articles mentioned seniors (n=35, 17.2%), families (n=29, 14.2%), children and youth (n=17, 8.3%), caregivers (n=13, 6.4%), veterans (n=10, 4.9%), refugees (n=7, 3.4%), pregnant people (n=4, 2%) and persons with disabilities (including but not limited to physical challenges) (n=3, 1.5%). Three articles (n=3, 1.5%) were classified as other and referred to children with special needs not otherwise specified (n=1, 0.5%), homebound individuals (n=1, 0.5%) and vulnerable adults (n=1, 0.5%) (see figure 3).
Types of social issues addressed by social workers in primary care (n=204).
Biopsychosocial issues
The articles described a range of biopsychosocial issues that social workers in primary care address with patients. Of the 204 articles included in our review, 79% (n=162) explicitly addressed social workers’ role in addressing specified (n=127, 62.3%) and unspecified (n=35, 17.2%) social determinants of health. For example, some of the specified social determinants of health issues mentioned included financial concerns (n=52, 25.5%), housing (n=44, 21.6%), food insecurity (n=23, 11.3%), employment (n=13, 6.4%) and structural racism (n=7, 3.4%). Additional biopsychosocial issues described in articles included patient complexity (n=50, 24.5%), interpersonal violence (n=29, 14.2%), relational issues (ie, marital, parenting) (n=29, 14.2%), social isolation (n=29, 14.2%), legal issues (n=14, 6.9%), insurance issues (including undocumented challenges) (n=11, 5.4%), end-of-life care needs (n=10, 4.9%), grief and loss (n=10, 4.9%) and transportation challenges (n=7, 3.4%). Four articles were classified as other (n=4, 2.0%), and these articles spanned school challenges (n=1, 0.5%), dental care (n=1, 0.5%), education (n=1, 0.5%) and significant contextual crisis (eg, terrorism and/or natural disasters) (n=1, 0.5%) (see figure 4).
Populations explicitly identified as served by social workers in primary care (n=204).
Modality used for service delivery
Various types of modalities were mentioned detailing how delivery of patient care occurred. Most articles (n=153, 75.0%) mentioned that patients were seen in-person and on-site, while a few articles (n=36, 17.6%) noted that social workers used synchronous methods of virtual care, including telephone and video. A few articles (n=23, 11%) mentioned that social workers conducted home visits, and a minority of articles (n=3, 1.5%) indicated that asynchronous virtual care was used for service delivery, including email and/or messaging through a patient portal.
Working in a team
In terms of practice location, most articles indicated that social workers were physically co-located with other members of the primary care team (n=140, 68.6%). Some articles indicated that social workers were part of a multisite organisation (n=52, 25.5%), meaning that not all members of the primary care team were physically located at the same site, while a few articles (n=31, 15.2%) specified that social workers were physically located in a different location from the primary care team.
With regards to who social workers in primary care collaborate with, articles mentioned a wide range of collaborators (see figure 5). The most frequent collaborators noted included primary care physicians (n=142, 69.6%), nurses (n=117, 57.4%), nurse practitioners (n=60, 29.4%), specialist physicians (n=58, 28.4%), pharmacists (n=43, 21.1%), psychologists (n=36, 20.6%), psychiatrists (n=29, 14.2%) and dietitians (n=24, 11.8%). Specialist physicians (n=58, 28.4%) included psychiatrists (n=29, 14.2%), paediatricians (n=22, 10.8%) and one mention each (n=1, 0.5%) of geriatricians, internal medicine physicians, nephrologists, oncologists, obstetricians/gynaecologists and palliative care. There was some mention of physician assistants (n=14, 6.9%) and medical assistants (n=11, 5.4%).
Types of health and social service providers (other than social work) with which social workers in primary care collaborate (n=204). *Not otherwise specified, NOS.
Physiotherapists (n=15, 7.4%) included persons noted as physiotherapists and physical therapists. Care coordinators included persons described as care facilitators, nurse coordinators/navigators, patient navigators, community resource liaisons and/or link workers (n=15, 7.4%). Mental health providers not otherwise specified (NOS) (n=14, 6.9%) included both instances where roles were indicated but unspecified (eg, mental health providers, applied behaviour analysts, behavioural health providers, certified substance abuse counsellors and mental health counsellors). Case managers included those with that explicit role title, as well as care managers and case administrators (n=10, 4.9%). Community health workers (n=7, 3.4%) included both those with this explicit title and those articles that mentioned community support workers and outreach workers. Residents/trainees (n=5, 2.5%) included mention of both resident physicians and interdisciplinary trainees. Health promotors (n=3, 1.5%) included both those with this title and health coaches; leaders/directors (n=3, 1.5%) were located within the primary care organisation; and patient educators and religious leaders included pastoral services and chaplains (n=3, 1.5%). Lastly, there were 12 (n=12, 5.9%) articles categorised as ‘Other’ that mentioned a variety of other providers with whom social workers collaborated in primary care, including Aboriginal health workers (n=1, 0.5%), chiropractors (n=1, 0.5%), dentists (n=1, 0.5%), interpreters (n=1, 0.5%), family planners (n=1, 0.5%), patient service representatives (n=1, 0.5%), peer-support specialists (n=1, 0.5%), physical trainers (n=1, 0.5%), quality improvement facilitators (n=1, 0.5%), recreation and vocational specialists (n=1, 0.5%), respiratory therapists (n=1, 0.5%), sociologists (n=1, 0.5%), surgical technologists (n=1, 0.5%) and teachers/school administrators (n=1, 0.5%).
