Review the case and consider opportunities for other disciplines to collaborate in care. Develop plans for discharge that would take into account the patient’s wishes and cultural factors.
Submit an narrated PowerPoint in which you present the case and plan to the patient, family, and IDT in a culturally competent manner.  

Describe the new, revised care plan that incorporates cultural factors and aspects of health:

Two identified problems
Three or four goals
Three or four interventions
Identify and explain at least one opportunity for another discipline (not currently a member of the IDT) to collaborate in care.

Describe plans for discharge or transition, taking into account the patient’s wishes and cultural considerations.

Ensure that you adapt your communication style to achieve buy-in from the patient, family, and IDT. Use the Learning Resources to support your presentation, and include a reference slide.

Drisko, J. (2017). Active collaboration with clients: An underemphasized but vital part of evidence-based practice. Social Work, 62(2), 114–121. https://doi.org/10.1093/sw/swx003 
Ruiz, Í. R., Santed Germán, M. Á., Burgos, J. F. A., Díaz, S. C., & Carralero Montero, A. (2020). Effectiveness of mindfulness?based interventions on anxiety for children and adolescents: A systematic review and meta?analysis. Early Intervention in Psychiatry, 14(3), 263–274. https://doi.org/10.1111/eip.12849 
Agency for Healthcare Research and Quality. (2013, March). Re-engineered discharge (RED) toolkitLinks to an external site.. Tool 4: How to deliver the re-engineered discharge to diverse populations. https://www.ahrq.gov/patient-safety/settings/hospi…
Ontario Social Work. (2018, May 17). Turn issues into answers: Hospital discharge planning and social work in healthcareLinks to an external site. [Video]. YouTube. 
Gehlert, S., & Browne, T. (Eds.). (2019). Handbook of health social work (3rd ed.). Wiley.

