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Institute on social practice integration research and education (INSPIRE): a workforce development solution to close the health gap

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Institute on social practice integration research and education (INSPIRE): a workforce development solution to close the health gap

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Content Institute on Social Practice Integration Research and Education
(INSPIRE): A Workforce Development Solution to Close the Health Gap
Raine McKenna ‘Āpuakea Arndt-Couch, DSW, JD
Doctoral Capstone Project
presented to the faculty of the
Suzanne Dworak-Peck School of Social
University of Southern California
under the guidance of Ron Mandersheid, PhD
in partial fulfillment for the degree
Doctor of Social Work
August 2023

© 2023 Raine McKenna ‘Āpuakea Arndt-Couch

Acknowledgements
I formally acknowledge that no part of this paper or capstone project was generated by an
artificial intelligence system.
I thank my capstone defense panel and external design partners including Dr. Melissa
Singh, Dr. Ellen Fink-Samnick, and Wiara Jackson, and my professor and capstone faculty chair,
Dr. Ron Manderscheid, who all gave of their time and insights freely to both encourage and
challenge me to present a cohesive, sustainable solution to a challenging, wicked problem.
I also acknowledge and hold in high esteem my cohort colleagues, especially Dr. Ilene
Candreva, Dr. Emiley Morton, and Dr. Erin Perry – for pushing me, holding me up, and proving
that we collectively have the power to change the future of the social work profession.
To my ‘ohana including my parents Daniel and Merryl Arndt, my sister Skye Schenk,
and many others - thank you for making it possible for this first-generation college student to
dream big and achieve anything I set my mind to, even if that dream ended up including three
post-graduate degrees. I honor both our ancestors and the next generation keiki who I hope to
INSPIRE through my accomplishments.
Last, but certainly not least, I owe my sanity to my husband Anthony Couch, who
demonstrated unwavering love and support no matter how many responsibilities I piled on my
plate, and who kept alive in me the competitive spirit to keep working toward my goals even
when I was tempted to give up. Aloha wau iā ‘oe.

Table of Contents
Executive Summary ....................................................................................................................1
Problem Description and the Grand Challenges for Social Work Context ................................1
Design Thinking Methodology ................................................................................................2
Theory of Change ....................................................................................................................3
Professional Significance .........................................................................................................4
Implementation Plan & Future Action Steps ............................................................................5
Abstract ......................................................................................................................................6
Positionality Statement ................................................................................................................7
Problem of Practice and Literature Review ..................................................................................8
Target Population .................................................................................................................. 10
Stakeholder Understanding .................................................................................................... 11
Conceptual Framework ............................................................................................................. 13
Logic Model .......................................................................................................................... 14
Project Description .................................................................................................................... 16
Proposed Solution .................................................................................................................. 16
Theory of Change .................................................................................................................. 19
Solution Landscape ............................................................................................................... 20
Prototype Description ............................................................................................................ 21
Likelihood of Success ............................................................................................................ 22
Methodology ............................................................................................................................. 23
Human Centered Design ........................................................................................................ 23
Design Criteria ...................................................................................................................... 24
Market Analysis .................................................................................................................... 25
Financial Plans & Implementation Overview ......................................................................... 25
Assessment of Impact ............................................................................................................ 26
Stakeholder Involvement ....................................................................................................... 26
Communications Products and Strategies ............................................................................... 27
Implementation Plan ................................................................................................................. 27
Timeline and Phasing ............................................................................................................ 27
Implementation Framework and Strategies ............................................................................ 28
Line-Item Budgets ................................................................................................................. 31
Methods for Assessment ........................................................................................................ 31
Plans for Stakeholder Involvement ........................................................................................ 32
Communication Strategies ..................................................................................................... 32
Potential Challenges and Leadership Strategies...................................................................... 32
Ethical Considerations and Design Justice Principles ............................................................. 34
Conclusion and Implications ..................................................................................................... 35
References ................................................................................................................................ 38
Appendix A - Stakeholder Map ................................................................................................. 49
Appendix B - Logic Model ........................................................................................................ 50
Appendix C - Prototype ............................................................................................................. 51
Appendix D - Data Collection Strategy ................................................................................... 149
Appendix E - Design Criteria .................................................................................................. 154
Appendix F - Communication/Marketing Materials ................................................................. 155
Appendix G - Project Timeline & Phases ................................................................................ 157
Appendix H - Implementation Framework .............................................................................. 159
Appendix I - Implementation Strategies .................................................................................. 160
Appendix J - Start-Up Budget ................................................................................................. 161
Appendix K - First Full Year of Operations Budget ................................................................. 162
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Executive Summary
The Institute on Social Practice Integration Research and Education (INSPIRE) program
is an innovative workforce development solution to achieve health equity by improving social
care integration in health care delivery. The purpose of the 10-month experiential learning and
certification program is to build the social care intervention evidence-base by empowering health
care social workers to engage in practitioner research, knowledge dissemination, and building a
business case for social care integration activities, while also engaging health care leaders toward
greater investments in social care integration activities.
Problem Description and the Grand Challenges for Social Work Context
The INSPIRE program was developed in direct alignment with the American Academy
of Social Work and Social Welfare (AASWSW) Grand Challenges for Social Work initiative to
Close the Health Gap, which promotes systemic solutions to combat health care disparities that
adversely and inequitably affect some of the most vulnerable and historically marginalized
populations in the United States (AASWSW, 2018; Barth et al., 2022; Bent-Goodley et al., 2019;
Fong et al., 2018; Spencer et al., 2016). The problem is that despite a proliferation of emerging
research and policy initiatives in the United States substantiating the importance of interventions
targeting social care needs like housing and food insecurity to move the needle toward health
equity and effectuate closure of the health gap, there remains poor investment in and inconsistent
integration of social care services within health care delivery (Fichtenberg et al., 2020; Horwitz
et al., 2020; Kelley, 2022; Lakey et al., 2021, Long et al., 2022, National Academies of Sciences,
Engineering, and Medicine [NASEM], 2019).
Furthermore, health care professionals who are competently trained to address the social
determinants of health are often undervalued and underutilized within health care organizations
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(Kelley, 2022; NASEM, 2019; Stein, 2016; Velásquez, 2019). This includes social workers often
being excluded from programmatic decisions made by health care organizations about why and
how to integrate social care in health care delivery, despite their demonstrated knowledge, skill,
and experience addressing social care needs (Barth et al., 2022; NASEM, 2019).
While there is a growing commitment among health care leaders and decision-makers to
improve integration of social care interventions as part of comprehensive clinical care, there has
been little consensus on what to do and how to do it (Horwitz et al., 2020; Lee & Korba, 2017;
NASEM, 2019; Zerden et al., 2020). This resultant social care integration implementation gap
reflects how unprepared health care delivery systems are to successfully address health care
disparities, leaving our most vulnerable populations including racial and ethnic minorities at-risk
for disproportionately poor clinical outcomes and overall wellbeing (Byhoff et al., 2019; De
Marchis et al., 2019; Fichtenberg et al., 2020).
Design Thinking Methodology
The INSPIRE program was developed in the context of design thinking methodology
which employs various tools within a four-stage design process that asks: What is? What if?
What wows? and What works? and that is centered in establishing a deep understanding of those
who will use and/or benefit from the innovation (Liedtka & Ogilvie, 2011). In the What is?
stage, secondary research and literature review, direct observation, personal interviews with key
stakeholders, and journey mapping tools were utilized to establish understanding of how things
work (or don’t work) today. Based on analysis of key takeaways from the initial research phase,
a distinct set of design criteria were developed to guide solution development and success. The
What if? stage focused on brainstorming and testing solutions against these established design
criteria. The strongest ideas were developed into low-fidelity and high-fidelity prototypes in the
3

What wows? stage, and in the final What works? stage the prototypes were presented to key
stakeholders and users for feedback and refinement through an iterative, co-creation process.
Theory of Change
The anticipated short- and intermediate- outcomes of the INSPIRE program include:
measurable changes in knowledge and skills of program participants in the areas of practitioner
research, knowledge dissemination, and building a business case for social care integration;
participant’s behavioral changes measured by the growth of the social care interventions
evidence-base and engagement in knowledge dissemination activities; and, increased health care
leadership buy-in as measured by actual financial and other resource investments in social care
intervention activities. After achieving short-term outcomes in knowledge and skill-building
using the experiential learning model, the INSPIRE program’s long-term outcomes rely on the
changed behaviors of program participants to develop and disseminate innovative best practices
in social care integration, creating long-lasting systemic change that incorporates the generation
of innovative models of care delivery. Long-term outcomes include projected systemic changes
tied to the ability of health care organizations to implement holistic, integrated care which will
ultimately result in improved population health outcomes by measuring incidence and impact of
health care disparities over time.
Though ambitious, the INSPIRE program’s goals are realistic, given the targeted program
outcomes. These expected program outcomes are grounded in experiential learning theory,
which holds that learners who are empowered to take charge of their own knowledge
development experience sustained performance improvement (Institute for Experiential
Learning, 2021). The INSPIRE program includes didactic learning modules but heavily
emphasizes hands-on engagement and practical application of the knowledge and skills gained
4

through participating, resulting in significant practice changes over time (Austin & Carnochan,
2020).
While other educational and training programs in integrated care do exist, there are none
to date that exclusively or even in large part focus on the integration of social care in health care
delivery (National Register of Health Service Psychologists, 2022; Society for Health
Psychology, 2022; University of Michigan, 2022). The INSPIRE program is innovative because
unlike other health equity-driven solutions that have traditionally focused on specific
interventions targeted on changed behaviors or improved outcomes in the beneficiary (patient)
population, this program employs a more expansive workforce development strategy that builds
a specialized social care workforce and generates health care leadership ready to develop and
implement these evidence-based interventions. The INSPIRE program seeks to fill a current void
in health care sector; namely, that without an adequately trained and prepared workforce,
evidence-based interventions will undoubtedly fail.
Professional Significance
As stated previously, the INSPIRE program was developed in alignment with the Grand
Challenges for Social Work initiative to Close the Health Gap. The INSPIRE program
contributes to progress under this Grand Challenge through its innovative workforce
development strategy that focuses on building a competent specialized workforce of social care
experts who are prepared and confident to lead change. These activities will promote sustained
improvements to the health care delivery system whereby the nation’s health care organizations,
providers, and other key stakeholders will have tangible solutions to implement more effective
integration of social care in health care delivery. These outcomes will contribute to increasing
readiness for health care systems to achieve overarching population health goals of eliminating
5

health disparities and closing the health gap in alignment with national health care policy
initiatives.
Implementation Plan & Future Action Steps
The plan to implement the INSPIRE program includes strategies to engage and prepare
key stakeholders including social workers and health care leaders interested in improving their
readiness to integrate social care activities more effectively into healthcare operations and
practice. More specifically, the INSPIRE program includes a phased implementation approach.
The DSW capstone year represented Phase I which focused on development and iteration of the
program curriculum and design in partnership with key stakeholders, users, and design partners.
This resulted in development of a high-fidelity prototype, a ready-to-implement version of the
program curriculum that includes relevant educational and administrative materials, timelines,
and outcomes evaluation tools.
Future action steps include securing the support of a national professional organization to
serve as a program host during the Phase II initial implementation phase of the program.
Leveraging existing professional organization affiliations and historical partnerships will be key
during this phase. Phase III is intended as an expansion phase with a focus on increasing the
number of participants and partner organizations and the inclusion of programmatic refinements
discovered through evaluation of Phase II. Phase IV will represent full scale-up with plans to
establish a nationally focused social enterprise to serve as a permanent program host, ensuring
long-term sustainability of the program. Ultimately, the ability to scale and implement the
program beyond local contexts will result in the ability to generate nationwide impact and
standardized adoption.
6

Abstract
The Grand Challenges for Social Work initiative to Close the Health Gap promotes systemic
solutions to address health care inequities and the social determinants of health across the United
States (Barth et al., 2022). National health care policy priorities and evidence-based research
have identified the ability to successfully integrate social care within health care delivery as key
to closing this health gap (Fichtenberg et al., 2020; Horwitz et al., 2020; Kelley, 2022; NASEM,
2019). Unfortunately, health care organizations have struggled with effectively integrating
social care interventions into practice. This is driven in part by the underutilization of social care
experts like social workers in integrated health care practice and program development, despite
evidence that successful social care integration requires an adequately trained specialized
workforce (NASEM, 2019; Velásquez, 2019). The Institute on Social Practice Integration
Research and Education (INSPIRE) program is an innovative solution for improving social care
integration implementation through a targeted workforce development strategy. The INSPIRE
program is an experiential learning and certification program for health care social workers to
develop skills in practitioner research, knowledge dissemination, and building a business case for
social care integration activities that simultaneously engages health care leaders around the
importance and benefits of increasing investments in social care integration activities and in a
specialized social care workforce. The INSPIRE program is innovative because of its mezzo-
level workforce development approach focused on generating new models of care in local
contexts intended for wide dissemination across local and national settings for maximum impact
and sustainability.
Keywords: close the health gap, social care integration, social workers, workforce
development, experiential learning
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Positionality Statement
My name is Raine Mckenna ‘Āpuakea Arndt-Couch. I am from Kailua, Hawai‘i. I am a
Native Hawaiian. I am a scholar. I am a social worker. I am a lawyer. I honor my culture and the
factors that have shaped me into the person I am today. These culturally ascribed characteristics,
along with my personal experiences and life history, have influenced my capstone project
including the selection of a Grand Challenge initiative and wicked problem on which I have
focused my efforts (Njeri, 2021).
Social work and law have taught me advocacy skills that have influenced my work. As
such, I came to my DSW capstone research and solution development from the perspective of
one seeking to make a difference in the lives of beneficiaries – those experiencing the brunt of
health care inequities – but also as one interested in advocating for improvements in processes
that affect the primary users of my solution – social workers – who I wholeheartedly believe are
in a unique position to bring sustainable, innovative change to the health care delivery system.
As a health care social worker, chosen capstone problem and solution are not without
bias. My decisions were driven at least partially by a desire to seek solutions that alleviate
barriers in the health care delivery system that have made my own work – and that of my
colleagues – unnecessarily challenging, slow, and ineffective. I recognize I bring a an inherently
subjective perspective to my capstone project. In response, I have engaged in healthy self-
reflection and have sought external feedback to mitigate the potential unintended consequences
of my work. Through design thinking strategies, I have worked with and for others to ensure
practicability, sustainability, and appropriateness of my innovative solution for wide
dissemination and implementation that meets both my own needs and those of primary
stakeholders, users, and beneficiaries.
8

Problem of Practice and Literature Review
The United States’ health care delivery system is unprepared to effectively integrate
social care with the provision of health care services, placing historically disenfranchised and
other vulnerable population groups at sustained risk of poorer clinical health outcomes, including
lower life expectancy and significantly higher incidence of chronic medical conditions affecting
quality of life across the lifespan (Byhoff et al., 2019; De Marchis et al., 2019; Fichtenberg et al.,
2020; Levins, 2021; Lockett, 2022). Despite the recognition that integrating social care into
health care delivery offers a key approach to addressing health care disparities, there is a practice
implementation gap present throughout our national health care delivery system which is fueled
by an extensive underinvestment in building evidence-based practices to integrate social care
interventions in health care delivery and an associated undervaluation and underutilization of the
social care expert workforce to close this gap (Horwitz et al., 2020; Kelley, 2022; Levins, 2021;
Lockett, 2022; NASEM, 2019; Office of Minority Health, 2021).
The American Academy of Social Work and Social Welfare (AASWSW) Grand
Challenges initiative to Close the Health Gap calls for solutions to eliminate health care
disparities adversely affecting the most historically marginalized populations in the United
States, including racial and ethnic minority groups and those experiencing poverty (AASWSW,
2018; Barth et al., 2022; Bent-Goodley et al., 2019; Fong et al., 2018; Gee et al., 2022; Get Well,
2022; Pillai et al., 2022; Radley et al., 2021; Reyes et al., 2021). Federal laws, policies, and
population health initiatives like the Affordable Care Act, the Social Determinants Accelerator
Act, Healthy People 2020/2030, and the Presidential COVID-19 Health Equity Task Force have
fueled momentum to tackle health care disparities, particularly in the context of political and
social unrest regarding pervasive racial injustice and inequities laid bare during the COVID-19
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pandemic (Barth et al., 2022; Bleser et al., 2022; Bullock et al., 2021; Cohn, 2020; National
Association of Social Workers [NASW], 2016; Office of Disease Prevention and Health
Promotion [ODPHP], 2022; Radley et al., 2021; U.S. Department of Health and Human
Services, 2021; Yancy, 2020).
The task of improving the integration of social care intervention activities within health
care delivery is certainly a challenge. In fact, this problem is held in place by contextual factors
including a medical model of health care delivery that has proven to be extremely resistant to
change (Gee et al., 2022; Horwitz et al., 2020). The medical model of health care delivery has
resulted in an increasingly myopic, uncoordinated approach to health care that has had a
disproportionate negative effect on historically disenfranchised populations by limiting access to
quality care and maintaining an inherent disregard for the complex, holistic health and wellness
needs of the population (Barth et al., 2022; NASEM, 2019).
Current research has powerfully suggested a shift in approach toward a more expansive
model of health care delivery that considers the upstream factors that influence population health
outcomes including political, economic, and social factors (Barth et al., 2022; Kelley, 2022;
NASEM, 2019). This has led to incremental rising awareness among health care leaders,
providers, policymakers, and other key stakeholders that integration of care is the way forward,
but the siloed nature of the persistent medical model of health care delivery makes this change
slow, uncoordinated, and ineffective (Barth et al. 2022; NASEM, 2019). Relatedly, there is a
research-to-practice translation gap existing within health care that is at least partially due to
ineffective dissemination of knowledge; despite a recent uptick in traditional social care research
activities, this has resulted in little progress being made toward practical social care integration
solutions (Ashcroft et al., 2021; Bleser et al., 2022; Brownson et al., 2018; Butler, 2021; Byhoff
10