In terms of the method of collaboration between social workers and other team members in primary care, articles most often (n=99, 48.5%) made mention of collaboration without specifying how it occurred. When collaborations were described in detail, they were most commonly the result of a formal consultation (n=55, 27.0%) or by way of an internal on-site referral (n=54, 26.5%). Other forms of collaboration mentioned included formal team meetings (n=41, 20.1%), informal hallway conversations (n=31, 15.2%), offsite referrals (n=21, 10.3%) and within electronic medical record messaging systems (n=13, 6.4%). Additional methods of collaboration specified in articles were social workers co-teaching with physicians (n=1, 0.5%), participating with colleagues in team-based continuing education sessions (n=1, 0.5%) and collaborating with other providers by telephone (n=1, 0.5%). 15 (n=15, 7.4%) articles did not mention collaboration related to social workers in primary care.
Discussion
This review aimed to provide a synthesis of the literature to provide clarity about the role of social workers in primary care. Reported ambiguity and a lack of understanding about social workers’ roles in primary care are creating challenges within some interprofessional primary care teams.5 32 33 Although roles, activities and functions of social workers may differ across primary care settings to align with patient care needs, availability of resourcing and scopes of practice legislation,5 30 33 42 our scoping review demonstrates the possibilities of what a social work role may consist of. As demonstrated by our study, social workers undertake a range of roles, activities and functions in primary care settings—spanning direct patient care, team processes and community engagement. Social workers in primary care are involved in supporting patients with a robust range of mental, behavioural and neurodevelopmental conditions, as well as other acute and chronic health conditions.
Expanding comprehensive, accessible, patient-centred care
It is evident in our study that social workers enhance comprehensiveness—a foundational attribute which refers to the degree to which primary care provides a broad range of services to meet patients’ wholistic-care needs, limiting the need for specialist referral.24 Findings in our study demonstrated that primary care social workers have capacity to address a number of diagnosable mental health conditions. This is particularly relevant as the prevalence of patients presenting with mental health concerns in primary care is high,43–45 and optimisation of the role of social work in this domain may help address the mental health treatment gap that continues to persist.46–48 In addition, the inclusion of social work in primary care may also improve patient outcomes for common chronic health conditions, such as diabetes.49–54 Demonstrating the mediating effect of social work’s involvement on patient care outcomes in primary care presents a promising area for future research. In our study, social workers enhanced patient-centeredness and were highlighted as expert patient collaborators, particularly for patients with multimorbidities. Although social workers in our study used various modalities to deliver patient care, it was surprising that there was not more mention of using synchronous and asynchronous virtual care given the rapid uptake of these modalities since the onset of the COVID-19 pandemic.55 Given that 40% of our review’s range included the COVID-19 pandemic, it was somewhat surprising that the use of virtual care was reported in less than 20% of our articles’ survey. It is not clear if these results represent a genuine maintenance of in-person services during the COVID-19 era or if the use of virtual methods for delivering social work services in primary care is being under-reported.
Contributing to health equity
The inclusion of social workers in primary care enhances primary care’s ability to attend to the core value and commitment to health equity.24 Health equity aims for the highest standard of health for everyone, which means attending to the needs of those at greatest risk of poor health because of social conditions and underlying disparities.28 Primary care social workers in our study directly addressed a broad range of social determinants of health such as issues related to gender-based violence, financial challenges and insecure housing.31 51 56–58 By doing so, social workers in primary care may contribute to the reduced overall mortality seen in countries with strong primary care systems.24 59
In our study, social workers in primary care were actively involved in caring for patients with complexities. Social workers improved the health outcomes of these patients by simultaneously addressing challenges resulting from chronic health (eg, mental illness, diabetes, chronic kidney disease) and social care needs (eg, social isolation, financial stress).60–62 Complex patients are described as some of the most challenging patients for family physicians.63 64 Given the high rates of complex patients in primary care—such as those living with multimorbidity—being able to support both medical and socioeconomic intervention makes social workers invaluable to the care of these patients.31 63–65 In addition, having social workers involved with complex primary care patients may also improve the well-being of family physicians and other providers who struggle with complexity.66 67 Social workers expand primary care teams’ capacity to care for complex patients.66 67 Promulgating how social worker’s role as complexity specialists may reduce physician burnout is an important consideration for future health system resource allocation, especially at this time when we are facing increasing physician shortages and increasing population in both age and size. Despite health equity being an important focus of primary care social work, greater attendance to the role of engaging community may be needed to advance work in this domain.18 30 62 Similarly, it may be necessary for social workers to clarify for other members of the primary care team how advocacy is a role of social work.
