At their core, social workers, community health workers, and peer support specialists are liaisons—serving as connective tissue between patients and providers; between patients and community resources; and between social and medical models of healthcare. These social service providers create a shared definition of health that prevents miscommunications and builds mutual investment in patient outcomes. While this connection is essential to providing holistic care, it may create strain for workers who straddle multiple realms. “If a patient wants to communicate with the clinical team, a peer support specialist can be a shortcut to get the doctor’s attention.” (PSS03) “[When] cultural views become directly at odds with the western medical system… the social worker gets brought in the middle, to bring these two views together.” (SW01)

While medical practitioners are guided by clear diagnostic criteria, social service providers deal largely with issues that transcend organizational and domain boundaries, each with their own challenges and metrics. In other words, traditional medicine views health through a microscope, whereas social service providers view health through a telescope. These different lenses may result in hierarchical friction, misunderstandings of roles, and disjointed collaboration between medical and social providers in certain care settings. When connective tissue is not valued, it breaks down—ultimately compromising the quality of patient care. “[Compared to doctors], social workers can be a bit more squishy in how they’re communicating with people…. But we all have a Masters of Science, and social workers do more than just the touchy feely side.” (SW01) “During one of our cross-hierarchy meetings, one of the surgeons turned to me and said, “What training do you even have?” (SW05) “Typically, social workers are advocating for patients one way, and the medical team the other way.” (SW04) “If we’re only working in silos, and we’re working against each other or not being complimentary, that leads to frustration.” (SW02)

Originally designed to fulfill reimbursement requirements, electronic health records (EHRs) lack the capacity for seamless integration of patient medical histories. As a result, social service providers often find themselves burdened with time-consuming chart reviews that are at odds with their demanding caseloads—impeding their ability to derive meaningful conclusions that are necessary for comprehensive patient care. “When I do chart review, I want to get a full picture of what’s going on with a patient. But I currently only get snippets here, snippets there. I could spend a whole day just doing one patient’s chart review.” (SW02) "I want to be able to tell the story about what we do and how we do it, and I wish it was easier to pull this info.” (SW04)

Due to the fragmented nature of health data systems, it difficult and time-consuming for social practitioners to track longitudinal patient outcomes and provide care continuity. This obscures the big-picture view both within and beyond their own care provision. As a result, social service providers must either go to great lengths, or give up altogether, on visualizing and documenting patient journeys. “Things are not always connected back to each other.” (PSS01) “The lack of follow-up with clients is frustrating. What happened to them? Do they still need connection to services?” (SW07) “It would be nice to close the loop with patients.” (CHW02)

Given the fragmented and outdated repository of community resources, social service providers go through roundabout and time-consuming processes to find and contact local organizations. Over time, these workers develop their own knowledge base through personal experience and word of mouth—but rarely is that knowledge passed on to the practitioners that follow them, creating a cycle of duplicative learning. “A lot of the resources out other are wrong or outdated. And then we’d have to say to the patients ‘Oh, you don’t qualify for this’ or ‘This doesn’t actually exist.’ Which is more demoralizing than it is beneficial. This is just creating more barriers to patients getting what they need.” (SW01) “We all just have a binder of different resources that we knew of or heard through the grapevine.” (SW05) “We generally have our list of go-to resources… and anything we don’t know about, we crowdsource with each other.” (SW06)

In trying to satisfy both the administrative and relational components of their work under time constraints, social service providers are forced to prioritize one at the expense of the other. However, achieving balance may mean sacrificing their own professional boundaries in the process. This may lead to feelings of chronic underperformance and failure to meet clients’ needs, ultimately contributing to high rates of staff turnover. "Documentation and billing are a necessary impediment to doing the real work." (PSS03) “Administrative things are taking up too much time, to the point where it’s not worth it anymore.” (SW01) “You don’t need a master’s degree to fill out family medical leave paperwork.” (SW06) "The administrative side piles up, and at that point you’ve forgotten your conversation with the patient…. But when patients see you taking notes, they're not going to share everything with you. So I try to avoid that." (CHW02)

Given the qualitative and nuanced nature of their work, social practitioners struggle to define success metrics for a job well done. This challenge is compounded by compassion fatigue and the inability to address underlying societal issues, resulting in the problematic tendency to gauge self-worth based on patient outcomes. “Talking with patients is the best part, but it’s also tough to realize that you don’t have all the answers and support for them.” (SW08) “It’s very intense, stressful work. Usually there’s an expiration date on clinicians in this field.” (SW05) “People go into this space because they hold the values and want to enter and disrupt these systems. But you just become pawns of the systems.” “Extension of a problematic system.” (CHW Intercepts)

Because they perceive AI to be formulaic, social service providers are concerned about its capability to comprehend and integrate the social nuances that are essential for customizing patient care. Ultimately, they worry about the impact of AI on both their own job security and patient outcomes. “AI is black and white. Social work is grey.” (SW01) “A lot of times, social circumstances don’t fit into a clinical algorithm.” (SME02) “Technology isn’t going to help us get better; it’s the relationships that will help us get better.” (CHW01) “Documenting conversations with patients is where my lack of trust in AI comes in. Much of what I’m documenting is my clinical judgement.” (SW05) “I don’t think a computer program can fully take into account someone’s 20-year history.” (PSS01)

Initially, the hard-to-define concept of AI doesn’t sit well with social service providers who want to ensure their patients/clients are receiving the best possible care. However, once prompted and given the opportunity to think through specific applications, they were cautiously optimistic of its potential. "Could Al actually take bias out of social work?" (SW01) "Maybe Al could democratize access to community resources." (CHW01) “AI has untapped potential.” (PSS03)