et al., 2019; Fichtenberg et al., 2020; Lakey et al., 2021; Lee & Korba, 2017; Levins, 2021;
NASEM, 2019; Zerden et al., 2020).
Target Population
Despite social workers and other social care experts having demonstrated knowledge,
skills, and experience to address social care needs in health care contexts, their voices and
contributions are largely absent from health care organization operational planning discussions
and in the available literature (Ashcroft et al., 2021; G. Downs, personal communication, June
21, 2022; Fichtenberg et al., 2020; E. Harris, personal communication, June 16, 2022; A. Seal
personal communication, June 2, 2022; R. Rodney, personal communication, June 21, 2022).
This reflects the reality that health care organizations have not relied heavily enough on the
expertise of the specialized social care workforce who have direct knowledge and experience
engaging in social care practice, a gap contributing toward the low effectiveness of current
strategies to integrate care and address health inequities (Levins, 2021; NASEM, 2019).
While social workers are generally comfortable in the micro-practice space, extensive
field-based research determined that health care social workers report low internal confidence
that they (or their colleagues) possess the requisite skills, knowledge, and business acumen to
engage in practice-based research and formal dissemination of knowledge activities or be
represented in decision-making spaces in order to contribute toward improved integration of care
within their respective health care organizations (G. Downs, personal communication, June 21,
2022; E. Harris, personal communication, June 16, 2022; A. Seal, personal communication, June
2, 2022; R. Rodney, personal communication, June 21, 2022). Furthermore, social workers and
other social care experts lack opportunities to engage in decision-making and strategic planning
regarding social care integration, held in place by barriers in the workplace including lack of
11

funding, guidance, and general support from health care and social work leadership to engage in
this work (Sheikhattari et al., 2022). Therefore, current conditions suggest the need and an
opportunity for strategic approaches that arm the social care expert workforce with the
knowledge and skills necessary to engage in research and effective knowledge dissemination,
while simultaneously preparing them to create and take a seat at the proverbial decision-making
table (Byhoff et al., 2019; De Marchis et al., 2019; Levins, 2021; Fichtenberg et al., 2020;
Zerden et al., 2020). This includes the need for social care experts to develop skills in building a
business case for the work they perform, to generate necessary buy-in and investments from
health care leadership toward sustainable social care integration strategies (Wetterman &
Tompsett, 2022; W. K. Kellogg Foundation, 2018).
Stakeholder Understanding
There are numerous stakeholders affected by efforts to improve the integration of social
care into health care delivery, that are discussed below. See the stakeholder map in Appendix A
for a visual depiction of key stakeholders identified throughout early problem definition and
solution development stages of the capstone project.
Beneficiaries
Vulnerable populations, including racial and ethnic minorities most significantly affected
by health care disparities, represent the key beneficiary stakeholder group of health care
consumers (“patients”) (Fong et al., 2018; Purnell et al., 2016). Literature and field-based
research confirm that beneficiary stakeholder needs will be best met through increased attention
being paid to patients’ comprehensive bio-psycho-social needs by ensuring they have access to a
qualified social care workforce able to meet these individual needs in a culturally competent
manner (NASW, 2021a; Smedley et al., 2003; Yong et al., 2010).
12

Users
Health care systems (“providers”) are key user stakeholders in closing the health gap and
implementing strategies to improve integration of social care within health care delivery.
Providers are under immense pressure to adapt their health care delivery practices in response to
national health policy shifts toward value-based care which seeks improvements in population-
based clinical outcomes with simultaneous reductions in health care costs (Yong et al., 2010).
Most providers value more comprehensive practice models; however, they are less likely to
adopt these practices if they are cost-prohibitive or are not clearly tied to improved clinical
outcomes (Yong et al., 2010).
In terms of implementation, current leaders in the field tout the engagement of health care
providers in this user stakeholder group including physicians and nurses as necessary partners in
tackling health care disparities (Attilus, 2020; Martinez & Dimitri, 2019). Less commonly,
leaders have singled out social workers as essential contributors due to their specific skill and
training in navigation of resources and facilitation between health care providers and community
partners (NASEM, 2019; Martinez & Dimitri, 2019).
Social Care Experts (“Social Workers”)
As discussed in the Target Population section, health policy priorities indicate that efforts
to integrate social care interventions in health care delivery should leverage the expertise of
social care experts (“social workers”), who represent a vital user stakeholder sub-group
(NASEM, 2019; Taylor et al., 2016). Social workers value initiatives that improve health
outcomes for vulnerable populations by elevating the importance of interventions that address
upstream social determinants of health (Bent-Goodley, 2014). Furthermore, successful strategies
to combat health care disparities from this stakeholder perspective include those that identify the
13

unique value of social work professionals engaging in collaborative, interprofessional practice
rooted in social justice, mutual respect, and cultural competence on behalf of vulnerable
populations (Bent-Goodley et al., 2019; Smedley et al., 2003). Social work stakeholders’ needs
will be satisfied through the provision of professional advocacy that gives the workforce a voice
and elevates social workers’ value as integral members of the health care delivery team
(NASEM, 2019).
Gatekeepers
Legislators and other policymakers, as well as health insurers and health care executives
play a unique role as gatekeeper stakeholders in the context of the problem of focus. Decisions
made by the members of this stakeholder group have the potential to make lasting, systemic
changes to the health care delivery system in support of health equity (Bleser et al., 2022;
NASW, 2021a). Engaging gatekeepers in solution strategies ensures the proper infrastructure is
in place to support, feasibility including adequate funding and buy-in from those with decision-
making power (Seervai, 2022).
Conceptual Framework
The specific mechanism of change driving the outcomes of the proposed solution can be
best explained by experiential learning theory, which holds that empowering learners to take
charge of their own knowledge development results in sustained performance improvement
(Institute for Experiential Learning, 2021). Based in experiential learning theory, the program’s
curriculum recognizes that learning is initiated by concrete experience coupled with reflection
about the experience, which ultimately results in a decision to change behavior through active
experimentation of the knowledge and skills learned (Institute for Experiential Learning, 2021).
Specifically, while the curriculum offers traditional didactic learning modules, there is a heavy
14

emphasis on self-reflection within a peer cohort setting and the curriculum model actively
facilitates engagement and practical application of the knowledge and skills learned. For
example, the practitioner research and knowledge dissemination components of the curriculum
have built-in deliverables requiring that participants tie their learning and development to
concrete experiences, making it more likely that they will sustain their engagement in these
desired activities over the course of long-term daily practice (Austin & Carnochan, 2020).
A secondary theoretical framework driving the success of this solution is the diffusion of
innovations theory which provides key guidance for the effective dissemination, implementation,
sustainability, process improvement, and scale-up of research to day-to-day health care practice
(Brownson et al., 2018; Dearing & Cox, 2018). After achieving short-term outcomes in
knowledge and skill-building using the experiential learning model, the program’s intermediate
and long-term outcomes rely on the changed behaviors of social work program participants (with
the support of their respective organizational leaders) to develop and disseminate innovative best
practices in social care integration. The key to generating these intermediate and long-term
outcomes is creating a culture that values and invests in social care activities, hence the focus not
only on health care social workers as the solution’s target population, but also health care
leaders, to ensure the requisite support exists for sustainability and scale-up of social care
implementation best practices in each participating health care organization.
Logic Model
A visual depiction of the logic model underlying the proposed solution can be found in
Appendix B. There are several resource inputs required for successful implementation of the
program including specialized staff, a tailored curriculum, certificate program infrastructure,
technological tools, partnerships with health care leaders and professional organizations, and
15

funding. These inputs support the main activities of the program, which are: 1) to provide an
experiential learning and certification program for frontline health care social workers to develop
skills in practitioner research, knowledge dissemination, and building a business case for social
care integration activities; 2) to facilitate program participants’ engagement in active knowledge
dissemination; and 3) to educate health care leaders on the importance and benefits of increasing
investments in social care integration activities and the specialized social care workforce.
Outputs of the program include the number of social workers and health care leaders
educated and/or certified, the number of original practitioner research products developed by
social work participants, the number of presentations or publications arising from knowledge
dissemination activities expected as a result of program completion, and the number of health
care leader attestations reflecting a commitment to increase financial and other resource
investments in social care intervention activities in their organizations. These outputs should be
distinguished from the programmatic outcomes that fall into three levels: short-term,
intermediate, and long-term.
Short-term outcomes include expected changes in knowledge and skills measured
through pre- and post- test evaluations of participants based on the program’s tailored curriculum
modules and experiential learning activities. Intermediate outcomes include expected behavioral
changes of social work program participants measured by the growth of the social care
interventions evidence-base and knowledge dissemination activities, and also behavior changes
resulting in increased health care leadership buy-in as measured by pre- and post- program actual
financial and other resource investments in social care intervention activities. Long-term
outcomes include desired system-wide changes as a result of improved implementation of
16

comprehensive integrated care which will ultimately result in improved population health
outcomes and reduction of health care disparities over time.
Project Description
Proposed Solution
The Institute on Social Practice Integration Research and Education (INSPIRE) program
was developed as an innovative response to the Grand Challenges for Social Work initiative to
Close the Health Gap, focused on achieving health equity with increased attention on addressing
the social determinants of health (AASWSW, 2018; Barth et al., 2022; Bent-Goodley et al.,
2019; Fong et al., 2018; Spencer et al., 2016). The purpose of the INSPIRE program is to build
the social care intervention evidence-base by supporting the ability of social care experts to
engage in practitioner research and effective dissemination of knowledge, while also facilitating
a cultural shift among health care leaders toward greater investments in social care integration
activities and in the social care workforce. This project is innovative because unlike other ad hoc
solution approaches to address social care needs that have focused narrowly on programs and
interventions targeting the beneficiary patient population, this project widens the scope using a
workforce development approach to ultimately build a specialized social care workforce and
generate health care leadership buy-in to support sustainable integration of social care in health
care delivery as the prevailing model of care.
The INSPIRE program is a 10-month experiential learning and certification program for
social care experts built on a foundational curriculum in practitioner research, knowledge
dissemination, and business case development taught by field-based subject matter experts in a
virtual format that can be adapted to hybrid or in-person applications as future needs or
preferences may require. The cornerstone of the program is its experiential component, whereby
17

program participants engage in original small-scale practitioner research projects targeting social
care related program or process improvements in their immediate workplaces. These projects are
intended to allow participants an opportunity to actively engage in practitioner research as an
experiential learning step, while also building the evidence-base. These projects will also serve
as the basis for active knowledge dissemination practice enabled by established partnerships with
relevant health care based professional organizations that will feature the work of program
participants in various forms including poster and podium presentations, publications, and virtual
educational webinars. At the end of the INSPIRE program, participants will earn over 30
professional continuing education credits through partnership with accredited educational bodies
like the National Association of Social Workers (NASW) and the Case Management Society of
America (CMSA). Participants will also earn a transferable, nationally recognized certification in
social care integration practice, a designation that will provide professional credibility for future
engagement and leadership in both small and large-scale social care integration roles.
Likewise, health care leaders will be offered a tailored educational module advancing
knowledge and attitude shifts towards greater valuation of social care integration initiatives with
an emphasis on building a capable and sustainable social care expert workforce. The program
will include strategic marketing of a strong business case for increased investments in social care
integration and practice implementation. Health care leaders are expected to recognize and value
staff who are well trained and certified, in alignment with standard professional development
goals. They will also value staff who are skilled in disseminating best practices, representing
their organizations in a positive light on a national level and establishing their organizations as
innovative practice leaders in the health care delivery space. At the end of the health care
leadership module and full partnership development with the INSPIRE program through a
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targeted marketing and engagement campaign, leaders will be asked to put forth an attestation of
their intention to increase investments in social care integration and associated workforce
development activities.
The 10-month timeline of the program will be organized as follows: 2-hour direct
curriculum module instruction for both social work and health care leader participants
approximately one to two times a month (months 1-3), participant engagement in practitioner
research & business case development with support and guidance check-ins with instructors and
peers approximately one to two times a month (months 4-8), and culminating knowledge
dissemination activities in a virtual or in-person format in collaboration with professional
organization partners (months 9-10). This timeline is modeled after similar professional training
programs that have proven successful, but the timeline will continue to be evaluated in
subsequent implementation phases through active solicitation of feedback and recommendations
from key stakeholders to ensure feasibility and appropriateness.
The program is intended for initial implementation in one to two health care organization
sites with approximately ten initial cohort participants that will leverage existing organizational
affiliations of the program creator, including those with Sharp Healthcare and Blue Shield of
California Promise Health Plan. Both organizations employ health care social workers and the
requisite health care leadership interest to pursue workforce development strategies toward
improving effectiveness of interventions that address the social determinants of health. The
initial implementation of the program will require a professional organization host interested in
supporting workforce development such as CMSA, which is a viable partnership leveraging the
program creator’s existing and well-established professional affiliations.

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Theory of Change
As previously discussed in the Executive Summary and in the Conceptual Framework
section of this paper, the Logic Model in Appendix B provides a visual depiction of the theory of
change that underlies the proposed solution’s goals, mechanisms for achieving these goals, and
alignment with current best practices. To summarize, the knowledge- and skill- based curriculum
coupled with embedded opportunities to engage directly in activities learned serve as key inputs
and activities driving change through the INSPIRE program. The outcomes resulting from these
activities include changes in knowledge and skills related to practitioner research, knowledge
dissemination, and building a business case for social care integration; behavioral outcomes
including growth of the social care interventions evidence-base and engagement in knowledge
dissemination activities; and, increased investments in social care intervention activities will
reflect changes in decision-making attitudes by health care organizational leaders and decision-
makers.
Grounded in both experiential learning theory and the diffusion of innovations theory, the
INSPIRE program can realistically achieve these outcomes through its unique workforce
development approach that provides requisite knowledge and skill-building activities in
conjunction with tangible experiential learning opportunities to engage in practitioner research
and knowledge dissemination through established health care stakeholder networks and methods.
The INSPIRE program’s workforce development strategy is intended for scaling nationwide,
ultimately ensuring a sustainable pathway for social care experts to maximize their impact on the
beneficiary patient population in both local and national contexts. Thus, long-term outcomes
produced by the solution align with current best practices and national health policy strategies
seeking to address the social determinants of health toward elimination of health care disparities.
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Solution Landscape
In an attempt to address health care disparities, there have been rapid and largely
uncoordinated changes to the health care delivery sector over the past decade (Fichtenberg et al.,
2020; Horwitz et al., 2020; Kelley, 2022; Mosen et al., 2020; NASEM, 2019). Some
interventions have incorporated the use of social care experts like social workers into the
provision of services such as the Ambulatory Integration of the Medical and Social (AIMS)
model intervention, delivered exclusively by master’s level social workers (Rowe et al., 2019).
In this intervention model, patients receive specialized care for their non-medical social needs
through intensive case management services that have been linked to a reduction in depression
symptoms for program participants as well as fewer emergency department visits,
hospitalizations, and hospital readmissions (Pantell et al., 2020; Rowe et al., 2019). Successful
programs like the AIMS model have begun to provide evidentiary support for the investment in
social needs experts like social workers but fall short of providing a pathway to develop the
social needs expert workforce (Rowe et al., 2019; Sheff et al., 2017).
A recent consensus study report published by the NASEM (2019) entitled Integrating
Social Needs Care into the Delivery of Health Care to Improve the Nation's Health involved a
comprehensive review of the available evidence related to integrating social care within health
care settings. The report identified significant implementation challenges despite the growing
emergence of best-practice strategies including difficulty generating buy-in from healthcare
leadership and staff, the presence of professional scope of practice and reimbursement barriers
for social care experts like social workers, the lack of an adequate integrated digital
infrastructure, and funding shortfalls (NASEM, 2019). The Social Work Reinvestment Act
[SWRA] is one proposed legislative action developed, in part, due to the recognition that
21