Advancing continuity of care
This study demonstrates that social workers in primary care advance continuity of care in multiple ways. Continuity of care refers to individuals and teams fostering relationships with patients across time, which enhances patient care experiences and even facilitates information transfer across organisational boundaries.68 Social workers were highlighted as integral to team continuity by coordinating team-based care.69 70 The close relationships fostered between social workers and their patients over time also assisted with delivering other aspects of care continuity.71 Longitudinal relationships facilitated information transfer between organisations, quality of care and comprehensiveness of services.72–74 Embedding social workers in primary care to ensure continuity of care during transitions was associated with reduced emergency room visits and readmission rates.71 72 Continuity of care improves access, reduces the need for specialised care in some cases and leads to system-level savings.75 76
Working in a team
In our study, it is impressive to note that no less than 34 distinct collaborators for primary care social workers were identified. While consistent with existing literature on the range of primary care social work collaborators,5 77 78 the sheer variety of collaborators was striking. It is unclear, however, if social workers collaborated with these other providers based on the availability of providers or if patient needs were driving these collaborations. It is anticipated, however, that social workers are routinely collaborating with primary care physicians and/or nurse practitioners given that they are core pillars in primary care.22 What is additionally striking is the degree to which social workers were co-located within primary care given that co-location is considered a key element for successful collaboration within primary care teams.5 77 78 It is unclear how the integration of the social work role varies between teams that are physically co-location, multisite and/or dispersed virtual teams which is an important area of investigation given the variations of primary care models that currently exist.79 Within teams, our scoping review also illustrated that the social work role included education which appeared beneficial for both trainees and other providers. These educational activities, which included formal in-services, proctoring and mentoring, and informal collaborations.77 80 Interestingly, discrepancies existed between articles first-authored by social workers and those written by non-social work authors, describing the role of primary care social workers. Articles with social workers as first authors more frequently reported counselling/therapy, case management, systems navigation and patient advocacy while these activities were less frequently identified by articles with a first author who was not a social worker.5 18
Strengths and limitations
There are several strengths related to this study. The large sample of 204 articles included in the final stage of the scoping review is a strength and provided a robust sample for data extraction. In addition, this scoping review can provide guidance related to the integration of social work in future primary care teams because it provides clarity about social work’s capacity and potential roles in such team-based models. In addition, this scoping review also provides insights into the modalities that social workers are using for direct patient care and team collaboration while also providing a comprehensive overview of the range of potential collaborators in team-based primary care.
A limitation is that the focus of this study examined literature pertaining to social workers in primary care practice and did not set out to understand education and training; thus, future research may be beneficial to ascertain if there are variations in the education and training between countries that may uniquely shape and account for variations in social workers’ professional roles between countries. An inherent limitation of scoping reviews, including this one, is potential omission of relevant literature because of methodological decisions that inform study selection. For example, there are various terms used for social workers and primary care across international jurisdictions, and as a result, our scoping review may not include all relevant articles. To mitigate this risk, our research team included a health sciences librarian who developed a broad search strategy. The search strategy was also limited to studies in English and did not include grey literature.
Conclusions
This scoping review contributes clarity about social work’s capacity for enhancing the delivery of primary care. Social work’s role in primary care facilitates comprehensive, continuous and patient-centred care that improves the experiences of both patients and teams. Social work clinicians, leaders and scholars are encouraged to seek out opportunities to participate in and undertake research identifying these contributions to primary care.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
X @RaynerJen
Contributors All authors conceptualised and designed the study. RA, KA, BW developed the search strategy. RA, PS, SL identified the relevant studies and charted the data. Results were reviewed and refined with input from all authors. RA and PS wrote the initial manuscript draft, which was then revised by all authors. All authors approved the final protocol manuscript and agreed to be accountable for all aspects of the work. RA is the guarantor.
Funding This project is one of a number of projects funded through Team Primary Care – Training for Transformation.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.