Chapter 16, “Social Work With Children and Adolescents With Medical Conditions” (pp. 361–380)·
Samantha
Samantha Polaski is a 14-year-old Caucasian female who lives at home with her
mother, Lauren, and her father, David.
Episode
Lauren rushed her daughter to the hospital after finding her unresponsive in her
bedroom one afternoon. Samantha was stabilized in the emergency room through IV
fluids and monitored further. Samantha denied taking any drugs or alcohol and reported
she had been feeling “lightheaded” and “nervous” lately. After lab tests and physical
examination ruled out an obvious medical cause, the ER doctor ordered a psychiatric
consult. The psychiatrist recommended admission to the hospital’s behavioral health
unit. Samantha was transferred there and began treatment with an interdisciplinary
team of Dr. Turner, a psychiatrist; Tayo, a nurse; and a social worker.
Signs of Anxiety
Samantha reported a recent history of anxiety and depression, centering around the
demands of school and her social life with peers. She said she had many friends in
junior high but that since starting high school, those friends seemed to fall away.
Samantha did not participate in sports or extracurricular activities, though she admits
running on her own. In fact, she said recently she had increased her daily jogs to
multiple miles to try to address the elevated anxiety she was feeling. She stated that
running was “the only time I feel like me.”
Samantha reported one prior episode in which she temporarily lost consciousness. It
was during her first midterm exam in high school. She felt her heart quickly begin to
race and pound loudly in her ears, and she had trouble getting air. She fainted but was
able to recover quickly in the school’s health office. She reported that her peers now
“stare at me” due to this incident.
Vaccine
As part of Samantha’s stay at the hospital, nurse Tayo mentioned administering the
COVID-19 vaccine if she and the parents would like. During the conversation with the
nurse, Samantha became tearful and related how her father was against the vaccine,
fearing side effects. The night prior to Samantha’s arrival at the hospital, in fact, her
father had argued with her mother that cases for minors were mild and that Samantha
did not need a vaccine right away. He felt that the risks were unknown, and he wanted
to wait until more children were vaccinated.
Samantha reported overhearing the conversation, and while she initially wanted to get
vaccinated, her father’s comments left her frightened. So much talk about the vaccine
had left her feeling very anxious, and she could not sleep at all. This lack of sleep led to
increased anxiety on the day of the episode.
Due to Samantha’s worry surrounding the vaccine, nurse Tayo and the team decided
not to continue offering vaccination and to allow the family to work through the topic on
their own after discharge.
Care and Discharge Planning
After 2 days, the social worker discussed with the parents that Samantha was ready to
be discharged to outpatient care. David expressed that he did not want Samantha to
receive any treatment whatsoever and certainly didn’t believe she belonged in inpatient
care, whereas Lauren did not think Samantha was ready for discharge yet. “She’s safe
here,” Lauren stated. “Maybe she needs psychiatric care, David. I don’t want to find her
like that again.”
When asked what she wanted, Samantha said, “I’m just so … tired. I want to sleep.”
Consider the following questions as you take on the role of the social worker and
develop the discharge plan in Week 10:
1. What are two social aspects to consider when developing a discharge plan for
Samantha? How would you include the team in the decision-making process?
2. How would you include other team members in providing education to this
family?
3. How would you reconcile the differing opinions of Samantha’s mother and father
and also consider her needs and wishes?
Role of a Biopsychosocial Assessment
Stephanie Petrosky
Walden University, Master of Social Work
SOCW 6206: Interdisciplinary Healthcare Practice
Dr. Adele Weiner
April 3, 2024
2
The Role of a Biopsychosocial Assessment Within a Healthcare Setting
Biopsychosocial assessments are vital in analyzing an individual’s health by
incorporating biological, psychological, and social factors that contribute to their well-being.
These comprehensive evaluations are crucial within healthcare settings, as they can inform social
work practice and improve patient care significantly (Gehlert & Browne, 2019). This paper will
explore biopsychosocial assessments within healthcare environments, identify critical
components aligning with social work values, and elucidate how they enhance understanding of
the biopsychosocial aspects of illness among interdisciplinary team (IDT) members.
Social work support
The biopsychosocial model, introduced by George Engel, suggests that to comprehend a
person’s medical condition fully, it is critical to consider the intricate interplay between
biological factors (genetic predispositions and health conditions), psychological components
(mood, behavior, stress), and social aspects (cultural influences, family relationships (Smith,
2002). This approach underscores an affirmative stance on social work practice. Social workers
utilize these assessments to formulate holistic interventions that cater to all dimensions impacting
an individual’s health trajectory. For instance, Gehlert and Browne (2019) illustrate how
integrated behavioral health models employ biopsychosocial assessments to tailor interventions
addressing mental health issues alongside physical conditions.
Vital aspects of social work values
Two significant aspects of biopsychosocial assessments that resonate with social work
values are their person-in-environment framework and strength-based perspective (Gehlert &
Browne, 2019). The person-in-environment framework echoes the core social work belief of
3
understanding individuals within the context of their cultural, societal, and familial
environmental influencers, which shape their experiences and behavior.
A strength-based perspective within these assessments identifies the challenges a person
is facing and the abilities and resources that can be leveraged in treatment and recovery (Singer
& Belluomini, 2018). Such approaches affirm the principles of dignity and worth of the person
and the importance of human relationships outlined in the National Association of Social
Workers’ Code of Ethics (NASW, 2021).
Interdisciplinary team benefits
Biopsychosocial assessments serve as educational tools for other IDT members,
intensifying their grasp of the multifaceted nature of illnesses. As Attilio et al. (2020) indicate, in
palliative care contexts, when social workers conduct comprehensive psychosocial assessments,
they help medical professionals understand factors such as family dynamics or financial stresses.
These can significantly impact patient care planning. Singer and Belluomini (2018) suggest that
well-constructed biopsychosocial evaluations facilitate detailed case conceptualization, which is
invaluable for clinicians who may otherwise focus predominantly on physiological symptoms.
Providing considerate care
Finally, these assessments drive better care by promoting personalized treatment plans
that address specific patient needs across biological, psychological, and social realms. Cagle et
al. (2017) advocate for tailored psychosocial assessments to identify patients’ emotional needs,
which may require intervention by hospice social workers along with medical treatment for their
physical symptoms. These tools foster an environment where IDT members can collaborate more
efficiently in patient-centered care.
4
Conclusion
A biopsychosocial assessment represents a comprehensive approach to understanding
patients holistically within healthcare settings, emphasizing the biological, psychological, and
social factors that significantly affect a patient’s health outcomes and endorsing critical social
work values such as the dignity and interconnectedness of individuals within their broader
environments. Biopsychosocial assessments provide a robust foundation for enhancing IDT
collaboration, resulting in superior patient care.
5
References
Altilio, T., Groninger, H., & Kelemen, A. (2020, April). Fast facts and concepts #396: The psychosocial
assessment in palliative care. Palliative Care Network of Wisconsin.