addressing social care needs in healthcare delivery creates increased demand for social workers
(NASEM, 2019; NASW, 2021b; White, 2021). The SWRA seeks to promote fair market
compensation, improve diversity in the social work profession, and translate social work research
to practice (NASW, 2021b). If this legislation passes, it will successfully promote an
environment conducive to effectively addressing the underlying social determinants of health
under the overarching goal of closing the health gap.
In summary, the current solution landscape consists largely of ad-hoc interventions and
programs narrowly focused on the micro-level typically ignore the need to develop sustainable
solutions including a focus on building an adequately trained workforce (NASEM, 2019). While
educational and training programs in integrated care are increasingly available, programs that
specifically focus on the integration of social care into health care delivery do not exist in the
current literature landscape or practice body of knowledge (National Register of Health Service
Psychologists, 2022; Society for Health Psychology, 2022; University of Michigan, 2022). This
makes the INSPIRE program innovative in that the goal is not solely to train professionals in an
established model of care delivery, but instead makes investments in developing the requisite
knowledge and skills for professionals to engage in activities that will continually expand
practice models to meet changing and growing needs of their unique patient populations and
workplace settings. It addresses the problem in a more targeted and elevated way that enhances
other solutions and strategies.
Prototype Description
The full library of prototype materials can be found in Appendix C and includes links to
source files for each prototype element. The INSPIRE program prototype is a collection of
comprehensive materials including: 1) a Program Instructor Manual complete with program
22

description, detailed curriculum outlines, and evaluation tools, 2) a Participant Guide that mirrors
the Instructor Manual but with far less detailed curriculum agendas, and 3) Program
Supplemental Materials including a detailed program calendar, complete asynchronous and
synchronous session presentation slides & instructor notes for all four learning modules, and
tailored learning module worksheets. Each element of the prototype has been developed with
sufficient detail, branding, and professional finishes which together represent the INSPIRE
program in a comprehensive form and is intended for out-of-the-box implementation capabilities.
The prototype has undergone several iterations in response to formal and informal
feedback garnered via focus groups and individual review by key stakeholders and trusted
advisors identified by the program creator. Reviewers critiqued and offered ideas for
improvement of the program structure, learning modules, detailed curriculum, and overall
formatting and branding of the product, resulting in an implementation ready prototype. While
significant development has already been done, the prototype remains in a state that can and will
be further tested in the first full year of implementation, allowing for additional feedback loops
intended to improve the curriculum and materials for effective sustained implementation.
Likelihood of Success
Success of the INSPIRE program includes the production of measurable outcomes
including improvements in knowledge and skills for program participants, greater engagement in
practitioner research and knowledge dissemination activities that will drive innovative evidence-
based interventions to address the social determinants of health and increased investments from
health care organizations on activities that strengthen integration of social care in health care
delivery. Ultimately, successful scale-up of the program across multiple health care
organizations nationwide will demonstrate success of the program as large-scale efforts to
23

improve the specialized social care workforce and evidence-base will demonstrate improved
ability to reduce and even eliminate health care disparities in pursuit of health equity.
Methodology
Human Centered Design
The methodology of human centered design is a distinct approach to problem solving that
starts by defining a problem as it is understood by the people affected by the problem and ends
with a solution that is intended to best address their needs (IDEO, 2023). Most importantly,
human centered design requires a deep understanding and empathy for those affected by the
problem, which infuses the work of designing a solution from start to finish and drives a co-
creation process (IDEO, 2023). Design thinking is based in human centered design and
describes the process of innovation utilizing key tools across four-stages of design: What is?
What if? What wows? and What works? developed to guide the co-creation process between
innovators and beneficiaries of the innovation (Liedtka & Ogilvie, 2011). The ideology behind
both human centered design and design thinking is the belief that in order to develop innovative
solutions to complex problems, the problem must be approached from the user’s perspective
(Stevens, 2020).
The INSPIRE program was developed through distinct human centered design and design
thinking methodology to ensure accountability of the creator to those for whom the solution was
being built. In the What is? stage, the focus was on defining the problem and understanding this
problem from the perspective of those most affected, in the present state (Liedtka & Ogilvie,
2011). Extensive research was performed to develop this understanding, and included literature
review, direct observation, personal interviews with key stakeholders, and a creative journey
mapping meant to guide the innovator through the user experience. Based on analysis of key
24

takeaways from the What is? phase, a clear set of design criteria were developed to guide
solution development and success. See Appendix D for the data collection strategy that formed
the basis for problem definition and design thinking criteria.
The What if? stage focused on brainstorming and testing solutions against the carefully
developed design criteria, using these criteria as a guidepost for what the solution must include
or address in order to successfully solve the defined problem. This was an inherently iterative
process and involved testing through individual and small group focus groups to garner
constructive feedback and ideas for revision. The criteria for determining what idea to pursue or
what form of the idea to pursue included the following: the targeted stakeholders want it, the idea
is realistic and feasible, and the idea meets the design criteria objectives (Liedtka & Ogilvie,
2011). Thus, the strongest idea coming out of this iterative process was developed into low-
fidelity and high-fidelity prototypes in the What wows? stage. In the What works? stage the
prototypes were presented again to key stakeholders and users for feedback and refinement
through the ongoing iterative, co-creation process.
Design Criteria
See Appendix E for complete design criteria. The design criteria reflect careful analysis
of gaps in current state and areas of need that culminated out of extensive review of the available
literature and through a series of personally conducted research activities. In short, the resulting
design criteria require solutions: 1) to promote diversity to include culturally competent
strategies and diverse providers of social care integration strategies, 2) to be supported by the
evidence-base to support wide adoption, 3) to be sustainable and adaptable for long-term
implementation, and 4) to demonstrate value to key stakeholders including to health care leaders
concerned about cost-reduction.
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Market Analysis
At this time, there are no known experiential learning and certification programs centered
around social care integration within health care. There is evidence of increased efforts by health
care organizations and practitioners to engage in evidence-based practices, but due to a lacking
research base, this myopic focus has limited the ability of health care organizations to
successfully address the social determinants of health through organic application of knowledge
and skills of their existing workforce (Fichtenberg et al., 2020; Horwitz et al., 2020; Lakey et al.,
2021, Long et al., 2022, NASEM, 2019). While there are no direct competitors in the
marketplace to compare against the INSPIRE program, the feasibility and readiness for program
participants and health care organizations (through health care leaders) to engage in the INSPIRE
program have been considered.
Given the almost unanimous positive stakeholder response to the program modality,
curriculum, and intended outcomes, it is likely that there is enough interest and motivation to
engage in workforce development activities as offered by the INSPIRE program. The alternative
being inaction or otherwise no workforce development activity, leaves health care organizations
at risk of continuously missing the mark on social care integration implementation. The market,
thus, is ripe for innovative strategies like the INSPIRE program that focus on workforce
development, to provide a path forward for organizations struggling to address this
implementation gap.
Financial Plans & Implementation Overview
Detailed financial analysis and budget projections have been developed and are reflected
in the Implementation Plan section of this paper, along with greater detail regarding the
implementation framework and strategies that consider financial viability. In short, the INSPIRE
26

program is intended to generate revenue through fees that are low in comparison to other
continuing education and certification programs, that will be sufficient to cover the costs of
administering the program in full. Successful implementation of the INSPIRE program is
dependent on key partner professional organizations investment in social care workforce
development strategies. Thus, the initial implementation phase will leverage the established
professional affiliations of the program creator, building upon current innovations in the field to
drive success and scale-up.
Assessment of Impact
Impact of the INSPIRE program will be measured through pre- and post- evaluation
methodology, specifically where knowledge and skills or specific behavioral changes (including
actual investments in social care integration activities) are to be measured. In large part,
behavior-related changes will be measured by the range of expected changes and impact driven
by successful implementation of the program and include: the number of social workers and
health care leaders educated and/or certified; the number of original practitioner research
products developed by social work participants; the number of presentations or publications
arising from knowledge dissemination activities built-in to the program; and, the number of
health care leader attestations reflecting a commitment to increase financial and other resource
investments in social care intervention activities.
Stakeholder Involvement
As discussed in the Problem of Practice and Literature Review section of this paper, there
are several key stakeholders with distinct needs and motivations that must remain involved
throughout the implementation and scale-up phases of the INSPIRE program to ensure fidelity to
the program goals and design, while remaining agile and responsive to changing needs or
27

ongoing feedback that may require iteration to the program in some way. Therefore, the plan is
to continue to engage these key stakeholders including most prominently the user group of health
care social workers who, while largely absent in the literature and in organizational decision-
making capacities, will be integral to the success and growth of the INSPIRE program. All key
stakeholder groups including beneficiaries, other providers, and gatekeepers will also be kept top
of mind in evaluating the INSPIRE program to ensure fidelity to the design thinking and human
centered design processes.
Communications Products and Strategies
See Appendix F for a visual depiction of communications and marketing products. To
garner a positive impact from relevant audiences, mass media including most prominently email,
informational videos, and social media will be utilized to increase awareness about the
implementation gap related to integrating social care into health care delivery and the proposed
solution to address this problem. This will include information about the impact to various
stakeholders, including health care organizations, social care experts, and beneficiaries of social
care interventions most disproportionately affected by health care disparities as a result of the
INSPIRE program and related efforts. Publications and public speaking opportunities will also
be pursued, to include presentations at national professional organization conferences and
meetings, demonstrating how unique professional organizational affiliations will serve to
facilitate knowledge dissemination throughout many stages of the INSPIRE program from
development through implementation.
Implementation Plan
Timeline and Phasing
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The INSPIRE program employs a phased implementation approach, occurring over four
1-year-long phases. The timeline and phases of the project are detailed in Appendix G. Phase I
occurred over the DSW capstone year and focused on development and iteration of the INSPIRE
program curriculum by leveraging partnership with stakeholders, users, and design partners to
produce constructive feedback loops and products developed within human centered design
processes and strategies discussed in the Methodology section. This included the development
of a high-fidelity prototype, a ready-to-implement version of the program curriculum that
includes relevant educational and administrative materials, timelines, and outcomes evaluation
tools discussed in detail in the Project Description section of this paper.
The Phase II initial implementation phase of the program represents the start-up year
where the program will be offered in partnership with a host health care professional
organization serving one to two health care organizational sites and approximately 10 social
work participants. Phase III is the expansion phase whereby the program will be modified as
needed based on feedback from Cohort 1 participants and organizational partners and will
involve a planned increase in the number of social work participants. Phase IV is the full scale-
up year of the program with plans to establish a non-profit social enterprise organization as
future program host, intended for long-term sustainability and facilitating the ability to bring the
INSPIRE program to scale nationwide.
Implementation Framework and Strategies
Successful implementation of the INSPIRE program requires strategies that support
engagement and preparation of key stakeholders including social workers and health care leaders
motivated to increase their ability to integrate social care activities more effectively within their
operations and practices. It also involves cultivating strong partnerships with professional
29

organizations in the health care sector. The implementation framework and implementation
strategies discussed below constitute the program’s comprehensive implementation plan.
Implementation Framework - EPIS
The Exploration, Preparation, Implementation, Sustainment (EPIS) framework guides
successful implementation of evidence-based interventions and programs (Moullin et al., 2019).
The EPIS framework consists of four distinct phases – exploration, preparation, implementation,
and sustainment – and involves the examination of inner organizational factors such as culture
and climate, leadership, and fidelity monitoring, as well as outer system contexts such as the
service sector, interorganizational environment, and sociopolitical context that may facilitate or
create barriers to successful implementation (Aarons et al., 2011; Moullin et al., 2019;
Suhrheinrich et al., 2020). A detailed EPIS implementation framework for the INSPIRE program
can be found in Appendix H.
The exploration phase considers what practices or interventions may be best suited to
address or solve a specific social problem (Moullin et al., 2019). For the INSPIRE program,
inner context factors include the organizational climate and absorptive capacity of health care
organizations to consider new and innovative approaches to integrating social care into practice,
while interorganizational networks and the sociopolitical context provide a backdrop for
emergence of new policy and interventions. The preparation phase focuses on planning for
integrating the program into an existing system (Moullin et al., 2019). Championing adoption is
one inner context factor that is vital to the success of the INSPIRE program, while establishing
and leveraging interorganizational networks to include professional organization linkages and
partnerships is a key outer context factor.
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In the implementation phase, the program is implemented in accordance with the plan
(Moullin et al., 2019). Like the preparation phase, inner and outer contextual factors of primary
concern to the successful implementation of the INSPIRE program include culture and climate of
health care organizations where participants work, as well as the ability to facilitate cross-
discipline translation of impact, purpose, and expected program outcomes. In the sustainment
phase, the focus shifts toward ongoing monitoring of the adopted program (Moullin et al., 2019).
For the INSPIRE program, inner context factors to consider are fidelity monitoring addressed
through targeted outcomes measurement, while the outer context will require securing funding
for long-term operational growth and stability.
Implementation Strategies - ERIC
Implementation strategies are methods or techniques to enhance and sustain the adoption,
implementation, and scale-up of evidence-based interventions and programs (Balis et al., 2022).
The Expert Recommendations for Implementing Change (ERIC) project yielded a compilation of
implementation strategies widely used in the field of implementation science to enable successful
implementation of programs and interventions (Balis et al., 2022; Powell et al., 2015; Waltz et
al., 2014). There are distinct implementation strategies selected from the ERIC compilation
described below that drive the INSPIRE program implementation plan and provide the
mechanism for successful implementation outcomes including acceptability, adoption, and
sustainability. Appendix I contains further detail of the selected ERIC implementation strategies,
mechanisms, and outcomes.
For Phase I initial implementation of the program, strategies include developing
professional partnerships and identifying and preparing champions. These strategies will result
in increased acceptability of the INSPIRE program among key stakeholders integral to the
31

program’s success. In Phases II and III implementation strategy will focus on identifying early
adopters and staging implementation scale-up. These strategies will support increased adoption
among health care organizations in the local and national context. In Phase IV, implementation
strategy will shift toward accessing new and existing funding sources to enable the establishment
of a social enterprise to administer the INSPIRE program in the long-term. This strategy will
position to the program for sustainability and growth.
Line-Item Budgets
The start-up and first-full year of implementation line-item budgets are available in
Appendices J and K, respectively. In summary, the start-up initial implementation year of the
INSPIRE program is expected to cost $15,000 based on various administrative operating costs,
which will be offset in full by associated generated revenue from organizational partner, program
participation, and certificate generation fees. The first-full year of implementation representing
an expansion year of the program is expected to cost $37,500 with similarly offsetting revenue of
the same amount, resulting in a break-even financial outcome.
Methods for Assessment
Methods for assessment has previously been discussed in the Methodology section of this
paper. As additional detail, the programmatic outcomes expected from the INSPIRE program
include: changes in knowledge and skills will be measured through pre- and post- test
evaluations of program participants; behavioral changes of social worker participants measured
both through the number of original research projects and related knowledge dissemination
activities developed by program participants; and, overall health care leadership buy-in will be
measured through pre- and post- program actual financial and other resource investments in
social care intervention activities to accompany health care leader attestations. Finally, long-term
32

outcomes will be measured on a larger scale by tracking improvements in population health
outcomes as measured by reduction of health care disparities over time.
Plans for Stakeholder Involvement
Plans for stakeholder involvement were discussed in the Methodology section of this
paper. As discussed in the Program Implementation Framework and Strategies section above,
engagement of key stakeholders including health care organizational leader champions and
social work participant early adopters are of primary concern to ensure diverse stakeholder
perspectives are present to test and establish the basis for viability and sustainability of the
INSPIRE program. Likewise, the Program Timelines and Phases section highlights plans for
stakeholder involvement to maintain ongoing feedback loops, ensuring program success in the
areas of appropriateness and effectiveness in the implementation and scale-up phases of the
program.
Communication Strategies
Communication and marketing products and strategies have previously been discussed in
the Methodology section of this paper. In summary, communication strategies for the INSPIRE
program include the use of email and social media, as well as engaging in publishing and public
speaking opportunities to promote the INSPIRE program to targeted stakeholder audiences, most
notably potential program participants (health care social workers) and health care organizational
leaders.
Potential Challenges and Leadership Strategies
Generating requisite buy-in from health care organizational leadership around the
workforce development focus of the INSPIRE program is one potential challenge that must be
considered. Strong initial business case development presented to health care leaders that
33

succinctly and clearly demonstrate a return on investment and highlight other benefits of
participation of their staff in the INSPIRE program is a response to this potential challenge.
During early development of the program, stakeholder feedback suggested that identifying
champions early within targeted health care organizations is also an ideal way to overcome this
challenge. Particularly for Phases II and III of the INSPIRE program, focusing on early adopters
and remaining agile to changing organizational landscape and priorities is essential to readiness.
Key leadership qualities and strategies include executing a compelling business case for the
program, exhibiting advanced business acumen and language effective when presenting and
communicating with an executive leadership audience.
Another potential challenge involves the ability to justify the time commitment required
of program participants. The nationally recognized certification in social care integration that
includes 30+ hours of continuing education credits was developed as part of the INSPIRE
program specifically to demonstrate value in a professional context in order overcome this
potential barrier. While early feedback indicates this is a sufficient response to the time
commitment concern, leadership strategies that will be employed if this situation arises include
the ability to understand the target audience’s goals and desired outcomes and ultimately to
remain agile to participant feedback during initial implementation and scale-up phases.
Ultimately, if the time commitment is too great to generate motivation to participate, the program
will require further iteration to effectively meet the needs of the target participant population.
Lastly, if initial targeted professional organization partnerships cannot be established or
fail for any reason, the program creator has ensured alternative potential partners are primed to
take on this partnership role. The leadership strategy of networking and leveraging both new and
34

well-established professional organization affiliations is vital to the ability to change course and
overcome this potential obstacle.
Ethical Considerations and Design Justice Principles
Under systems theory, as complex systems like health care systems change and
innovations are developed to address increasingly complex health care problems, unintended
consequences are inevitable (Kannampallil et al., 2011; Lipsitz, 2012). In recognition of this
fact, the capstone project has carefully considered potential unintended consequences throughout
the design thinking process. For example, the idea of charging a fee for the program must
consider Who is left out? Is cost a prohibiting factor for those who could benefit the most from
the program? In this example, extensive stakeholder feedback drove the solution to keep fees
low in comparison to the program’s value. It is because of this that the continuing education and
certification component is offered at a steep discount in comparison to other similar programs
and embedded in the fee structure is encouragement for participants to pursue employer-based
educational credits or other scholarship opportunities to offset any cost-prohibitive issues.
Similarly, the plan to maintain the program within a non-profit host organization and eventually
housing it within a social enterprise helps to ensure that profitability does not impact the
availability of the program to those most in need.
Furthermore, when considering the ethical implications of change efforts under the
proposed solution, it was necessary to enhance design by ensuring the social work code of ethics
principles and values were upheld, including the dignity and worth of the person, cultural
competence, and social justice, helping to mitigate any compounding negative effects on
vulnerable populations (NASW, 2021a). Targeting the social work population through the
proposed solution was intentional to ensure fidelity to these values within the program itself and
35

using the program to promote collaborative, interprofessional practice rooted in social justice,
mutual respect, and cultural competence to best serve historically disadvantaged populations
most affected by health care disparities (Bent-Goodley et al., 2019; NASW, 2021a; Smedley et
al., 2003).
Likewise, the capstone project has carefully considered and applied the design justice
network principles to support the design thinking process of centering users, particularly those
who have historically been silenced or absent from the process of innovation and problem-
solving (Design Justice Network, 2018). Core design justice network principles reflected in the
design process that helped to ensure alignment with these purposes include Principle 5 - We see
the role of the designer as a facilitator rather than an expert and Principle 10 - Before seeking
new design solutions, we look for what is already working at the community level (Design Justice
Network, 2018). Thus, users and beneficiaries of the solution were included every step of the
way, with the creator as advocate and facilitator to ensure the voices of those often missing from
health care decision-making (social care experts) are now invited to take their seat at the table.
Conclusion and Implications
There is growing awareness and agreement in the United States today that in order to
achieve the population health outcomes set forth in nationally-based initiatives like those
promulgated under Healthy People 2030, including addressing the social determinants of health
in pursuit of eliminating health care disparities, the health care delivery system must be more
responsive to the needs of its beneficiaries (Bleser et al., 2022; Bullock et al., 2021; Cohn, 2020;
ODPHP, 2022; Radley et al., 2021; U.S. Department of Health and Human Services, 2021).
Relatedly, a NASEM (2019) consensus study report on Integrating Social Needs Care into the
Delivery of Health Care to Improve the Nation's Health highlighted the need for stakeholders to
36

take action, and specifically called out a void in the research base and also in the area of
workforce development and served as a call to action to fill these voids. Thus, the stage is set for
development of creative, new solutions to equip the health care system with the tools and
motivation to integrate the provision of social care services with traditional medical and
behavioral health care.
In response, and in alignment with the Grand Challenges for Social Work initiative to
Close the Health Gap, the Institute on Social Practice Integration Research and Education
(INSPIRE) program was developed an innovative solution for improving social care integration
implementation through a targeted workforce development strategy. The mechanism behind the
INSPIRE program is straightforward; it provides an experiential learning and certification
program for health care social workers to develop skills and experience engaging in practitioner
research, knowledge dissemination, and building a business case for social care integration
activities. It also engages health care leaders and holds them to account to consider concrete
strategies to advance the health care political landscape to achieve improved health equity.
The INSPIRE program is innovative because of its unique mezzo-level approach that
focuses on workforce development as the mechanism to generate new models of care in local
contexts, to drive improved integration of social care into health care delivery that remains
responsive to the needs of the beneficiaries served. While planned initially for local
implementation, it is built upon a strategy that is intended for scale-up and adoption nationwide;
in this way, it goes beyond current solutions that considers a specialized social care workforce as
essential to sustainability of social care integration that is not confined to local contexts. In this
way, the INSPIRE does not only answer what to do or how to do it but goes a step further and
37

ensures that those who will do the work are prepared, well-trained, and are ready to serve as key
drivers of change across the health care delivery system.
The plan to implement the INSPIRE program will take additional work. Successful
engagement and preparation of key stakeholders including social workers and health care leaders
interested in improving their readiness to integrate social care activities more effectively into
healthcare operations and practice is required. Through the phased implementation approach
embedded into the INSPIRE program, next steps include solidifying a national professional
organization host to programmatically administer the program. Upon completion of the
successful initial implementation year of the program, ongoing revisions and improvements to
the curriculum and delivery model will be of utmost priority. Finally, full scale-up will be
accomplished upon establishment of a social enterprise to permanently administer the program
toward sustainable implementation in settings across the country.

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49

Appendix A - Stakeholder Map

50

Appendix B - Logic Model
51

Appendix C - Prototype
The INSPIRE program prototype is made up of 19 distinct elements that appear in subsequent pages of this Appendix C. They
are listed below and accompanied by direct source files intended for use as a ready-to-implement suite of necessary program materials
for successful deployment of the INSPIRE program.
1

INSPIRE
Program
Instructor
Manual

Instructor Manual

2
INSPIRE
Program
Participant
Guide
Participant Guide

3
INSPIRE
Program
Cohort 1
Calendar
Program Calendar

4
INSPIRE
Program
Practitioner
Research Plan
Worksheet
Practitioner Research
Plan Worksheet

5
INSPIRE
Program
Knowledge
Dissemination
Plan
Worksheet
Knowledge Dissem.
Plan Worksheet

6
INSPIRE
Program
Business Case
Development
Worksheet
Business Case Dev.
Worksheet

7
INSPIRE
Module 1
Asynchronous
Session Slides
& Instructor
Notes
Module 1 Asynch
Slides

8
INSPIRE
Module 1
Synchronous
Session Slides
& Instructor
Notes
Module 1 Synch
Slides

9
INSPIRE
Module 2
Asynchronous
Session Slides
& Instructor
Notes
Module 2 Asynch
Slides

10
INSPIRE
Module 2
Synchronous
Session Slides
& Instructor
Notes
Module 2 Synch
Slides

11
INSPIRE
Module 2
Workshop
Session Slides
& Instructor
Notes
Module 2 Workshop
Slides

12
INSPIRE
Module 2
Activity
Session Slides
& Instructor
Notes
Module 2 Activity
Slides

13
INSPIRE
Module 3
Asynchronous
Session Slides
& Instructor
Notes
Module 3 Asynch
Slides

14
INSPIRE
Module 3
Synchronous
Session Slides
& Instructor
Notes
Module 3 Synch
Slides

15
INSPIRE
Module 3
Workshop
Session Slides
& Instructor
Notes
Module 3 Workshop
Slides

16
INSPIRE
Module 3
Activity
Session Slides
& Instructor
Notes
Module 3 Activity
Slides

17
INSPIRE
Module 4
Asynchronous
Session Slides
& Instructor
Notes
Module 4 Asynch
Slides

18
INSPIRE
Module 4
Synchronous
Session Slides
& Instructor
Notes
Module 4 Synch
Slides

19
INSPIRE
Module 4
Workshop
Session Slides
& Instructor
Notes
Module 4 Workshop
Slides

52

1. INSPIRE Experiential Training & Certification Program Instructor Manual

Experiential Learning
& Certification Program

Cohort 1 | 2023-2024

INSTRUCTOR MANUAL

53

Program Description

Purpose:
The purpose of the Institute on Social Practice Integration Research and Education
(INSPIRE) program (“the program”) is to build the social care intervention evidence-
base by supporting the ability of frontline health care social workers to engage in
practitioner research and effective dissemination of knowledge, while also facilitating a
cultural shift among health care leaders toward greater investments in social care
integration activities and in the social care workforce.

Goals/Functions:
The primary functions of the program are:
1) to offer an experiential learning and certification program for frontline health care
social workers to develop skills in practitioner research, knowledge dissemination, and
building a business case for social care integration activities; and
2) to educate health care leaders on the importance and benefits of increasing
investments in social care integration activities and in a specialized social care
workforce.

Program Model Infographic:

54

Foundational Curriculum & Program Model:
The program foundational curriculum is built on 4 learning modules:
1. Social Care Integration
2. Practitioner Research,
3. Knowledge Dissemination, and
4. Business Case Development
Health Care Leaders are offered a tailored learning module aimed at advancing
knowledge and attitude shifts towards greater valuation of social care integration
initiatives with an emphasis on building a capable and sustainable social care expert
workforce.
The program is taught by field-based subject matter experts utilizing both online
asynchronous and synchronous session formats.
Asynchronous learning modules fulfills the knowledge-building component of the
curriculum.
Synchronous sessions provide an opportunity for participants to engage in interactive
discussions and workshops to build requisite skills and to immerse themselves in field-
based practice.
Guest subject matter experts and practitioners are incorporated into curriculum
offerings to support practical applicability of all knowledge and skill-building
components of the program.
Experiential Learning Component:
The cornerstone of the program is its experiential component, whereby program
participants engage in original small-medium scale practitioner research projects
targeting social care related program or process improvements in their immediate
workplaces.
Research projects are intended to allow participants an opportunity to actively engage in
practitioner research as an experiential learning step, while also building the evidence-
base.
These projects will also serve as the basis for active knowledge dissemination practice
enabled by established partnerships with relevant health care based professional
organizations that will feature the work of program participants in various forms
including poster and podium presentations, publications, and virtual educational
webinars.

55

Program Activities:
Over 10-months, program participants will engage in the following:
• 4 Asynchronous Learning Modules (2.5 hours per module)
• 12 Synchronous Cohort Group Sessions (1-2 hours per session)
• 8 Individual Mentorship Sessions (1 hour per session)
• 1 Cohort-facing Practitioner Research Presentation (2 hour session)
• 1 Cohort-facing Business Case Presentation (2 hour session)
• Independent Practitioner Research Activities (varied hours)
• Independent Knowledge Dissemination Activities (varied hours)

Program Timeline:
Month 1:
• Orientation (2 hours)
• Module 1 Review & Discussion (2 hours)
• Module 2 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
Month 2:
• Module 2 Workshop (1 hour)
• Mentorship Session (1 hour)
• Module 2 Cohort Activity (1 hour)
• Independent Practitioner Research
Month 3:
• Mentorship Session (1 hour)
• Independent Practitioner Research
Month 4:
• Module 3 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
• Independent Practitioner Research
Month 5:
• Module 3 Workshop (1 hour)
• Mentorship Session (1 hour)
• Independent Practitioner Research
• Independent Knowledge Dissemination Planning
Month 6:
• Module 3 Cohort Activity (1 hour)
• Mentorship Session (1 hour)
• Independent Practitioner Research
• Independent Knowledge Dissemination Planning

Month 7:
• Module 4 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
56

• Independent Practitioner Research
• Independent Knowledge Dissemination Planning
Month 8:
• Module 4 Workshop (2 hours)
• Mentorship Session (1 hour)
• Independent Practitioner Research WRAP-UP
• Independent Knowledge Dissemination Planning
Month 9:
• Cohort Practitioner Research Presentations (2 hours)
• Independent Knowledge Dissemination Activities
Month 10:
• Cohort Business Case Presentations & Program Wrap-Up (2 hours)
• Independent Knowledge Dissemination Activities

Program Calendar:
See attached Cohort 1 2023-2024 Program Calendar

Continuing Education Credits:
The program offers participants a minimum of 30 professional continuing education
credits through partnership with accredited educational bodies including NASW and the
Case Management Society of America (CMSA). Additional credit hours may result from
participation in active knowledge dissemination activities.
Projected Minimum Credit Hours:
• Synchronous Activities = 20 Credit Hours
• Asynchronous Activities = 10 Credit Hours

Certification in Social Care Integration Practice:
Upon successful completion of the program, participants will earn a transferable
certification in social care integration practice, a designation that will provide
professional credibility for future engagement and leadership in both small and large-
scale social care integration roles.

57

Program Outputs & Outcomes:
Program Outputs include:
• the number of social workers and health care leaders educated and/or certified
through the program
• the number of original small-medium scale practitioner research projects
conducted by participants as a result of the program
• the number of presentations or publications arising from knowledge
dissemination activities built-in to the program, and
• the number of health care leader attestations reflecting a commitment to increase
financial and other resource investments in social care intervention activities.
Programmatic outcomes fall into three levels: short-term, intermediate, and long-term.
• Short-term outcomes include expected changes in knowledge and skills measured
through pre- and post- test evaluations (see Appendix A) of program participants
based on the program’s tailored curriculum modules and experiential learning
activities.
• Intermediate outcomes include expected behavioral changes of social worker
participants measured by the growth of the social care interventions evidence-
base and knowledge dissemination activities, as well as increased health care
leadership buy-in as measured by pre- and post- program reported financial and
other resource investments in social care intervention activities.
• Long-term outcomes include projected systemic changes tied to the ability of
health care organizations to implement holistic, integrated care which will
ultimately result in improved population health outcomes measured by reduction
of health care disparities over time.

58

Program Orientation
Agenda
• Introductions
• Program Overview/Description
• Program Model
o Asynchronous work
o Synchronous work
o Independent research & knowledge dissemination practice
o Mentorship/Cohort Check-ins and support
• Program Calendar
• Questions

59

Program Curriculum Overview

Learning Modules:
• Module 1: Social Care Practice Integration
• Module 2: Practitioner Research
• Module 3: Knowledge Dissemination
• Module 4: Building a Business Case

Primary Texts/Articles:
• National Academies of Sciences, Engineering, and Medicine. (2019). Integrating
social care into the delivery of healthcare: Moving upstream to improve the
nation’s health. National Academies Press.
• Sheikhattari, P., Wright, M. T., Silver, G. B., van Der Donk, C., & van Lanen, B.
(2022). Practitioner Research for Social Work, Nursing, and the Health
Professions. Johns Hopkins University Press.
• Mitchell, F., Lunt, N., & Shaw, I. (2010). Practitioner research in social work: A
knowledge review. Evidence & Policy, 6(1), 7-31.
https://doi.org/10.1332/174426410X482971

Notes on Materials:
• Supplementary reference materials are suggested in each subsequent module
curriculum outline.
• Program instructors are encouraged to source and select timely, appropriate
supplementary materials to ensure the program curriculum remains relevant and
highly applicable for program participants.

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Module 1: Social Care Practice Integration
For Participants & Health Care Leaders

Primary Materials
Fichtenberg, C. M., Alley, D. E., & Mistry, K. B. (2019). Improving social needs
intervention research: Key questions for advancing the field. American Journal of
Preventive Medicine, 57(6, Suppl. 1), S47-S54.
https://doi.org/10.1016/j.amepre.2019.07.018
Kelley, T. (2022, May 18). Heading upstream to the social determinants of health.
Managed Healthcare Executive, 32(5), 16-17, 19-22.
https://cdn.sanity.io/files/0vv8moc6/mhe/ff411a4a0ceef7bb1d8a54b00d46d491589
0b988.pdf/MHE0522%20ezine.pdf
Levins, H. (2021, March 7). Integrating social needs into health care practice:
Evidence and barriers. https://ldi.upenn.edu/our-work/research-updates/integrating-
social-needs-into-health-care-practice-evidence-and-barriers/
National Academies of Sciences, Engineering, and Medicine. (2019). Integrating social
care into the delivery of healthcare: Moving upstream to improve the nation’s health.
National Academies Press.

Website: http://nationalacademies.org/socialcare

PDF download:
https://nap.nationalacademies.org/catalog/25467/integrating-social-care-into-the-
delivery-of-health-care-moving]
National Academies Sector Briefs:
• Sector Brief - Health Care Leaders
• Sector Brief - Social Workers
Richman, E. L., Lombardi, B. M., de Saxe Zerden, L., & Forte, A. B. (2022). What do
EHRs tell us about how we deploy health professionals to address the social
determinants of health. Social Work in Public Health, 37(3), 287–296.
https://doi.org/10.1080/19371918.2021.2001406

Supplemental Materials
Alley, D., Mistry, K., & Fichtenberg, C. (2020, February 25). Key questions for
improving social needs intervention research [Video]. Social Interventions Research &
Evaluation Network. https://sirenetwork.ucsf.edu/tools-resources/resources/key-
questions-improving-social-needs-intervention-research

Webinar recording link: https://youtu.be/V5W8rQlNKdo
Griffin, G. (2022). Social workers as emergent leaders in research, technology, and
practice. The New Social Worker. https://www.socialworker.com/feature-
articles/technology-articles/social-workers-as-emergent-leaders-research-technology-
practice/
Lakey, D., Marks, E., & Nehme, E. (2021, April 22). Finding effective ways to address
social determinants of health. Health Affairs Forefront.
https://www.healthaffairs.org/do/10.1377/forefront.20210420.146637/
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Module 1 Curriculum Outline
1. The Social Determinants of Health & Present-Day Health Policy
• Federal laws, policies, and population health initiatives like the Affordable Care
Act, the Social Determinants Accelerator Act, Healthy People 2020/2030, and the
Presidential COVID-19 Health Equity Task Force have fueled momentum to
tackle health care disparities, particularly in the context of political and social
unrest regarding pervasive racial injustice and inequities laid bare during the
COVID-19 pandemic (Barth et al., 2022; Bleser et al., 2022; Bullock et al., 2021;
Cohn, 2020; National Association of Social Workers [NASW], 2016; Office of
Disease Prevention and Health Promotion [ODPHP], 2022; Radley et al., 2021;
U.S. Department of Health and Human Services, 2021; Yancy, 2020).
• Extensive research into health care disparities has led to a growing recognition
that efforts to address the social determinants of health, defined as “the
conditions in the environments in which people are born, live, learn, work, play,
worship, and age that affect a wide range of health, functioning, and quality-of-
life outcomes and risks” (ODPHP, 2022, para. 1), are essential to closing the
health gap (Bullock et al., 2021; Byhoff et al., 2019; De Marchis et al., 2019;
Kelley, 2022; NASEM, 2019; Reyes et al., 2021).
• Unfortunately, despite a growing acknowledgment about the importance of
integrating effective interventions targeting social care needs like housing and
food insecurity to improve population health outcomes, the United States’ health
care delivery system as a collective does not adequately invest in or address
critical social care needs (Fichtenberg et al., 2020; Gottlieb et al., 2022; Horwitz
et al., 2020; Lakey et al., 2021; Lee & Korba, 2017; Long et al., 2022).

2. Social Care Integration & The Practice Implementation Gap
• Video: https://vimeo.com/user13782109/review/412809379/6d7aee745b
• Infographic: Missing the Mark – the Health Equity Implementation Gap
• The United States’ health care delivery system is unprepared to effectively
integrate social care with the provision of health care services, placing historically
disenfranchised populations at sustained risk of poorer clinical health outcomes
in comparison to other groups, including experiencing lower life expectancy and
significantly higher incidence of chronic medical conditions affecting quality of
life across the lifespan (Byhoff et al., 2019; De Marchis et al., 2019; Fichtenberg
et al., 2020; Levins, 2021; Lockett, 2022).
• Despite the recognition that integrating social care into health care delivery offers
a key approach to addressing health care disparities, there is a practice
implementation gap present throughout our national health care delivery system
(Levins, 2021; National Academies of Sciences, Engineering, and Medicine
[NASEM], 2019).
• This implementation gap is fueled by an extensive underinvestment in building
evidence-based practices to integrate social care interventions in health care
delivery and an associated undervaluation and underutilization of the social care
expert workforce to close this gap (Horwitz et al., 2020; Lockett, 2022; Office of
Minority Health, 2021).
• The literature has powerfully suggested a shift in approach toward a more
expansive model of health care delivery that considers the upstream factors that
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influence population health outcomes including political, economic, and social
factors (Barth et al., 2022; NASEM, 2019).
• This has led to incremental rising awareness among health care leaders,
providers, policymakers, and other key stakeholders that integration of care is the
way forward, but the siloed nature of historical health care delivery makes this
change slow, uncoordinated, and ineffective (Barth et al. 2022; NASEM, 2019).
• Relatedly, there is a research-to-practice translation gap existing within health
care that is at least partially due to ineffective dissemination of knowledge;
despite a recent uptick in traditional social care research activities, this has
resulted in little progress being made toward practical social care integration
solutions (Ashcroft et al., 2021; Bleser et al., 2022; Brownson et al., 2018; Butler,
2021; Byhoff et al., 2019; Fichtenberg et al., 2020; Lakey et al., 2021; Lee &
Korba, 2017; Levins, 2021; NASEM, 2019; Zerden et al., 2020).

3. The Research-Practice Gap
• A research-practice gap exists across all fields of public health and medical
practice as well as in other disciplines as diverse as education, engineering,
music, psychology, business, and agriculture (Brownson et al., 2018)
• It has been shown in the health care field that it takes an average of 17 years for
research evidence to reach clinical practice (Sheikhattari et al., 2022).
• Even when there is an abundance of academic research, not all successful studies
find their way fast enough into the development of innovative solutions at the
practice level (Sheikhattari et al., 2022).
o Published literature (the evidence base) is important, but increasing
demands, limited resources, and time constraints often leave practitioners
with little time to implement this more traditional research.
o These sources also often do not address the questions practitioners face in
their everyday practices – which includes novel situations and difficult and
recurring problems specific to their practice setting.
• Practitioners cannot rely solely on the usual learning opportunities for staying up
to date and providing the best possible care.
• Practitioner research seeks to understand what stands in the way of translating
research knowledge into practice.
• On a national level, health care organizations and systems are being called on to
fund, conduct, and translate research and evaluation on the effectiveness and
implementation of social care practices in health care settings.

4. The Role of Social Workers & Other Social Care Experts
• The health care environment is ripe with opportunities, and social workers are in
a unique position to enact change given their historical commitment to
improving population health and working to advocate on behalf of historically
marginalized populations through both direct practice interventions and policy
initiatives (Barth et al., 2022; NASEM, 2019).
• Given this context, it is imperative that social workers advance the fundamental
value of social justice by engaging other health care professionals and leaders to
make investments in upstream, social factors that influence health, while working
to advance practice-based strategies to overcome these systemic barriers to
effective integration of care (Barth et al., 2022; NASW, 2021).
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• There is a widespread underinvestment and underutilization of social care
experts in health care. This includes social workers, community health workers,
health care navigators, and interdisciplinary case managers often being excluded
from policy and programmatic decisions made by health care organizations about
how and why to integrate social care in health care delivery despite their history
of professional knowledge, skill, and experience addressing social care needs
(Barth et al., 2022; NASEM, 2019).
• Therefore, there is a need for social care experts to develop skills in building a
business case for the work they perform, to generate necessary buy-in and
investments from health care leadership toward sustainable social care
integration strategies.
• The key to engaging health care leaders and decision-makers in this work will be
to influence a cultural shift toward holistic, preventive care approaches backed by
research and evidence of strong population health and cost-containment
outcomes in alignment with contemporary health care transformation goals
(Wetterman & Tompsett, 2022; W. K. Kellogg Foundation, 2018).
• Furthermore, social workers and other social care experts lack opportunities to
engage in decision-making and strategic planning regarding social care
integration, held into place by external barriers in the workplace including lack of
funding, guidance, and general support from health care and social work
leadership to engage in this work (Sheikhattari et al., 2022).
• Therefore, current conditions provide the need and an opportunity for strategic
approaches that arm the social care expert workforce with the knowledge and
skills necessary to engage in research and effective knowledge dissemination,
while simultaneously preparing them to create and take a seat at the proverbial
table (Byhoff et al., 2019; De Marchis et al., 2019; Levins, 2021; Fichtenberg et
al., 2020; Zerden et al., 2020).
• Social workers and other social care experts lack opportunities to engage in
decision-making and strategic planning regarding social care integration, held
into place by external barriers in the workplace including lack of funding,
guidance, and general support from health care and social work leadership to
engage in this work (Sheikhattari et al., 2022).
• Practitioner research studies have the potential to save time and costs, the
savings being the result of improved practice, an enhanced capacity for problem-
solving, and a broadened understanding of the bigger picture and the real needs
of clients/patients.
• Research & Knowledge Dissemination is lacking.

5. Workforce Development
• The purpose of the Institute on Social Practice Integration Research and
Education (INSPIRE) program is to build the social care intervention evidence-
base by supporting the ability of frontline health care social workers to engage in
practitioner research and effective dissemination of knowledge, while also
facilitating a cultural shift among health care leaders toward greater investments
in social care integration activities and in the social care workforce.
• This program is innovative because unlike other ad hoc solution approaches to
address social care needs that have focused narrowly on programs and
interventions targeting the beneficiary patient population, this project widens the
scope using a workforce development approach to build a specialized social care
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workforce and health care leadership buy-in to support sustainable integration of
social care in health care delivery as a new model of care.
• Outputs of the INSPIRE program include the number of social workers and
health care leaders educated and/or certified, the number of original practitioner
research products developed by social work participants, the number of
presentations or publications arising from knowledge dissemination activities
built-in to the program, and the number of health care leader attestations
reflecting a commitment to increase financial and other resource investments in
social care intervention activities. These outputs should be distinguished from the
programmatic outcomes that fall into three levels: short-term, intermediate, and
long-term.
o Short-term outcomes include expected changes in knowledge and skills
measured through pre- and post- test evaluations of program participants
based on the program’s tailored curriculum modules and experiential
learning activities.
o Intermediate outcomes include expected behavioral changes of social
worker participants measured by the growth of the social care
interventions evidence-base and knowledge dissemination activities, as
well as increased health care leadership buy-in as measured by pre- and
post- program actual financial and other resource investments in social
care intervention activities.
o Long-term outcomes include projected systemic changes tied to the ability
of health care organizations to implement holistic, integrated care which
will ultimately result in improved population health outcomes measured
by reduction of health care disparities over time.

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Module 1 Synchronous Session Activities

Discussion Questions

Participants:
• What current investments are you aware of that your organizations is making to
address health inequities?
• How is your organization addressing the social determinants of health? Is your
department or work unit involved in these efforts? If so, in what capacity?
• Do you discuss social care integration strategies in your workplace?
• Are you or your colleagues in medical social services consulted during strategic
planning on health inequities or social determinants of health efforts?
• What would you like your health care leadership to know about your skills,
expertise, and/or passions for social care integration work?

Health Care Leaders:
• What current investments are you and other leaders making to address health
inequities?
• How is your organization addressing the social determinants of health?
• Are there systematic efforts to promote social care integration strategies and
interventions in your organization?
• Who are your identified experts/leaders in advancing these strategies?
• Are social workers involved in the strategic planning of these efforts?
• What unanswered questions do you have that, if answered, might motivate you to
invest in more widespread social care integration activities in your organization?
• Are there any current barriers in implementing social care activities in your
organization that you need help solutioning through? If so, what are they?

Group Activity
• Upon completion of your breakout group discussion, create a visual depiction of
the problems (or barriers) AND solutions (or ideas) related to addressing
healthcare inequities.
• Specifically highlight actions that are currently working as well as ideas for future
application.
• Prepare a ~5 minute report out for the larger group.

Assignment
Complete Module 2 Asynchronous Lecture & Readings

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Module 2: Practitioner Research

Primary Resource
Sheikhattari, P., Wright, M. T., Silver, G. B., van Der Donk, C., & van Lanen, B. (2022).
Practitioner Research for Social Work, Nursing, and the Health Professions. Johns
Hopkins University Press.

Supplemental Resources
Allen, K. M. & Spitzer, W. J. (2016). Practice-based research in healthcare social work.
https://in.sagepub.com/sites/default/files/upm-
binaries/68395_Allen_Chapter_6.pdf
Dodd, S. J., & Epstein, I. (2012). Practice-based research in social work: A guide for
reluctant researchers. Routledge.
Esposito, J., Lavelle, J., M'Farrej, M., Jhonsa, A., Perry, E., Felix, A., Crescenzo, K.,
Abbadessa, M., Hayes, K. (2022). Responding to a behavioral health crisis: Applying a
new care model in the emergency department. Pediatric Emergency Care 38(3),
e1147-e1150. https://doi.org/10.1097/PEC.0000000000002407
Joubert, L. B. & Webber, M. (2020). The Routledge handbook of social work practice
research. Routledge.
Mauldin, R. L. (2020). Foundations of social work research. Mavs Open Press.
Mitchell, F., Lunt, N., & Shaw, I. (2010). Practitioner research in social work: A
knowledge review. Evidence & Policy, 6(1), 7-31.
https://doi.org/10.1332/174426410X482971

67

Module 2 Curriculum Outline
1. Introduction to Practitioner Research
• Practitioner Research is an entire course or series of courses standing alone. As
part of this program, we will review the main concepts, tools, and processes of
practitioner research so that you all can put into motion some of your own small
(or large) scale research projects that will form the basis for this training
program.
• Do not get overwhelmed. The structure of this training program includes
individual mentorship, additional resources, and the power of group think to get
you over the finish line.
• You can’t improve if you don’t start.
• Don’t Let “Perfect” Be the Enemy of “Good”

2. Definition/Goals of Practitioner Research
• Practitioner Research is a strategic approach for improving professional practice.
• Practitioner Research consists of empirical studies conducted by social workers,
nurses and other health professionals to answer questions resulting from their
practices. The research takes place as an interaction between the practitioner
doing the research and his or her colleagues, patients, or clients. The primary
goal of practitioner research is to improve one’s own practice.
• The goal of Practitioner Research is to study professional practice within its local
context for the purpose of generating knowledge on how to improve services.
• Practitioner Research is a systematic, empirical approach embedded in daily
work routines that provides new insights that in turn serve as a basis for
innovation in practice.
• In particular, health care organizations expend considerable time, money, and
energy evaluating the quality of their services. Practitioner research stands in
alignment with these strategies and should be utilized more effectively in health
care practice settings.

3. How Practitioner Research Works
• Practitioners are empowered to collect & analyze data as an active part of
everyday professional practice.
• Learning on the part of professionals in the interest of improving their practice
requires asking questions, making intentional observations, and sharing ideas
and knowledge.
• Practitioner Research enables practitioners to learn systematically from their
own experience.
• Practitioner research is a form of implementation science: the study of
integrating evidence-based interventions into a practice setting.
• Practitioner research is a strategic approach to advance professional development
through experiential learning.
o Experiential Learning:
▪ Kolb’s Learning Cycle:
• Concrete Experience
• Reflective Observation
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• Abstract Conceptualization
• Active Experimentation

4. The Practitioner Research Method
• Select a practice problem; collect data; analyze the data according to a
detailed research plan. Program participants will begin this planning process
when completing the Practitioner Research Plan worksheet.
• Practitioner research starts with identifying a practice problem that is
perceived to be significant by both the practitioner and her organization and
clientele. This is an important precondition for developing a sense of
ownership over the research process and the results.
• 7 Key Components:
o Orientation – How is the issue defined? What is the scope of the
problem?
o Focusing – In-depth problem analysis based on theoretical frameworks
and empirical data (literature review)
o Planning – The research plan; describing and planning the activities
needed for conducting the study.
o Data Collection – quantitative & qualitative tools help collect data
o Analysis & Conclusion
o Design & Innovation
o Documentation & Presentation

5. Practice Problems & Research Question Development:
• Practice Problems
o Situations arising in professional practice that may become a starting
point for in-depth studies.
o Practice problems arise from REAL-LIFE experiences.
o Broadly refers to challenges, opportunities, needs, and areas that can
be improved.
• Practice Problem Categories:
o Real-life situations in which you may not be confident how they need to
be handled (uncertainty)
o Challenging dilemmas that need robust and clear answers (challenges)
o The need to improve the effectiveness and/or quality of services or
develop new components for the organization (enhancement)
o Desired learning outcomes of providers, experts, management teams,
etc. (learning)
o Making sure that we are doing the right thing (validation)
o Anticipating future developments (anticipation)
o Sustaining resources by satisfying funding agencies’ expectations
(sustainability)
o Introducing best practices and contributing to professional practice
(dissemination & scalability)
• Research Question Development – think about the processes that take place
in your work setting. Where are there gaps?

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Module 2 Synchronous Session Activities

Discussion Questions
• What questions do you have from the asynchronous lecture and/or readings?
• How might you go about ensuring your topic/practice problem is important to
relevant stakeholders?
• For anyone in the group who may have previously engaged in practitioner
research, what insights can you provide for the rest of the cohort?

Guest Speaker – Practitioner from the field of health care social work who has
experience with practitioner research activities.

Group Activity
• Six techniques are described on pages 43-46 in the Sheikhattari text that can help
you identify potential practice problems in your professional setting.
• Practice at least one technique and discuss the findings with your team members.
• Be prepared to summarize your experience and any idea generation with the
larger group.

Module 2 Assignments
Practitioner Research Plan Worksheet |Due: Wednesday, November 1, 2023

Module 2 Practitioner Research Plan Workshop Session (1 hour)
In the Practitioner Research Plan Workshop Session, participants will present and seek
feedback on their Practitioner Research Plan Worksheet development from their cohort
as well as guest mentors who will be available to offer guidance and share their
experiences with participants. The workshop session will provide participants with an
opportunity to solidify their research plans to ensure readiness for implementation on
their research projects that will serve as a basis for program outcomes and
achievements.

Module 2 Practitioner Research Activity Session (1 hour)
In the Practitioner Research Activity Session, participants will provide updates on their
research project statuses, seek ongoing feedback, and ensure projects align with
overarching program goals and timelines.

70

Module 3: Knowledge Dissemination
Primary Resources
Brownson, R. C., Eyler, A. A., Harris, J. K., Moore, J. B., & Tabak, R. G. (2018).
Getting the word out: New approaches for disseminating public health science.
Journal of Public Health Management and Practice, 24(2), 102–111.
https://doi.org/10.1097/PHH.0000000000000673
Sage, M., Hitchcock, L. I., Bakk, L., Young, J., Michaeli, D., Jones, A. S., & Smyth, N. J.
(2021). Professional collaboration networks as a social work research practice
innovation: preparing DSW students for knowledge dissemination roles in a digital
society. Research on Social Work Practice, 31(1), 42–52.
https://doi.org/10.1177/1049731520961163

Supplemental Resources
Mauldin, R. L. (2020). Foundations of social work research. Mavs Open Press.
Important Tips for Writing an Effective Conference Abstract
https://www.enago.com/academy/important-tips-for-writing-an-effective-
conference-
abstract/#:~:text=The%20first%20step%20is%20to,present%20in%20the%20academ
ic%20conference
How do you write a social work abstract?
http://melaniesagephd.blogspot.com/2013/11/cswe-apm-abstracts.html?m=1
How to Create a Research Poster https://guides.nyu.edu/posters
How to Write a Blog Post in 10 Steps https://www.masterclass.com/articles/how-to-
write-a-blog-post

Module 3 Curriculum Outline
1. What is Knowledge Dissemination? {note, see resource: Mauldin, 2020}
• Knowledge Dissemination refers to “a planned process that involves
consideration of target audiences and the settings in which research findings are
to be received and, where appropriate, communicating and interacting with wider
policy and…service audiences in ways that will facilitate research uptake in
decision-making processes and practice”
• In other words, dissemination of research findings involves careful planning,
thought, consideration of target audiences, and communication with those
audiences. Writing up results from your research and having others take notice
are two entirely different propositions. In fact, the general rule of thumb is that
people will not take notice unless you help and encourage them to do so.
• Disseminating your findings successfully requires determining who your
audience is, where your audience is, and how to reach them. When considering
who your audience is, think about who is likely to take interest in your work. Your
audience might include those who do not express enthusiastic interest but might
nevertheless benefit from an awareness of your research.

71

2. Why is Knowledge Dissemination Important?
• Bridging the gap between research and practice has been a long-standing
problem in the social work profession.
• This is at least partially, if not largely due to lack of adequate knowledge
dissemination among and between social workers and other interdisciplinary
collaborative disciplines.
• It goes without saying that social workers, especially those on the frontlines, are
often overburdened with day-to-day work to consider that their work is valuable
and worth sharing, let alone trying to carve out the time to engage in such
activities. However, the impact that this knowledge dissemination can and does
make cannot be overlooked.
• The importance of knowledge dissemination lies in the ability to represent social
work voices in public discourse to achieve greater impact and influence decision
making across fields.
• Knowledge dissemination also provides a pathway for social workers to remain
engaged in lifelong professional learning, to ensure practices are in alignment
with best practices and are adequately adapted for use in specific practice
settings.
• Knowledge dissemination conducted in a variety of methods, including by way of
leveraging technology, offers social workers a practical and socially just way to
professionally engage with a variety of stakeholders to address the research-to-
practice gap.
• In addition, practitioner research without knowledge dissemination lacks value,
and furthermore, leaves a large opportunity to advance the field on the table.

3. Types of Knowledge Dissemination Activities
• Peer-Reviewed Journal Articles
• Researchers commonly submit manuscripts to peer-reviewed academic
journals. These journals are commonly read by other researchers,
students, and practitioners. Peer review is a formal process in which other
scholars review the work to ensure it is a high quality before publication.
• While perhaps not feasible for the bounds of this program, this is an
important knowledge dissemination activity you can and should consider
in the future.
• Informal and Formal Professional Presentations
• Consider opportunities to share your work with your immediate work
groups – let’s say, in a staff meeting, quarterly in-service, or research fair.
If opportunities are not readily available, consider whether you could
initiative such a setting/platform in your work setting.
• Formal professional presentation opportunities abound. Despite the
seemingly daunting task of engaging in this type of activity, there are
available options. Consider following key professional organizations like:
The Society for Social Work Leadership in Health Care, National
Association of Social Workers, The Case Management Society of America,
The American Gerontological Society, and more who have national and
local conference opportunities for both experienced and novice presenters.
72

• Presenting at a conference can take the form of podium (large
presentations) as well as poster presentations.
• The use of technology in networking and sharing knowledge: Complex social
problems require collaboration and innovative thinking from nimble and
engaged researchers and practitioners. Technology offers a new avenue to
connect those interested in complex social problems. Frequently working in
multidisciplinary settings, social workers can potentially use technology reach
across professional boundaries, contribute to public conversations that inform
policy and practices, and help overcome research-to-practice gaps. Practice
connections mediated by social media can increase researchers’ ability to connect
with people who can help them understand and address factors that affect the
uptake, use, and sustainability of evidence-based interventions in the practice
setting. Social work researchers are taught the importance of disseminating their
research findings to practitioners, community-based settings, and other
researchers, but often traditional outlets like peer-reviewed publications and
conference presentations are insufficient in transferring research to practice.
Digital and social technologies provide new opportunities for professional
engagement and sharing across disciplines and geography.

4. Getting Started
• Disseminating findings involves the following five steps:
• Who: Determine your audience
• What: What does your audience want or need to know?
• Where: Identify where to reach your audience
• Why: Why is it important to reach this audience?
• How: Discover how best to reach your audience
• Sharing your research with the wider world (let’s say, beyond your immediate
work group or setting) can seem daunting. But sharing your practitioner research
findings with professional audiences is designed to bring your work to the
attention of other social workers or professionals who practice in areas related to
your research. Remember, professional social workers will want to hear about the
practice and policy implications of your research.

5. How To Guide
• Non-Scientific Articles, Blog Posts, Social Media
• Peer-Reviewed Journal Articles – may not be feasible for this program, but could
evolve over time. Set out to conduct a search on call for journal abstracts.
• Conference/Presentation Abstract Submissions
• Submissions usually require you to include the following elements (not an
exhaustive list):
• Title
• Topic
• Target Audience
• Learning Objectives
• Abstract/Summary
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• Your reading for this module includes examples of abstract submissions and can
be used as a guide as you think about developing your own knowledge
dissemination strategies and plans.
• Poster Presentation Development
• What Elements Do I Include?
• Standard Poster Sizes
• What questions should I be prepared to answer?
• Public Speaking Tips
• Practice
• Talking Points
• Choose what you are passionate about!
• Take a leap – you can do this

Module 3 Synchronous Session Activities
• Guest Speaker – Social Work Presentation Pro

• Research Poster Presentation Activity: How to Plan Your 1 Minute Pitch

Module 3 Assignment
Knowledge Dissemination Plan Worksheet | Due: Friday, February 9, 2024

Module 3 Knowledge Dissemination Plan Workshop Session (1 hour)
In the Knowledge Dissemination Plan Workshop Session, participants will present and
seek feedback on their Knowledge Dissemination Plan Worksheet development from
their cohort as well as guest mentors who will be available to offer guidance and share
their experiences with participants. The workshop session will provide participants with
an opportunity to solidify their knowledge dissemination plans that will serve as the
basis for culmination of their program participation.

Module 3 Knowledge Dissemination Activity Session (1 hour)
In the Knowledge Dissemination Activity Session, participants will provide updates on
their knowledge dissemination activity statuses, seek ongoing feedback, and ensure
these activities align with overarching program goals and timelines.

74

Module 4: Building a Business Case
Primary Resources
LexisNexis. (2023). 3 steps for building an SDOH business case.
https://risk.lexisnexis.com/insights-resources/white-paper/3-steps-for-building-
sdoh-business-case (includes video and white paper)
The Commonwealth Fund. (2022). Making the business case for social needs
interventions — An update. https://www.commonwealthfund.org/blog/2022/making-
business-case-social-needs-interventions-update
Wetterman, T. & Tompsett, L. (2022, January 31). Capturing value in social health:
Lessons in developing the business case for social health integration in primary care.
Commonwealth Fund. https://doi.org/10.26099/grzg-3593

Supplemental Resources
Carter, H. (2017). How to write a robust business case for service development.
Nursing Times, 113(7), 25–.
Health Leads (2018). Creating the business case for addressing social health.
https://healthleadsusa.org/resources/creating-the-business-case-for-addressing-
social-health/
Turner, A. (2018). The business case for racial equity.
https://altarum.org/sites/default/files/uploaded-publication-
files/WKKellogg_Business-Case-Racial-Equity_National-Report_2018.pdf

75

Module 4 Curriculum Outline
1. Introduction to Social Care Business Cases
• Healthcare organizations understand that SDOH factors can improve health
outcomes and minimize medical costs. However, many still miss the opportunity
to maximize investments in social care interventions.
• Many health care leaders still do not understand how to effectively use the
insights derived from the integration of social care interventions.
• The bottom line is that many healthcare organizations recognize the value of
SDOH data and social care interventions, but simply have no idea where to start.
• This is where you come in. As direct practice health care social workers, you have
the power to craft the narrative around what you do, why you do it (i.e. what
problems you are seeking to solve) and how it benefits the organizations where
you work, as well as the larger community, and of course, individual
members/patients/clients.
• The goal of “building a business case” for social care integration strategies,
programs, and interventions is to connect your specific use case to a return on
investment, in order get leadership and other stakeholder buy-in.
• A business case is a formal document submitted to decision makers for approval
and/or funding of a service development initiative
• A convincing business case must link the proposed service improvement to local,
regional and national priorities and constraints.
• The financial section of a business case will be analyzed closely, so costs and
benefits need to be made clear (if available).
• If social workers learn to articulate the needs of their services in the language of
health care leadership, they have a good chance of securing support and ongoing
investments in social care integration activities.
• The current move towards more integrated health and social care means this is a
opportune time for social workers to engage in activities to try to influence
decisions.

2. What is Known About the Impacts of Social Care Interventions?
• There is mounting evidence that addressing social needs of complex patients can
reduce costly forms of health care utilization and result in savings.
• More research is being produced in this area as more attention is given to social
care integration work.
• The Commonwealth Fund has compiled an evidence guide that helps tie specific
interventions, programs, or strategies to return on investment for health care
organizations.
• During the past three years, they have spoken with leaders of health care and
community-based organizations interested in developing partnerships to
address social determinants of health for the high-need, high-cost populations
they serve. They’ve concluded that leaders need information on what works and
the expected impact from investments.
• They focus on health care utilization and cost impact for adults with complex
needs, with an intention of helping organizations make a business case for
delivering social services.
76

• They also published and maintain a Return on Investment (ROI) Calculator to
inform program planning and in negotiating financially sustainable
contractual relationships.
• In their work with the ROI Calculator, they learned that decision-makers often
lacked benchmarks on program impact and costs,
• Therefore, the opportunities are ripe for you to craft your story, to develop a
business case for your work withing your host workplaces/organizations, and
beyond.

3. How to Develop a Business Case
• Financial Impact: Calculating financial impact for defined populations does not
mean that social need interventions should be undertaken only when they yield a
positive ROI for the health care sector. The human impact on access to services,
health outcomes, and economic opportunity can justify the investment to meet
community benefit and health equity goals. Even so, it is useful to know the
financial impact.
• Quality Impact: Qualitative data about quality of care, patient and/or provider
satisfaction can be used to develop robust quality data for business case
development.
• Health Care Outcomes Impact: Of course, if there are clinical outcomes data
related to social care interventions or strategies, these are also a great source or
ROI to be used in business case development.
• Societal Impact: Considering how a social care intervention or program impacts
the greater community or society is also important to include in any business case
proposal.
• Writing a business case can be frustrating. It is made easier by engaging decision
makers from the outset to ensure the proposal is in alignment with organizational
goals and strategies. Involving patients and getting qualitative feedback to
support the quantitative data will enhance your proposal.

Module 4 Synchronous Session Activities
• Guest Speaker – Business Case/Return on Investment in Health Care Pro

• Activity: Speaking the Right Language – Practitioners are often confused about
how to effectively engage and connect with health care decision-makers and
leaders. This activity will explore the language nuances practitioners must learn
to make effective business case pitches that result in value propositions of their
work and that help to secure ongoing investments in these strategies.

Module 4 Assignment
Business Case Development Worksheet |Due: Wednesday, May 22, 2024

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Module 4 Business Case Development Workshop Session (1 hour)
In the Business Case Development Workshop Session, participants will present and seek
feedback on their Business Case Worksheet development from their cohort as well as
guest mentors who will be available to offer guidance and share their experiences with
participants. The workshop session will provide participants with an opportunity to
solidify their business case to ensure readiness for presentation to key leaders and other
stakeholders to ensure support for their projects and future implementation
opportunities.
Rapid Fire Business Case Presentations
Participants will have an opportunity to present their business case proposals in a mock
professional setting to fellow cohort participants, instructors, and guests (as
appropriate).

78

Appendix A

Program Pre- & Post- Survey

Knowledge
• On a scale of 1-10 (1 being no knowledge, 10 being expert knowledge) how would
you rate your knowledge of social care interventions and the current evidence base?
• On a scale of 1-10 (1 being no knowledge, 10 being expert knowledge) how would
you rate your knowledge of practitioner research?
• On a scale of 1-10 (1 being no knowledge, 10 being expert knowledge) how would
you rate your knowledge of social care knowledge dissemination?
• On a scale of 1-10 (1 being no knowledge, 10 being expert knowledge) how would
you rate your knowledge of health care-related business case development as it
relates to increasing investments in social care integration strategies?
Confidence Statements
• I have the requisite knowledge, skill, and confidence to engage in practitioner
research activities.
o Strongly Disagree
o Disagree
o Neutral
o Agree
o Strongly Agree

• I have the requisite knowledge, skill, and confidence to engage in knowledge
dissemination activities.
o Strongly Disagree
o Disagree
o Neutral
o Agree
o Strongly Agree

• I have the requisite knowledge, skill, and confidence to develop a business case to
increase social care practice integration investments in my workplace.
o Strongly Disagree
o Disagree
o Neutral
o Agree
o Strongly Agree

79

Skill/Performance
• Have you engaged in practitioner research? Yes/No
o If yes, how many practitioner research projects? __ (#)
▪ Topic(s), Dates
[TOTAL NUMBER OF PRACTITIONER RESEARCH PROJECTS/ACTIVITIES]
• Have you engaged in social care knowledge-dissemination? Yes/No
o If yes, select the type: News or Magazine Articles; Blogs; Scientific Journal
Article; Podium Presentation; Other in-person presentation; Online/Virtual
presentation; Poster Presentation; Training/Course Facilitation; Other (select
all that apply)
o If yes, how many publications? (#)
o If yes, how many in-person presentations? (#)
o If yes, how many online/virtual presentations? (#)
o If yes, how many in-person poster presentations? (#)
o If yes, how many trainings or course facilitation activities? (#)
o If yes, how many “other” knowledge dissemination activities? (#)
[TOTAL NUMBER OF FORMAL KNOWLEDGE DISSEMINATION ACTIVITIES]
• Do you have a professional mentor that has taught you/supported your engagement
in practitioner research, knowledge dissemination and/or business case
development activities? Yes/No

Post-Survey Only:
• I intend to continue engagement in practitioner research activities.
o Strongly Disagree
o Disagree
o Neutral
o Agree
o Strongly Agree

• I intend to continue engagement in knowledge dissemination activities.
o Strongly Disagree
o Disagree
o Neutral
o Agree
o Strongly Agree

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Appendix B

Health Care Leader Attestation

I commit to increasing financial and other related resource investments in social care
intervention activities at my health care agency/institution and will make available
any pre- and post- INSPIRE program actual financial and other resource investment
data.

Name:
Title:
Organization:

Signature: ___________________________ Date: _____________

81

2. INSPIRE Experiential Training & Certification Program Participant Guide

Experiential Learning
& Certification Program

Cohort 1 | 2023-2024

PARTICIPANT GUIDE

Program Description
82

Purpose:
The purpose of the Institute on Social Practice Integration Research and Education
(INSPIRE) program (“the program”) is to build the social care intervention evidence-
base by supporting the ability of frontline health care social workers to engage in
practitioner research and effective dissemination of knowledge, while also facilitating a
cultural shift among health care leaders toward greater investments in social care
integration activities and in the social care workforce.

Goals/Functions:
The primary functions of the program are:
1) to offer an experiential learning and certification program for frontline health care
social workers to develop skills in practitioner research, knowledge dissemination, and
building a business case for social care integration activities; and
2) to educate health care leaders on the importance and benefits of increasing
investments in social care integration activities and in a specialized social care
workforce.

Program Model Infographic:

83

Foundational Curriculum & Program Model:
The program foundational curriculum is built on 4 learning modules:
5. Social Care Integration
6. Practitioner Research,
7. Knowledge Dissemination, and
8. Business Case Development
Health Care Leaders are offered a tailored learning module aimed at advancing
knowledge and attitude shifts towards greater valuation of social care integration
initiatives with an emphasis on building a capable and sustainable social care expert
workforce.
The program is taught by field-based subject matter experts utilizing both online
asynchronous and synchronous session formats.
Asynchronous learning modules fulfills the knowledge-building component of the
curriculum.
Synchronous sessions provide an opportunity for participants to engage in interactive
discussions and workshops to build requisite skills and to immerse themselves in field-
based practice.
Guest subject matter experts and practitioners are incorporated into curriculum
offerings to support practical applicability of all knowledge and skill-building
components of the program.
Experiential Learning Component:
The cornerstone of the program is its experiential component, whereby program
participants engage in original small-medium scale practitioner research projects
targeting social care related program or process improvements in their immediate
workplaces.
Research projects are intended to allow participants an opportunity to actively engage in
practitioner research as an experiential learning step, while also building the evidence-
base.
These projects will also serve as the basis for active knowledge dissemination practice
enabled by established partnerships with relevant health care based professional
organizations that will feature the work of program participants in various forms
including poster and podium presentations, publications, and virtual educational
webinars.

84

Program Activities:
Over 10-months, program participants will engage in the following:
• 4 Asynchronous Learning Modules (2.5 hours per module)
• 12 Synchronous Cohort Group Sessions (1-2 hours per session)
• 8 Individual Mentorship Sessions (1 hour per session)
• 1 Cohort-facing Practitioner Research Presentation (2 hour session)
• 1 Cohort-facing Business Case Presentation (2 hour session)
• Independent Practitioner Research Activities (varied hours)
• Independent Knowledge Dissemination Activities (varied hours)

Program Timeline:
Month 1:
• Orientation (2 hours)
• Module 1 Review & Discussion (2 hours)
• Module 2 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
Month 2:
• Module 2 Workshop (1 hour)
• Mentorship Session (1 hour)
• Module 2 Cohort Activity (1 hour)
• Independent Practitioner Research
Month 3:
• Mentorship Session (1 hour)
• Independent Practitioner Research
Month 4:
• Module 3 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
• Independent Practitioner Research
Month 5:
• Module 3 Workshop (1 hour)
• Mentorship Session (1 hour)
• Independent Practitioner Research
• Independent Knowledge Dissemination Planning
Month 6:
• Module 3 Cohort Activity (1 hour)
• Mentorship Session (1 hour)
• Independent Practitioner Research
• Independent Knowledge Dissemination Planning

85

Month 7:
• Module 4 Review & Discussion (2 hours)
• Mentorship Session (1 hour)
• Independent Practitioner Research
• Independent Knowledge Dissemination Planning
Month 8:
• Module 4 Workshop (2 hours)
• Mentorship Session (1 hour)
• Independent Practitioner Research WRAP-UP
• Independent Knowledge Dissemination Planning
Month 9:
• Cohort Practitioner Research Presentations (2 hours)
• Independent Knowledge Dissemination Activities
Month 10:
• Cohort Business Case Presentations & Program Wrap-Up (2 hours)
• Independent Knowledge Dissemination Activities

Program Calendar:
See attached Cohort 1 2023-2024 Program Calendar

Continuing Education Credits:
The program offers participants a minimum of 30 professional continuing education
credits through partnership with accredited educational bodies including NASW and the
Case Management Society of America (CMSA). Additional credit hours may result from
participation in active knowledge dissemination activities.
Projected Minimum Credit Hours:
• Synchronous Activities = 20 Credit Hours
• Asynchronous Activities = 10 Credit Hours

Certification in Social Care Integration Practice:
Upon successful completion of the program, participants will earn a transferable
certification in social care integration practice, a designation that will provide
professional credibility for future engagement and leadership in both small and large-
scale social care integration roles.

86

Program Curriculum Overview

Learning Modules:
• Module 1: Social Care Practice Integration
• Module 2: Practitioner Research
• Module 3: Knowledge Dissemination
• Module 4: Building a Business Case

Primary Texts/Articles:
• National Academies of Sciences, Engineering, and Medicine. (2019). Integrating
social care into the delivery of healthcare: Moving upstream to improve the
nation’s health. National Academies Press.
• Sheikhattari, P., Wright, M. T., Silver, G. B., van Der Donk, C., & van Lanen, B.
(2022). Practitioner Research for Social Work, Nursing, and the Health
Professions. Johns Hopkins University Press.
• Mitchell, F., Lunt, N., & Shaw, I. (2010). Practitioner research in social work: A
knowledge review. Evidence & Policy, 6(1), 7-31.
https://doi.org/10.1332/174426410X482971

87

Module 1: Social Care Practice Integration
For Participants & Health Care Leaders
Primary Materials
Fichtenberg, C. M., Alley, D. E., & Mistry, K. B. (2019). Improving social needs
intervention research: Key questions for advancing the field. American Journal of
Preventive Medicine, 57(6, Suppl. 1), S47-S54.
https://doi.org/10.1016/j.amepre.2019.07.018
Kelley, T. (2022, May 18). Heading upstream to the social determinants of health.
Managed Healthcare Executive, 32(5), 16-17, 19-22.
https://cdn.sanity.io/files/0vv8moc6/mhe/ff411a4a0ceef7bb1d8a54b00d46d491589
0b988.pdf/MHE0522%20ezine.pdf
Levins, H. (2021, March 7). Integrating social needs into health care practice:
Evidence and barriers. https://ldi.upenn.edu/our-work/research-updates/integrating-
social-needs-into-health-care-practice-evidence-and-barriers/
National Academies of Sciences, Engineering, and Medicine. (2019). Integrating social
care into the delivery of healthcare: Moving upstream to improve the nation’s health.
National Academies Press.

Website: http://nationalacademies.org/socialcare

PDF download:
https://nap.nationalacademies.org/catalog/25467/integrating-social-care-into-the-
delivery-of-health-care-moving]
National Academies Sector Briefs:
• Sector Brief - Health Care Leaders
• Sector Brief - Social Workers
Richman, E. L., Lombardi, B. M., de Saxe Zerden, L., & Forte, A. B. (2022). What do
EHRs tell us about how we deploy health professionals to address the social
determinants of health. Social Work in Public Health, 37(3), 287–296.
https://doi.org/10.1080/19371918.2021.2001406

Supplemental Materials
Alley, D., Mistry, K., & Fichtenberg, C. (2020, February 25). Key questions for
improving social needs intervention research [Video]. Social Interventions Research &
Evaluation Network. https://sirenetwork.ucsf.edu/tools-resources/resources/key-
questions-improving-social-needs-intervention-research

Webinar recording link: https://youtu.be/V5W8rQlNKdo
Griffin, G. (2022). Social workers as emergent leaders in research, technology, and
practice. The New Social Worker. https://www.socialworker.com/feature-
articles/technology-articles/social-workers-as-emergent-leaders-research-technology-
practice/
Lakey, D., Marks, E., & Nehme, E. (2021, April 22). Finding effective ways to address
social determinants of health. Health Affairs Forefront.
https://www.healthaffairs.org/do/10.1377/forefront.20210420.146637/
88

Module 1 Curriculum Topics
1. The Social Determinants of Health & Present-Day Health Policy

2. Social Care Integration & The Practice Implementation Gap

3. The Research-Practice Gap

4. The Role of Social Workers & Other Social Care Experts

5. Workforce Development

89

Module 2: Practitioner Research

Primary Resource
Sheikhattari, P., Wright, M. T., Silver, G. B., van Der Donk, C., & van Lanen, B. (2022).
Practitioner Research for Social Work, Nursing, and the Health Professions. Johns
Hopkins University Press.

Supplemental Resources
Allen, K. M. & Spitzer, W. J. (2016). Practice-based research in healthcare social work.
https://in.sagepub.com/sites/default/files/upm-
binaries/68395_Allen_Chapter_6.pdf
Dodd, S. J., & Epstein, I. (2012). Practice-based research in social work: A guide for
reluctant researchers. Routledge.
Esposito, J., Lavelle, J., M'Farrej, M., Jhonsa, A., Perry, E., Felix, A., Crescenzo, K.,
Abbadessa, M., Hayes, K. (2022). Responding to a behavioral health crisis: Applying a
new care model in the emergency department. Pediatric Emergency Care 38(3),
e1147-e1150. https://doi.org/10.1097/PEC.0000000000002407
Joubert, L. B. & Webber, M. (2020). The Routledge handbook of social work practice
research. Routledge.
Mauldin, R. L. (2020). Foundations of social work research. Mavs Open Press.
Mitchell, F., Lunt, N., & Shaw, I. (2010). Practitioner research in social work: A
knowledge review. Evidence & Policy, 6(1), 7-31.
https://doi.org/10.1332/174426410X482971

90

Module 2 Curriculum Topics
1. Introduction to Practitioner Research

2. Definition/Goals of Practitioner Research

3. How Practitioner Research Works

4. The Practitioner Research Method

5. Practice Problems & Research Question Development

91

Module 3: Knowledge Dissemination
Primary Resources
Brownson, R. C., Eyler, A. A., Harris, J. K., Moore, J. B., & Tabak, R. G. (2018).
Getting the word out: New approaches for disseminating public health science.
Journal of Public Health Management and Practice, 24(2), 102–111.
https://doi.org/10.1097/PHH.0000000000000673
Sage, M., Hitchcock, L. I., Bakk, L., Young, J., Michaeli, D., Jones, A. S., & Smyth, N. J.
(2021). Professional collaboration networks as a social work research practice
innovation: preparing DSW students for knowledge dissemination roles in a digital
society. Research on Social Work Practice, 31(1), 42–52.
https://doi.org/10.1177/1049731520961163

Supplemental Resources
Mauldin, R. L. (2020). Foundations of social work research. Mavs Open Press.
Important Tips for Writing an Effective Conference Abstract
https://www.enago.com/academy/important-tips-for-writing-an-effective-
conference-
abstract/#:~:text=The%20first%20step%20is%20to,present%20in%20the%20academ
ic%20conference
How do you write a social work abstract?
http://melaniesagephd.blogspot.com/2013/11/cswe-apm-abstracts.html?m=1
How to Create a Research Poster https://guides.nyu.edu/posters
How to Write a Blog Post in 10 Steps https://www.masterclass.com/articles/how-to-
write-a-blog-post

92

Module 3 Curriculum Topics
1. What is Knowledge Dissemination?
2. Why is Knowledge Dissemination Important?
3. Types of Knowledge Dissemination Activities
4. Getting Started
5. How To Guide

93

Module 4: Building a Business Case
Primary Resources
LexisNexis. (2023). 3 steps for building an SDOH business case.
https://risk.lexisnexis.com/insights-resources/white-paper/3-steps-for-building-
sdoh-business-case (includes video and white paper)
The Commonwealth Fund. (2022). Making the business case for social needs
interventions — An update. https://www.commonwealthfund.org/blog/2022/making-
business-case-social-needs-interventions-update
Wetterman, T. & Tompsett, L. (2022, January 31). Capturing value in social health:
Lessons in developing the business case for social health integration in primary care.
Commonwealth Fund. https://doi.org/10.26099/grzg-3593

Supplemental Resources
Carter, H. (2017). How to write a robust business case for service development.
Nursing Times, 113(7), 25–.
Health Leads (2018). Creating the business case for addressing social health.
https://healthleadsusa.org/resources/creating-the-business-case-for-addressing-
social-health/
Turner, A. (2018). The business case for racial equity.
https://altarum.org/sites/default/files/uploaded-publication-
files/WKKellogg_Business-Case-Racial-Equity_National-Report_2018.pdf

94

Module 4 Curriculum Topics
1. Introduction to Social Care Business Cases
2. What is Known About the Impacts of Social Care Interventions?
3. How to Develop a Business Case

95

3. INSPIRE Program Cohort 1 Calendar

All Day INSPIRE Program Applications Open

10:00 AM - 11:00 AM INSPIRE Program Informational Session

All Day INSPIRE Program Applications Due

All Day INSPIRE Program Participant Selection Notifications

All Day INSPIRE Program Participant Acceptances Due

All Day INSPIRE Program Starts

10:00 AM - 12:00 PM Session 1 - INSPIRE Program Orientation & Pre-Survey

10:00 AM - 12:00 PM Session 2 - INSPIRE Program (Module 1 - Social Care Practice Integration)

10:00 AM - 12:00 PM Session 3 - INSPIRE Program (Module 2 - Practitioner Research)

All Day INSPIRE Program - Individual Practitioner Research Mentorship Sessions [10/23/23 - 10/27/23]

All Day INSPIRE Program Practitioner Research Plan Worksheet Due

10:00 AM - 11:00 AM Session 4 - INSPIRE Program (Practitioner Research Plan Workshop)
August 1, 2023
Tuesday
September 5, 2023
Tuesday
September 18, 2023
Monday
September 25, 2023
Monday
October 2, 2023
Monday
October 11, 2023
Wednesday
October 18, 2023
Wednesday
October 23, 2023
Monday
November 1, 2023
Wednesday
INSPIRE Program Cohort 1 Calendar
96

All Day INSPIRE Program - Individual Practitioner Research Mentorship Sessions [11/6/23 - 11/17/23]

All Day INSPIRE Program Practitioner Research Check Point

10:00 AM - 11:00 AM Session 5 - INSPIRE Program (Practitioner Research Activity)

All Day INSPIRE Program - Individual Practitioner Research Mentorship Sessions [12/4/23 - 12/15/23]

All Day INSPIRE Program Practitioner Research Check Point

10:00 AM - 12:00 PM Session 6 - INSPIRE Program (Module 3 - Knowledge Dissemination)

All Day INSPIRE Program - Individual Mentorship Sessions [1/8/24 - 1/19/24]

10:00 AM - 11:00 AM Session 7 - INSPIRE Program (Knowledge Dissemination Plan Workshop)

All Day INSPIRE Program Knowledge Dissemination Plan Worksheet Due

All Day INSPIRE Program - Individual Knowledge Dissemination Mentorship Sessions [2/12/24 - 2/23/24]

All Day INSPIRE Program Practitioner Research Check Point

10:00 AM - 11:00 AM Session 8 - INSPIRE Program (Knowledge Dissemination Activity)
November 6, 2023
Monday
November 29, 2023
Wednesday
December 4, 2023
Monday
January 3, 2024
Wednesday
January 8, 2024
Monday
February 7, 2024
Wednesday
February 9, 2024
Friday
February 12, 2024
Monday
March 6, 2024
Wednesday
97

All Day INSPIRE Program - Individual Mentorship Sessions [3/11/24 - 3/22/24]

10:00 AM - 12:00 PM Session 9 - INSPIRE Program (Module 4 - Building a Business Case)

All Day INSPIRE Program - Individual Mentorship Sessions [4/15/24 - 4/26/24]

All Day INSPIRE Program Practitioner Research Wrap-Up / Knowledge Dissemination Check Point

10:00 AM - 12:00 PM Session 10 - INSPIRE Program (Business Case Development Workshop)

All Day INSPIRE Program - Business Case Development Worksheet Due

All Day Target: Formal Knowledge Dissemination Activities [6/1/24 - 7/31/24]

10:00 AM - 12:00 PM Session 11 - INSPIRE Program (Rapid Fire Practitioner Research Presentations)

All Day INSPIRE Program - Final Knowledge Dissemination Deliverable(s) Due

All Day INSPIRE Program Ends

10:00 AM - 12:00 PM Session 12 - INSPIRE Program (Rapid Fire Business Case Presentations, Program Wrap-Up, &
Post-Survey)

All Day INSPIRE Program - Program Evaluation Due
March 11, 2024
Monday
April 10, 2024
Wednesday
April 15, 2024
Monday
May 8, 2024
Wednesday
May 22, 2024
Wednesday
June 1, 2024
Saturday
June 12, 2024
Wednesday
July 31, 2024
Wednesday
August 14, 2024
Wednesday

All Day INSPIRE Program Certificates Released to Participants
August 28, 2024
Wednesday
98

4. Practitioner Research Plan Worksheet

INSPIRE Program – Cohort 1
Practitioner Research Plan Worksheet
Due: Wednesday, November 1, 2023

Participant Name:
Topic Area:
• What social care need or area does this involve/impact?
Practice Problem:
• Who are the key stakeholders? Are they on board with researching this problem?
• Who are the key users (colleagues)? Are they on board with researching this
problem?
• What is the gap?
• Why do I want to improve the situation?
• What are the underlying benefits associated with the desired
innovation/improvement?
Research Question:
Plan
• Significance of research:
• Setting:
• Research team:
• Alignment with internal policies & procedures:
• Timeline:
• Participants:
• Data Collection:
• Measurement/Outcomes:

99

5. Knowledge Dissemination Plan Worksheet

INSPIRE Program – Cohort 1
Knowledge Dissemination Plan Worksheet
Due: Friday, February 9, 2024

Participant Name:
Topic Area:
• What social care need or area does this involve/impact?
Practitioner Research Summary:
• Brief description of your research project, key preliminary and anticipated
outcomes, stakeholder feedback to date.
Knowledge Dissemination Title(s):
Knowledge Dissemination Plans:
• Type (presentation, poster, article/publication)
• Target Forum/Setting(s)
• Submission Due Date(s)
• Target Date(s) of Knowledge Dissemination
• Organizational Affiliation(s)

100

6. Business Case Development Worksheet

INSPIRE Program – Cohort 1
Business Case Development Worksheet
Due: Wednesday, May 22, 2024

Participant Name:
Business Case Template
Calculating financial impact for defined populations does not mean that social need interventions should be undertaken only when
they yield a positive ROI for the health care sector. The human impact on access to services, health outcomes, and economic
opportunity can justify the investment to meet community benefit and health equity goals. Even so, it is useful to know the
financial impact.
Financial Impact:

Qualitative data about quality of care, patient and/or provider satisfaction can be used to develop robust quality data for business
case development.
Quality Impact:

If there are clinical outcomes data related to social care interventions or strategies, these are also a great source or ROI to be used
in business case development.
Health Care Outcomes Impact:

Considering how a social care intervention or program impacts the greater community or society is also important to include in
any business case proposal.
Societal Impact:

Writing a business case can be frustrating. It is made easier by engaging decision makers from the outset
to ensure the proposal is in alignment with organizational goals and strategies. Involving patients and
getting qualitative feedback to support the quantitative data will enhance your proposal.
101

7. INSPIRE Module 1 Asynchronous Session Slides & Instructor Notes
Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 1.
My name is ____________________ and I will be your
instructor for this module.
Today, we will focus on setting the stage for the important
work ahead in this program by discussing: Social Care
Practice Integration.

Slide 2

Specifically, we’ll speak about the problem landscape fueling
the need for a program of this kind.

We will cover:
The Social Determinants of Health & Present-Day Health
Policy;
Social Care Integration & what we commonly refer to as: The
Practice Implementation Gap
Then we’ll cover the Research to Practice Gap
And spend considerable time discussing the unique role
Social Workers and Other Social Care Experts play in filling
these gaps.
And last but not least, we’ll cover workforce development,
including the role that Health Care Leadership can play in
supporting a well-informed, highly-skilled specialty
workforce to meet these needs.

Slide 3

Federal laws, policies, and population health initiatives like
the Affordable Care Act, the Social Determinants Accelerator
Act, Healthy People 2020/2030, and the Presidential
COVID-19 Health Equity Task Force have fueled momentum
to tackle health care disparities, particularly in the context of
political and social unrest regarding pervasive racial injustice
and inequities laid bare during the COVID-19 pandemic
(Barth et al., 2022; Bleser et al., 2022; Bullock et al., 2021;
Cohn, 2020; National Association of Social Workers
[NASW], 2016; Office of Disease Prevention and Health
Promotion [ODPHP], 2022; Radley et al., 2021; U.S.
Department of Health and Human Services, 2021; Yancy,
2020).

Social Care
Practice Integration
Module 1:
Asynchronous Session
Setting the Stage:
The Problem Landscape
The Social Determinants of Health & Present-Day Health Policy
Social Care Integration & The Practice Implementation Gap
The Research-Practice Gap
The Role of Social Workers & Other Social Care Experts
Workforce Development
Federal laws, policies, and population health initiatives:
• Affordable Care Act
• the Social Determinants Accelerator Act
• Healthy People 2020/2030
• Presidential COVID-19 Health Equity Task Force
Fuel momentum to tackle health care disparities
The Social Determinants of Health & Present-Day Health Policy
102

Slide 4

Extensive research into health care disparities has led to a
growing recognition that efforts to address the social
determinants of health, defined as “the conditions in the
environments in which people are born, live, learn, work,
play, worship, and age that affect a wide range of health,
functioning, and quality-of-life outcomes and risks”
(ODPHP, 2022, para. 1), are essential to closing the health
gap (Bullock et al., 2021; Byhoff et al., 2019; De Marchis et
al., 2019; Kelley, 2022; NASEM, 2019; Reyes et al., 2021).

Slide 5

Unfortunately, despite a growing acknowledgment about the
importance of integrating effective interventions targeting
social care needs like housing and food insecurity to improve
population health outcomes, the United States’ health care
delivery system as a collective does not adequately invest in
or address critical social care needs (Fichtenberg et al., 2020;
Gottlieb et al., 2022; Horwitz et al., 2020; Lakey et al., 2021;
Lee & Korba, 2017; Long et al., 2022).

Slide 6

Click to watch a short social care spending video highlighting
the U.S.’ lack of investment in social care.

Infographic – further illustrates the lack of investment which
fuels ongoing health care disparities.

Health Care Disparities Research:
Addressing the social determinants of health, defined as- “the
conditions in the environments in which people are born, live, learn,
work, play, worship, and age that affect a wide range of health,
functioning, and quality-of-life outcomes and risks”
Essential to closing the health gap
The Social Determinants of Health & Present-Day Health Policy
The importance of integrating effective interventions targeting social
care needs like housing and food insecurity to improve population health
outcomes is known.
Despite this, the United States’ health does not adequately invest in or
address critical social care needs.
The Social Determinants of Health & Present-Day Health Policy
Social Care Integration & The Practice Implementation Gap
Social Care Spending Video
103

Slide 7

The United States’ health care delivery system is unprepared
to effectively integrate social care with the provision of
health care services, placing historically disenfranchised
populations at sustained risk of poorer clinical health
outcomes in comparison to other groups, including
experiencing lower life expectancy and significantly higher
incidence of chronic medical conditions affecting quality of
life across the lifespan (Byhoff et al., 2019; De Marchis et al.,
2019; Fichtenberg et al., 2020; Levins, 2021; Lockett, 2022).

Slide 8

Despite the recognition that integrating social care into
health care delivery offers a key approach to addressing
health care disparities, there is a practice implementation
gap present throughout our national health care delivery
system (Levins, 2021; National Academies of Sciences,
Engineering, and Medicine [NASEM], 2019).

This implementation gap is fueled by an extensive
underinvestment in building evidence-based practices to
integrate social care interventions in health care delivery and
an associated undervaluation and underutilization of the
social care expert workforce to close this gap (Horwitz et al.,
2020; Lockett, 2022; Office of Minority Health, 2021).

Slide 9

The literature has powerfully suggested a shift in approach
toward a more expansive model of health care delivery that
considers the upstream factors that influence population
health outcomes including political, economic, and social
factors (Barth et al., 2022; NASEM, 2019).
This has led to incremental rising awareness among health
care leaders, providers, policymakers, and other key
stakeholders that integration of care is the way forward, but
the siloed nature of historical health care delivery makes this
change slow, uncoordinated, and ineffective (Barth et al.
2022; NASEM, 2019).

The U.S. health care delivery system is unprepared to effectively
integrate social care with the provision of health care services.
Sustained risk of poorer clinical health outcomes of disenfranchised
populations affecting quality of life across the lifespan
• Lower life expectancy
• Higher incidence of chronic medical conditions
• Higher health care utilization & costs
Social Care Integration & The Practice Implementation Gap
The Practice Implementation Gap
Fueled by:
• Extensive underinvestment in building evidence-based practices
to integrate social care interventions in health care delivery
• Undervaluation and underutilization of the social care expert
workforce
Social Care Integration & The Practice Implementation Gap
Must shift to a more expansive model of health care delivery that considers
the upstream factors that influence population health outcomes including
political, economic, and social factors
To date - incremental rising awareness among health care leaders, providers,
policymakers, and other key stakeholders that integration of care is the way
forward
BUT the siloed nature of historical health care delivery makes this change
slow, uncoordinated, and ineffective
Social Care Integration & The Practice Implementation Gap
104

Slide 10

A research-practice gap exists across all fields of public
health and medical practice as well as in other disciplines as
diverse as education, engineering, music, psychology,
business, and agriculture.
It has been shown in the health care field that it takes an
average of 17 years for research evidence to reach clinical
practice.

Slide 11

Published literature (the evidence base) is important, but
increasing demands, limited resources, and time constraints
often leave practitioners with little time to implement this
more traditional research.
Even when there is an abundance of academic research, not
all successful studies find their way fast enough into the
development of innovative solutions at the practice level.

Slide 12

These sources also often do not address the questions
practitioners face in their everyday practices – which
includes novel situations and difficult and recurring
problems specific to their practice setting.
Practitioners cannot rely solely on the usual learning
opportunities for staying up to date and providing the best
possible care.
Practitioner research seeks to understand what stands in the
way of translating research knowledge into practice.

On a national level, health care organizations and systems
are being called on to fund, conduct, and translate research
and evaluation on the effectiveness and implementation of
social care practices in health care settings.

Exists across all fields of public health and medical practice as well as
in other disciplines as diverse as education, engineering, music,
psychology, business, and agriculture
In the health care field:
• It takes an average of 17 years for research evidence to reach
clinical practice
The Research-Practice Gap
Published literature = important
• But increasing demands, limited resources, and time constraints often
leave practitioners with little time to implement this in practice.
• Not all successful studies find their way fast enough into the
development of innovative solutions at the practice level.
The Research-Practice Gap
Key = addressing the needs practitioners face in their everyday practices –
which includes novel situations and difficult and recurring problems specific
to their practice setting.
Practitioner research seeks to understand what stands in the way of
translating research knowledge into practice.
Requires more action: funding & conducting research and evaluation on the
effectiveness and implementation of social care practices in health care
settings.
The Research-Practice Gap
105

Slide 13

The health care environment is ripe with opportunities, and
social workers are in a unique position to enact change given
their historical commitment to improving population health
and working to advocate on behalf of historically
marginalized populations through both direct practice
interventions and policy initiatives (Barth et al., 2022;
NASEM, 2019).
Given this context, it is imperative that social workers
advance the fundamental value of social justice by engaging
other health care professionals and leaders to make
investments in upstream, social factors that influence health,
while working to advance practice-based strategies to
overcome these systemic barriers to effective integration of
care (Barth et al., 2022; NASW, 2021).

Slide 14

There is a widespread underinvestment and underutilization
of social care experts in health care. This includes social
workers, community health workers, health care navigators,
and interdisciplinary case managers often being excluded
from policy and programmatic decisions made by health care
organizations about how and why to integrate social care in
health care delivery despite their history of professional
knowledge, skill, and experience addressing social care needs
(Barth et al., 2022; NASEM, 2019).
Therefore, there is a need for social care experts to develop
skills in building a business case for the work they perform,
to generate necessary buy-in and investments from health
care leadership toward sustainable social care integration
strategies.
The key to engaging health care leaders and decision-makers
in this work will be to influence a cultural shift toward
holistic, preventive care approaches backed by research and
evidence of strong population health and cost-containment
outcomes in alignment with contemporary health care
transformation goals (Wetterman & Tompsett, 2022; W. K.
Kellogg Foundation, 2018).

Slide 15

Furthermore, social workers and other social care experts
lack opportunities to engage in decision-making and
strategic planning regarding social care integration, held into
place by external barriers in the workplace including lack of
funding, guidance, and general support from health care and
social work leadership to engage in this work (Sheikhattari et
al., 2022).
Therefore, current conditions provide the need and an
opportunity for strategic approaches that arm the social care
expert workforce with the knowledge and skills necessary to
engage in research and effective knowledge dissemination,
while simultaneously preparing them to create and take a
seat at the proverbial table (Byhoff et al., 2019; De Marchis
et al., 2019; Levins, 2021; Fichtenberg et al., 2020; Zerden et
al., 2020).
Social workers and other social care experts lack
opportunities to engage in decision-making and strategic
planning regarding social care integration, held into place by
external barriers in the workplace including lack of funding,
guidance, and general support from health care and social
work leadership to engage in this work .
Practitioner research studies have the potential to save time
and costs, the savings being the result of improved practice,
an enhanced capacity for problem-solving, and a broadened
understanding of the bigger picture and the real needs of
clients/patients.
Research & Knowledge Dissemination is lacking.

The health care environment is ripe with opportunities
Social Workers are in a unique position to enact change –
• Commitment to improving population health
• Advocacy on behalf of historically marginalized populations
• Direct practice interventions and policy experience
Social workers should be given opportunities to utilize their unique skills,
knowledge & abilities to improve the system of care
The Role of Social Workers & Other Social Care Experts
Social Care Experts must be included in policy & programmatic decisions
made by health care organizations
Social Workers & other social care experts must also develop skills to
support a business case for the work they perform
Focus: cultural shift toward holistic, preventive care approaches backed by:
• research
• population health outcomes improvement
• cost-containment results
The Role of Social Workers & Other Social Care Experts
Practitioner research studies have the potential to save time and costs:
• improved practice efficiency
• enhanced capacity for problem-solving
• broadened understanding of the bigger picture and the real needs of
clients/patients
Opportunities for Social Workers to engage are limited by lack of:
• Funding
• Guidance
• Professional growth support
We have the power to change this!
The Role of Social Workers & Other Social Care Experts
106

Slide 16

The purpose of the Institute on Social Practice Integration
Research and Education (INSPIRE) program is to build the
social care intervention evidence-base by supporting the
ability of frontline health care social workers to engage in
practitioner research and effective dissemination of
knowledge, while also facilitating a cultural shift among
health care leaders toward greater investments in social care
integration activities and in the social care workforce.
This program is innovative because unlike other ad hoc
solution approaches to address social care needs that have
focused narrowly on programs and interventions targeting
the beneficiary patient population, this project widens the
scope using a workforce development approach to build a
specialized social care workforce and health care leadership
buy-in to support sustainable integration of social care in
health care delivery as a new model of care.

Slide 17

Outputs of the INSPIRE program include the number of
social workers and health care leaders educated and/or
certified, the number of original practitioner research
products developed by social work participants, the number
of presentations or publications arising from knowledge
dissemination activities built-in to the program, and the
number of health care leader attestations reflecting a
commitment to increase financial and other resource
investments in social care intervention activities. These
outputs should be distinguished from the programmatic
outcomes that fall into three levels: short-term, intermediate,
and long-term.
Short-term outcomes include expected changes in knowledge
and skills measured through pre- and post- test evaluations
of program participants based on the program’s tailored
curriculum modules and experiential learning activities.
Intermediate outcomes include expected behavioral changes
of social worker participants measured by the growth of the
social care interventions evidence-base and knowledge
dissemination activities, as well as increased health care
leadership buy-in as measured by pre- and post- program
actual financial and other resource investments in social care
intervention activities.
Long-term outcomes include projected systemic changes tied
to the ability of health care organizations to implement
holistic, integrated care which will ultimately result in
improved population health outcomes measured by
reduction of health care disparities over time.

Slide 18

These outputs should be distinguished from the
programmatic outcomes that fall into three levels: short-
term, intermediate, and long-term.
Short-term outcomes include expected changes in knowledge
and skills measured through pre- and post- test evaluations
of program participants based on the program’s tailored
curriculum modules and experiential learning activities.
Intermediate outcomes include expected behavioral changes
of social worker participants measured by the growth of the
social care interventions evidence-base and knowledge
dissemination activities, as well as increased health care
leadership buy-in as measured by pre- and post- program
actual financial and other resource investments in social care
intervention activities.
Long-term outcomes include projected systemic changes tied
to the ability of health care organizations to implement
holistic, integrated care which will ultimately result in
improved population health outcomes measured by
reduction of health care disparities over time.

Purpose: build the social care intervention evidence-base by supporting the
ability of frontline health care social workers to engage in practitioner
research and effective dissemination of knowledge, while also facilitating a
cultural shift among health care leaders toward greater investments in social
care integration activities and in the social care workforce
This program is innovative because: unlike other ad hoc solution approaches
to address social care needs that have focused narrowly on programs and
interventions targeting the beneficiary patient population, this project
widens the scope using a workforce development approach
Workforce Development Strategies – INSPIRE Program
Programmatic expectations are to increase:
• the number of social workers and health care leaders educated and/or certified
• the number of original practitioner research products developed by social work
participants
• the number of presentations or publications arising from knowledge dissemination
activities built-in to the program
• the number of health care leader attestations reflecting a commitment to increase
financial and other resource investments in social care intervention activities.
Workforce Development Strategies – INSPIRE Program
Programmatic outcomes:
Short-term - increased knowledge and skills measured through pre- and
post- test evaluations of program participants
Intermediate – behavioral changes of participants measured by:
• growth of the social care interventions evidence-base
• growth of dissemination activities
• pre- and post- program actual financial and other resource investments in
social care intervention activities by health care systems
Long-term - systemic changes tied to the ability of health care
organizations to implement holistic, integrated care AND improved
population health outcomes measured by reduction of health care disparities
over time.
Workforce Development Strategies – INSPIRE Program
107

Slide 19

You have now completed Module 1.

Please ensure you complete the required Module 1 readings
and prepare for synchronous discussion and activities when
we convene live on Wednesday, October 11, 2023.

108

8. INSPIRE Module 1 Synchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 1
Synchronous Session.
My name is ____________________ and I will be your
instructor for today.

Today is an exciting day as we welcome both INSPIRE
Program Participants and their respective Health Care
Leadership to join in on important discussion topics and in
highlighting the collaborative role each key stakeholder can
play in closing the health gap through improved social care
practice integration.

Slide 2

The Agenda for today is as follows:
• Introductions
• Lecture and Readings Review (this will be a high-level
overview of the module you completed prior to this
session)
• Then, we’ll move to a breakout session where we’ll tackle
this week’s discussion questions
• We’ll have our breakout groups report out on key
discussion points before covering
• What’s next in the program
• Then we’ll finish with any questions you may have and a
final wrap-up of Module 1

Social Care
Practice Integration
Module 1:
Synchronous Session -
Wednesday, October 11, 2023
Agenda
Introductions
Lecture & Readings Review
Breakout Session: Discussion & Activity
Group Report Out
What’s Next?
Questions & Wrap-Up
109

Slide 3

Today we have in attendance both our cohort participants
(front line health care social workers) as well as our cohort
health care leadership.

Let’s start with a brief round of introductions. Please tell us
who you are/your name, your organization, your title, and 1
thing you are hoping to gain from today’s session/the
program.

Slide 4

Let’s do a quick review of this week’s asynchronous lecture
and reading materials.

Volunteer please to give us one major takeaway from each
lecture topic {engage the participants in lively discussion
about the module material}:
• The Social Determinants of Health & Present-Day
Health Policy
• Social Care Integration & The Practice Implementation
Gap
• The Research to Practice Gap
• The Role of Social Workers and Other Social Care
Experts
• