The Pursuit of Quality for Social Work Practice: Three Generations and Counting

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Previous articleNext article FreeThe Pursuit of Quality for Social Work Practice: Three Generations and CountingEnola ProctorEnola ProctorWashington University in St. Louis Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreThis invited article is based on the 2017 Aaron Rosen Lecture presented by Enola Proctor at the Society for Social Work and Research 21st Annual Conference—"Ensure Healthy Development for All Youth"—held January 11–15, 2017, in New Orleans, LA. The annual Aaron Rosen Lecture features distinguished scholars who have accumulated a body of significant and innovative scholarship relevant to practice, the research base for practice, or effective utilization of research in practice.Social work addresses some of the most complex and intractable human and social problems: poverty, mental illness, addiction, homelessness, and child abuse. Our field may be distinct among professions for its efforts to ameliorate the toughest societal problems, experienced by society's most vulnerable, while working from under-resourced institutions and settings. Members of our profession are underpaid, and most of our agencies lack the data infrastructure required for rigorous assessment and evaluation.Moreover, social work confronts these challenges as it is ethically bound to deliver high-quality services. Policy and regulatory requirements increasingly demand that social work deliver and document the effectiveness of highest quality interventions and restrict reimbursement to those services that are documented as evidence based. Social work's future, its very survival, depends on our ability to deliver services with a solid base of evidence and to document their effectiveness. In the words of the American Academy of Social Work and Social Welfare (AASWSW; n.d.), social work seeks to "champion social progress powered by science." The research community needs to support practice through innovative and rigorous science that advances the evidence for interventions to address social work's grand challenges.My work seeks to improve the quality of social work practice by pursuing answers to three questions:1. What interventions and services are most effective and thus should be delivered in social work practice?2. How do we measure the impact of those interventions and services? (That is, what outcomes do our interventions achieve?)3. How do we implement the highest quality interventions?This paper describes this work, demonstrates the substantive and methodological progression across the three questions, assesses what we have learned, and forecasts a research agenda for what we still need to learn. Given Aaron Rosen's role as my PhD mentor and our many years of collaboration, the paper also addresses the role of research mentoring in advancing our profession's knowledge base.What Interventions and Services Are Most Effective?Answering the question "What services are effective?" requires rigorous testing of clearly specified interventions. The first paper I coauthored with Aaron Rosen—"Specifying the Treatment Process: The Basis for Effectiveness Research" (Rosen & Proctor, 1978)—provided a framework for evaluating intervention effectiveness. At that time, process and outcomes were jumbled and intertwined concepts. Social work interventions were rarely specified beyond theoretical orientation or level of focus: casework (or direct practice); group work; and macro practice, which included community, agency-level, and policy-focused practice. Moreover, interventions were not named, nor were their components clearly identified. We recognized that gross descriptions of interventions obstruct professional training, preclude fidelity assessment, and prevent accurate tests of effectiveness. Thus, in a series of papers, Rosen and I advocated that social work interventions be specified, clearly labeled, and operationally defined, measured, and tested.Specifying InterventionsSuch specification of interventions is essential to two professional responsibilities: professional education and demonstrating the effectiveness of the field's interventions. Without specification, interventions cannot be taught. Social work education is all about equipping students with skills to deliver interventions, programs, services, administrative practices, and policies. Teaching interventions requires an ability to name, define, see them in action, measure their presence (or absence), assess the fidelity with which they are delivered, and give feedback to students on how to increase or refine the associated skills.To advance testing the effectiveness of social work interventions, we drew distinctions between interventions and outcomes and proposed these two constructs as the foci for effectiveness research. We defined interventions as practitioner behaviors that can be volitionally manipulated by practitioners (used or not, varied in intensity and timing), that are defined in detail, can be reliably measured, and can be linked to specific identified outcomes (Rosen & Proctor, 1978; Rosen & Proctor, 1981). This definition foreshadowed the development of treatment manuals, lists of specific evidence-based practices, and calls for monitoring intervention fidelity. Recognizing the variety of intervention types, and to advance their more precise definition and measurement, we proposed that interventions be distinguished in terms of their complexity. Interventive responses comprise discrete or single responses, such as affirmation, expression of empathy, or positive reinforcement. Interventive strategies comprise several different actions that are, together, linked to a designated outcome, such as motivational interviewing. Most complex are interventive programs, which are a variety of intervention actions organized and integrated as a total treatment package; collaborative care for depression or community assertive treatment are examples. To strengthen the professional knowledge base, we also called for social work effectiveness research to begin testing the optimal dose and sequencing of intervention components in relation to attainment of desired outcomes.Advancing Intervention Effectiveness ResearchOur "specifying paper" also was motivated by the paucity of literature at that time on actual social work interventions. Our literature review of 13 major social work journals over 5 years of published research revealed that only 15% of published social work research addressed interventions. About a third of studies described social problems, and about