Are Social Workers replacing Mental Health Professionals in the VA?

There is a place for Social Workers in the VA, but there is a concern that they are replacing licensed Mental Health Councilors and therapists. Are the Social Workers experts on PTSD? Do they have to have special training to take care of veterans with PTSD? If not, then is this practice part of the problem? Here is a look at what the VA says about the role of social workers.

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Department of Veterans Affairs
VHA DIRECTIVE 2004-030
Veterans Health Administration
Washington, DC 20420
July 2, 2004
SOCIAL WORK PROFESSIONAL STANDARDS: ACCREDITATION AND REIMBURSEMENT FROM THIRD-PARTY PAYERS
1. PURPOSE: This Veterans Health Administration (VHA) Directive outlines the requirements for ensuring the competence of clinical social workers for accreditation and the licensure requirements for clinical social workers by VHA, Medicare, and TRICARE for the purpose of third-party reimbursement.
2. BACKGROUND
a. Ensuring the clinical competence of all disciplines is extremely important as VHA facilities continue to be accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Commission on the Accreditation of Rehabilitation Facilities (CARF) and as the facilities move toward generating more revenue from third-party insurers (i.e., Medicare and TRICARE). Though similar, the Department of Veterans Affairs (VA) requirements for an employee to qualify as a “Social Worker” are not identical to the requirements of third-party payers for Social Work services to be reimbursable. It is important that VHA continue to provide the necessary structure and training to ensure the competence and licensure of social workers employed by VHA so that their services are appropriately reimbursed.
b. Definitions. The following definitions assure that social workers meet the requirements for third-party reimbursement.
(1) Clinical Social Work. The National Association of Social Workers (NASW) defines Clinical Social Work as follows: “Clinical social work shares with all social work practice the goal of enhancement and maintenance of psychosocial functioning of individuals, families and small groups. Clinical social work practice is the professional application of social work theory and methods to the treatment and prevention of psychosocial dysfunction, disability, or impairment, including emotional and mental disorder. It is based on knowledge of one or more theories of human development within a psychosocial context. Clinical social work services consist of: assessment; diagnosis; treatment, including psychotherapy and counseling; client-centered advocacy; consultation; and evaluation. The process of clinical social work is undertaken within the objectives of social work and the principles and values contained in the NASW Code of Ethics.”
(2) Social Worker, VHA
(a) Within VHA, a Social Worker is defined as: “An individual who has a Master's Degree in Social Work from a school of social work, which is accredited by the Council on Social Work Education.”
THIS VHA DIRECTIVE EXPIRES JULY 31, 2009
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(b) All candidates hired after August 14, 1991, must possess a license, certificate, or registration, issued by a State to independently practice social work. Title II, Section 205 of the “Veterans Benefits and Health Care Improvement Act of 2000” allows VHA social workers to obtain and maintain out-of-state licenses, consistent with the licensure laws for other clinical disciplines in VHA.
NOTE: Exceptions can be made for certain new appointments, subject to meeting the full requirements within 3 years of appointment, or 1 year from the time that the social worker meets the full State prerequisites for licensure, whichever is greater.
(3) Social Worker, CARF. CARF no longer defines “social worker” or any other discipline. Rather, CARF standards identify members of interdisciplinary teams, which includes social workers. The standards state that: “The organization ensures that the individual team members provide services consistent with:
(a) State practice acts,
(b) Licensure requirements,
(c) Registration requirements,
(d) Certification requirements,
(e) Their educational degrees,
(f) Professional training to maintain established competency levels,
(g) The program’s on-the-job training requirements, and
(h) Professional standards of practice.”
NOTE: The program needs to be prepared to identify how verification of these issues for individual team members is addressed by the organization by statements of intent.
(4) Clinical Social Worker (CSW), Medicare. For purposes of Medicare reimbursement, the Center for Medicare and Medicaid Services (CMS) provides the following information:
(a) Definition. A Clinical Social worker is an individual who:
1. Possesses a master's or doctor's degree in social work;
2. Has performed at least 2 years of supervised clinical social work; and
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3. Either:
a. Is licensed or certified as a clinical social worker by the State in which the services are performed, or
b. In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post-Master's Degree supervised clinical social work practice under the supervision of a master's level social worker in an appropriate setting such as a hospital, Skilled Nursing Facility (SNF), or clinic.
(b) CSW Services Defined. Title 42 United States Code (U.S.C.) Section 1861 (hh)(2) (i.e., the Social Security Act) defines “clinical social workers services” as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses. Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as an incident to physician’s professional service.
(c) Outpatient Mental Health Services Limitation. All covered therapeutic services furnished by qualified CSWs are subject to the outpatient psychiatric services limitation in the Social Security Act Sections 2470ff (i.e., only 62 ½ percent of expenses for theses services are considered incurred expenses for Medicare purposes). The limitation does not apply to diagnostic services (see Sec.2476.5 of the Social Security Act).
(5) CSW, TRICARE. For purposes of TRICARE reimbursement, authorized providers include CSWs. CSWs may provide covered services independent of physician referral and supervision. The CSW must:
(a) Be licensed or certified at the master’s level as a CSW by the state where care is provided;
NOTE: For New Jersey, Indiana and Wisconsin, TRICARE Standard accepts ACSW-level certification in the National Association of Social Workers, or the Diplomate status granted by the American Board of Examiners in Clinical Social Work.
(b) Have a Master's Degree in social work from a graduate school of social work accredited by the Council on Social Work Education; and
(c) Have a minimum of 2 years or 3,000 hours of post-Master's Degree clinical social work practice under the supervision of a master's degree level social worker in an accredited hospital, a mental health center, or other appropriate clinical setting.