Cagle, J. G., Osteen, P., Sacco, P., & Jacobson Frey, J. (2017). Psychosocial assessment by hospice
social workers: A content review of instruments from a national sample. Journal of Pain and
Symptom Management, 53(1), 40–48. https://doi.org/10.1016/j.jpainsymman.2016.08.016
Gehlert, S., & Browne, T. (Eds.). (2019). Handbook of health social work (3rd ed.). Wiley.
National Association of Social Workers, 2021. Code of Ethics.
https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-EthicsEnglish.aspx#principles
Singer, J. B., & Belluomini, E. (2018). Social work assessment. In J. C. Heyman & E. P. Congress
(Eds.), Health and social work: Practice, policy, and research (pp. 67–86). Springer Publishing
Company. https://doi.org/10.1891/9780826141644.0005
Smith, R. C. (2002). The Biopsychosocial Revolution: Interviewing and provider-patient relationships
becoming key issues for primary care. J Gen Intern Med. 17(4). 10.1046/j.15251497.2002.20210.x
Care Plan
S
Master of Social Work, Walden University
SOCW 6206: Interdisciplinary Healthcare Practice
Dr.
ddate
TO PREPARE
•
•
•
Review the Learning Resources on care planning.
Revisit the biopsychosocial assessment you developed in Week 5, as well as the
Discussion on interventions from last week. Review this week’s Discussion and
the problem and goal you identified there. Consider how you might use these
elements for patient care planning within an IDT.
Add to the elements you have already drafted by identifying at least one more
problem and further goals and interventions to address this problem.
BY DAY 7-DUE 4.17
Design a care plan for your selected patient case that includes:
•
•
•
•
•
Two identified problems
Three goals
Three interventions
Justification for the care plan (i.e., Why is it appropriate for the patient?)
Explanation of how you would advocate for this plan within the IDT and achieve
buy-in from the patient, caregiver, and other members
Care Plan
Samantha Polaski is a 14-year-old female who was referred to care within this clinic
because of an emergency room visit on March 28, 2023. Samantha was found unresponsive by
her mother. Samantha reported feeling the pressure from school and her peers did not help her
feelings.
Identified Problems Two identified problems
Samantha has exhibited signs of anxiety, affecting her social interactions and academic
performance, leading to physical symptoms like lightheadedness and fainting. She is also
showing symptoms of depression. The detachment from her peer group and the lack of
engagement in extracurricular activities suggest a withdrawal from previously enjoyable
activities.
Goals Three or four goals
A care plan must have goals for what the patient ultimately needs to overcome the
symptoms associated with the problems that are present. The first goal would be to reduce
Samantha’s symptoms of anxiety and depression that affect her daily functioning. The second
goal would be to empower Samantha with effective coping mechanisms for managing stressors
related to school and her social life. The third goal would be to improve the family dynamics and
understanding to ensure a supportive environment for Samantha’s recovery.
Interventions
Three or four interventions
Cognitive Behavioral Therapy (CBT): CBT will help Samantha challenge and reframe
negative thought patterns, thus reducing anxiety and depressive symptoms (Rohovit, n.d.).
Structured Physical Activity: Incorporating structured physical activity, such as a daily
running program, as a positive coping strategy for anxiety management.
Family Therapy: Engaging in family therapy sessions to address communication barriers
and conflicting views on vaccination and treatment, thereby fostering a supportive home
environment.
Care Plan Justification
Justification for the care plan (i.e., Why is it appropriate for the
patient?)
This care plan is appropriate for Samantha given the proven efficacy of CBT in treating
adolescent anxiety and depression (Donnelly et al., 2018). The inclusion of physical activity
leverages Samantha’s affinity for running, promoting a healthy outlet for stress. Family therapy is
critical, considering the discordant views on Samantha’s healthcare needs, which may be
contributing to her emotional distress.
Plan Advocate
Explanation of how you would advocate for this plan within the IDT and
achieve buy-in from the patient, caregiver, and other members
To advocate for this plan, it will be crucial to present evidence-based research, such as the
studies by Donnelly et al. (2018) and Kwak et al. (2021), to the IDT, highlighting the benefits of
the proposed interventions. Achieving buy-in from Samantha will involve empathetic
communication and ensuring her voice is heard in her care plan. For Lauren, reinforcing the
safety and preparedness for discharge will be key, while for David, presenting factual
information regarding treatment efficacy may alleviate concerns. Engaging in open dialogue with
all parties and addressing their specific apprehensions will be central to the plan’s acceptance and
success.
References
Donnelly, S., Cahill, S., & O’Neill, D. (2018). Care planning meetings: Issues for policy, multidisciplinary practice and patient participation. Practice: Social Work in Action, 30(1), 53–
71. https://doi.org/10.1080/09503153.2017.1385758
Kwak, J., Jamal, A., Jones, B., Timmerman, G. M., Hughes, B., & Fry, L. (2021). An
interprofessional approach to advance care planning. American Journal of Hospice and
Palliative Medicine. https://doi.org/10.1177/10499091211019316
Rohovit, J. (n.d.). Clinical tools: Guide to goal setting and tracking. University of Minnesota
Center for Practice Transformation.
https://practicetransformation.umn.edu/clinical-tools/guide-to-goal-setting-and-tracking/
Ruiz, Í. R., Santed Germán, M. Á., Burgos, J. F. A., Díaz, S. C., & Carralero Montero, A. (2020).
Effectiveness of mindfulness?based interventions on anxiety for children and adolescents:
A systematic review and meta?analysis. Early Intervention in Psychiatry, 14(3), 263–274.
https://doi.org/10.1111/eip.12849