half explored factors associated with the problem (Rosen, Proctor, & Staudt, 2003). Most troubling was our finding that only 3% of articles described the intervention or its components in sufficient detail for replication in either research or practice. Later, Fraser (2004) found intervention research to comprise only about one fourth of empirical studies in social work. Fortunately, our situation has improved. Intervention research is more frequent in social work publications, thanks largely to the publication policies of the Journal of the Society for Social Work and Research and Research on Social Work Practice.Research PrioritiesSocial work faces important and formidable challenges as it advances research on intervention effectiveness. The practitioner who searches the literature or various intervention lists can find more than 500 practices that are named or that are shown to have evidence from rigorous trials that passes a bar to qualify as evidence-based practices. However, our profession still lacks any organized compendium or taxonomy of interventions that are employed in or found to be effective for social work practice. Existing lists of evidence-based practices, although necessary, are insufficient for social work for several reasons. First, as a 2015 National Academies Institute of Medicine (IOM) report—"Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards" (IOM, 2015)—concluded, too few evidence-based practices have been found to be appropriate for low-resource settings or acceptable to minority groups. Second, existing interventions do not adequately reflect the breadth of social work practice. We have too few evidence-based interventions that can inform effective community organization, case management, referral practice, resource development, administrative practice, or policy. Noting that there is far less literature on evidence-based practices relevant to organizational, community, and policy practice, a social work task force responding to the 2015 IOM report recommended that this gap be a target of our educational and research efforts (National Task Force on Evidence-Based Practice in Social Work, 2016). And finally, our field—along with other professions that deliver psychosocial interventions—lacks the kinds of procedure codes that can identify the specific interventions we deliver. Documenting social work activities in agency records is increasingly essential for quality assurance and third-party reimbursement.Future Directions: Research to Advance Evidence on InterventionsSocial work has critically important research needs. Our field needs to advance the evidence base on what interventions work for social work populations, practices, and settings. Responding to the 2015 IOM report, the National Task Force on Evidence-Based Practice in Social Work (2016) identified as a social work priority the development and testing of evidence-based practices relevant to organizational, community, and policy practice. As we advance our intervention effectiveness research, we must respond to the challenge of determining the key mechanisms of change (National Institute of Mental Health, 2016) and identify key modifiable components of packaged interventions (Rosen & Proctor, 1978). We need to explore the optimal dosage, ordering, or adapted bundling of intervention elements and advance robust, feasible ways to measure and increase fidelity (Jaccard, 2016). We also need to conduct research on which interventions are most appropriate, acceptable, and effective with various client groups (Zayas, 2003; Videka, 2003).Documenting the Impact of Interventions: Specifying and Measuring OutcomesOutcomes are key to documenting the impact of social work interventions. My 1978 "specifying" paper with Rosen emphasized that the effectiveness of social work practice could not be adequately evaluated without clear specification and measurement of various types of outcomes. In that paper, we argued that the profession cannot rely only on an assertion of effectiveness. The field must also calibrate, calculate, and communicate its impact.The nursing profession's highly successful campaign, based on outcomes research, positioned that field to claim that "nurses save lives." Nurse staffing ratios were associated with in-hospital and 30-day mortality, independent of patient characteristics, hospital characteristics, or medical treatment (Person et al., 2004). In contrast, social work has often described—sometimes advertised—itself as the low-cost profession. The claim of "cheapest service" may have some strategic advantage in turf competition with other professions. But social work can do better. Our research base can and should demonstrate the value of our work by naming and quantifying the outcomes—the added value of social work interventions.As a start to this work—a beginning step in compiling evidence about the impact of social work interventions—our team set out to identify the outcomes associated with social work practice. We felt that identifying and naming outcomes is essential for conveying what social work is about. Moreover, outcomes should serve as the focus for evaluating the effectiveness of social work interventions.We produced two taxonomies of outcomes reflected in published evaluations of social work interventions (Proctor, Rosen, & Rhee, 2002; Rosen, Proctor, & Staudt, 2003). They included such outcomes as change in clients' social functioning, resource procurement, problem or symptom reduction, and safety. They exemplify the importance of naming and measuring what our profession can contribute to society. Although social work's growing body of effectiveness research typically reports outcomes of the interventions being tested, the literature has not, in the intervening 20 years, addressed the collective set of outcomes for our field.Fortunately, the Grand Challenges for Social Work (AASWSW, n.d.) now provide a framework for communicating social work's goals. They reflect social work's added value: improving individual and family well-being, strengthening social fabric, and helping to create a more just society. The Grand Challenges for Social Work include ensuring healthy development for all youth, closing the health gap, stopping family violence, advancing long and productive lives, eradicating social isolation, ending homelessness, creating social responses to a changing environment, harnessing technology for social good, promoting smart decarceration, reducing extreme economic inequality, building financial capability for all, and achieving equal opportunity and justice (AASWSW, n.d.).These important goals appropriately