NOTE: When a patient has an organic medical problem, a physician must concurrently manage the patient’s care.
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(6) JCAHO. JCAHO does not define “social worker”; however, the Human Resources Standard (HR.2) states that, “Departments will provide an adequate number of staff members with the experience and training needed to serve and fulfill the department’s part of the hospital’s mission.” The standard goes on to state that, “For each employee or contracted personnel, the department verifies the following elements, where relevant:
(a) Education and training are consistent with applicable legal and regulatory requirements and hospital policy;
(b) The individual is licensed, certified, or registered; and
(c) The individual’s knowledge and experience are appropriate for the individual’s assigned responsibilities.”
3. POLICY: It is VHA policy that licensed clinical social workers are independent practitioners whose services are reimbursable by various health insurance carriers, including TRICARE and Medicare, and that VHA will provide accreditation to social work staff in order to obtain third-party reimbursement.
4. ACTION: Integrating these definitions and planning for the VA of the future, the Office of Social Work Service has developed the following guidance for managers at the network and local levels. This guidance for the programmatic and organizational components of VHA Social Work positions is necessary to ensure that VA is prepared to pursue reimbursement opportunities.
a. Functions. VHA social workers are qualified to perform the following functions, from which their core competencies are developed.
(1) Development of psychosocial databases and histories;
(2) Psychosocial assessments and psychosocial diagnoses;
(3) Psychosocial casework and treatment planning;
(4) Psychosocial treatment (individual, family, and group);
(5) Case management;
(6) Information and referral services,
(7) Resource brokering and community organization;
(8) Admission diversion;
(9) Discharge planning and coordination;
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(10) Aftercare planning and follow-up services;
(11) Independent documentation in medical records;
(12) Patient advocacy;
(13) Crisis intervention and management;
(14) Patient and family education;
(15) Consultation; and
(16) Counseling patients regarding advance directives.
b. Clinical Mental Health Social Work Functions. VHA CSWs, licensed by a State, who have the training and expertise, and who have authority delegated to them from the Executive Committee of the medical staff or the facility’s appropriate approving body through clinical privileging or an approved scope of practice statement. The decision to delegate the authority to perform these clinical mental health social work functions is made at the local facility level and must be made in accordance with VHA policy and accreditation standards. CSWs delegated to perform clinical mental health social work functions must participate in provider-specific data analysis, which compares provider-specific data of licensed clinical social workers with data from providers with comparable clinical privileges, or comparable delegations of authority. Additional functions which may be provided are:
(1) Individual, family and group psychotherapy;
(2) Independent DSM-IV diagnoses; and
(3) Mental Health Compensation and Pension examinations, under the supervision of a psychiatrist or clinical psychologist.
c. Competency Assessment. The competency of individual social workers must be assessed, maintained, and improved on an annual basis, through a variety of mechanisms. The facility Social Work Executive participates in, or oversees the competency assessment of all social workers. This assessment includes, but is not limited to:
(1) Review and/or verification of applicant credentials and qualifications;
(2) Confirmation of experience, education, and abilities during orientation;
(3) Review of medical record documentation;
(4) Periodic supervisory observation of or participation in client interviews;
(5) Peer review;
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(6) Feedback from peers and interdisciplinary professionals;
(7) Results of customer satisfaction and other surveys and outcome studies;
(8) Demonstration of competency using skills inventories and checklists;
(9) Annual and mid-year performance appraisals; and
(10) Continuing education. NOTE: Requirements need to be developed locally, corresponding to the requirements for continued licensure by the individual state. Where such requirements are not defined, continuing education requirements should follow the guidelines established by the National Association of Social Workers (NASW).
c. Supervision. Social workers hired after August 14, 1991, who have not yet attained their State licenses are to be afforded clinical supervision by a qualified social worker, in order to meet the minimum prerequisites needed to take the State licensing examination. Similarly, social workers hired with no prior VA experience must be supervised on a frequent basis for the first year in order to ensure that they receive individual instruction in each of their duties and that their performance is closely monitored.
d. Professional Guidance. Regardless of the structure of the organization, the facility’s Social Work Executive must participate in competency assessment activities, performance appraisals, and the development of relevant continuing education programs.
NOTE: A Social Work professional standards board should be created in each VHA facility to review and recommend approval or disapproval of requests for clinical privileges and clinical scope of practice statements from social workers.
5. REFERENCES
a. NASW Standards for the Practice of Clinical Social Work, NASW, 1989.
b. VHA Handbook 5338.4.
c. Veterans Benefits and Health Care Improvement Act of 2000, Title II, Section 205, “Qualifications of Social Workers,” signed November 1, 2000.
d. CARF Manual 2003, Medical Rehabilitation, Section 3 - CIIRP.
e. Medicare Carriers Manual, Part 3, Claims Process, Change Request 710, Section 2152, “Clinical Social Worker Services,” dated March 2000.
f. Social Security Act, Section 1861(hh).
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g. TRICARE Non-Network Provider and Medical Office Manager Handbook, Department of Defense, Office of the Assistant Secretary of Defense for Health Affairs, TRICARE Management Activity, pages 34-35, dated November 2002.
h. “Human Resources Standards,” Joint Commission 2003, pp. HR.1-HR.2, May 2003.
6. RESPONSIBLE OFFICE: The Office of Social Work Service (11CCSW) is responsible for the contents of this Directive. Questions may be referred to 202-273-8549.
7. RESCISSION: VHA Directive 98-013, dated February 23, 1998, is rescinded. This VHA Directive expires July 31, 2009.
S/ Jacquelyn Vassanelli for
Jonathan B. Perlin, MD, PhD, MSHA, FACP
Acting Under Secretary for Health
DISTRIBUTION:
CO:
E-mailed 7/2/2004
FLD:
VISN, MA, DO, OC, OCRO, and 200 – E-mailed 7/2/2004
http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1108

Rules changed

Department of Veterans Affairs VHA DIRECTIVE 2008-033
Veterans Health AdministrationWashington, DC 20420 July 14, 2008
SUPERVISION OF PSYCHOLOGISTS AND SOCIAL WORKERS PREPARING FOR LICENSURE
1. PURPOSE: This Veterans Health Administration (VHA) Directive clarifies the duties and responsibilities of Department of Veterans Affairs (VA) staff who are licensed independent practitioners and who serve as clinical supervisors to psychologists or social workers who are not yet licensed to practice at the independent level.
2. BACKGROUND
a. VHA Psychology Qualification Standards (VA Handbook 5005, Pt. II, App. G18) require that a VHA psychologist must hold a full, current, and unrestricted license to practice psychology at the doctoral level in a State, Territory, or Commonwealth of the United States, or the District of Columbia. It allows an exception to this requirement for individual psychologists, for a period not to exceed 2 years from the date of employment, on the condition that such a psychologist provide care only under the supervision of a psychologist who is fully licensed.
b. Social Work Qualification Standards (VA Handbook 5005, Pt. II, App. F7) require all social workers hired after August 14, 1991, to possess a license, certificate, or registration, issued by a State, to practice social work independently. Exceptions can be made for certain new appointments, subject to meeting the full requirements within 3 years of appointment, or 1 year from the time that the social worker meets the full State prerequisites for licensure, whichever is greater.
c. Because most state licensure laws require postgraduate clinical supervision experience, many newly-hired psychologists and social workers who are recent graduates work under the supervision of a licensed clinician while completing full licensure requirements.
d. Definitions(1) Supervision. Supervision consists of clinical consultation between the independent practitioner serving as supervisor and the psychologist or social worker who is not licensed, for the purposes of monitoring, informing, and guiding the provision of services.

(2) Psychotherapy. Psychotherapy refers to a specific psychological treatment modality utilized to address a DSM-IV diagnosis.

(3) Psychosocial Counseling. Psychosocial Counseling is a primarily educational service provided to address a psychosocial problem.
THIS VHA DIRECTIVE EXPIRES JULY 31, 2013
http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1716

Mental health and substance abuse social workers assess and treat individuals with mental illness or substance abuse problems, including abuse of alcohol, tobacco, or other drugs. Such services include individual and group therapy, outreach, crisis intervention, social rehabilitation, and teaching skills needed for everyday living. They also may help plan for supportive services to ease clients’ return to the community. Mental health and substance abuse social workers are likely to work in hospitals, substance abuse treatment centers, individual and family services agencies, or local governments. These social workers may be known as clinical social workers. (counselors and psychologists, who may provide similar services, are discussed elsewhere in the Handbook.)

Other types of social workers include social work administrators, planners and policymakers, who develop and implement programs to address issues such as child abuse, homelessness, substance abuse, poverty, and violence. These workers research and analyze policies, programs, and regulations. They identify social problems and suggest legislative and other solutions. They may help raise funds or write grants to support these programs.
http://www.bls.gov/oco/ocos060.htm#nature

This is what a clinical social worker is

Clinical social workers provide mental health services for the prevention, diagnosis, and treatment of mental, behavioral, and emotional disorders in individuals, families, and groups. Their goal is to enhance and maintain their patients' physical, psychological, and social function.

Educational requirements
Clinical social workers must have a master's or doctorate degree in social work, with an emphasis on clinical experience. They must undergo a supervised clinical field internship and have at least 2 years of postgraduate supervised clinical social work employment.

Clinical social workers are approved providers in most insurance and managed care plans, and practice in the following settings:

Private practice
Medical facilities (e.g., hospitals)
Mental health clinics
Child welfare agencies
Schools
http://www.mentalhealthchannel.net/csw.shtml