reflect much of what we are all about in social work, and our entire field has been galvanized—energized by the power of these grand challenges. However, the grand challenges require setting specific benchmarks—targets that reflect how far our professional actions can expect to take us, or in some areas, how far we have come in meeting the challenge.For the past decade, care delivery systems and payment reforms have required measures for tracking performance. Quality measures have become critical tools for all service providers and organizations (IOM, 2015). The IOM defines quality of care as "the degree to which … services for individuals and populations increase the likelihood of desired … outcomes and are consistent with current professional knowledge" (Lohr, 1990, p. 21). Quality measures are important at multiple levels of service delivery: at the client level, at the practitioner level, at the organization level, and at the policy level. The National Quality Forum has established five criteria for quality measures: They should address (a) the most important, (b) the most scientifically valid, (c) the most feasible or least burdensome, (d) the most usable, and (e) the most harmonious set of measures (IOM, 2015.) Quality measures have been advanced by accrediting groups (e.g., the Joint Commission of the National Committee for Quality Assurance), professional societies, and federal agencies, including the U.S. Department of Health and Human Services. However, quality measures are lacking for key areas of social work practice, including mental health and substance-use treatment. And of the 55 nationally endorsed measures related to mental health and substance use, only two address a psychosocial intervention. Measures used for accreditation and certification purposes often reflect structural capabilities of organizations and their resource use, not the infrastructure required to deliver high-quality services (IOM, 2015). I am not aware of any quality measure developed by our own professional societies or agreed upon across our field.Future Directions: Research on Quality Monitoring and Measure DevelopmentAlthough social work as a field lacks a strong tradition of measuring and assessing quality (Megivern et al., 2007; McMillen et al., 2005; Proctor, Powell, & McMillen, 2012), social work's role in the quality workforce is becoming better understood (McMillen & Raffol, 2016). The small number of established and endorsed quality measures reflects both limitations in the evidence for effective interventions and challenges in obtaining the detailed information necessary to support quality measurement (IOM, 2015). According to the National Task Force on Evidence-Based Practice in Social Work (2016), developing quality measures to capture use of evidence-based interventions is essential for the survival of social work practice in many settings. The task force recommends that social work organizations develop relevant and viable quality measures and that social workers actively influence the implementation of quality measures in their practice settings.How to Implement Evidence-Based CareA third and more recent focus of my work addresses this question: How do we implement evidence-based care in agencies and communities? Despite our progress in developing proven interventions, most clients—whether served by social workers or other providers—do not receive evidence-based care. A growing number of studies are assessing the extent to which clients—in specific settings or communities—receive evidence-based interventions. Kohl, Schurer, and Bellamy (2009) examined quality in a core area of social work: training for parents at risk for child maltreatment. The team examined the parent services and their level of empirical support in community agencies, staffed largely by master's-level social workers. Of 35 identified treatment programs offered to families, only 11% were "well-established empirically supported interventions," with another 20% containing some hallmarks of empirically supported interventions (Kohl et al., 2009). This study reveals a sizable implementation gap, with most of the programs delivered lacking scientific validation.Similar quality gaps are apparent in other settings where social workers deliver services. Studies show that only 19.3% of school mental health professionals and 36.8% of community mental health professionals working in Virginia's schools and community mental health centers report using any evidence-based substance-abuse prevention programs (Evans, Koch, Brady, Meszaros, & Sadler, 2013). In mental health, where social workers have long delivered the bulk of services, only 40% to 50% of people with mental disorders receive any treatment (Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Merikangas et al., 2011), and of those receiving treatment, a fraction receive what could be considered "quality" treatment (Wang, Demler, & Kessler, 2002; Wang et al., 2005). These and other studies indicate that, despite progress in developing proven interventions, most clients do not receive evidence-based care. In light of the growth of evidence-based practice, this fact is troubling evidence that testing interventions and publishing the findings is not sufficient to improve quality.So, how do we get these interventions in place? What is needed to enable social workers to deliver, and clients to receive, high-quality care? In addition to developing and testing evidence-based interventions, what else is needed to improve the quality of social work practice? My work has focused on advancing quality of services through two paths.Making Effective Interventions Accessible to Providers: Intervention Reviews and TaxonomiesFirst, we have advocated that research evidence be synthesized and made available to front-line practitioners. In a research-active field where new knowledge is constantly produced, practitioners should not be expected to rely on journal publications alone for information about effective approaches to achieve desired outcomes. Mastering a rapidly expanding professional evidence base has been characterized as a nearly unachievable challenge for practitioners (Greenfield, 2017). Reviews should critique and clarify the intervention's effectiveness as tested in specific settings, populations, and contexts, answering the question, "What works where, and with whom?" Even more valuable are studies of comparative effectiveness—those that answer, "Which intervention works where, and of clearly and interventions their and the of research reports and A is the consistent nam

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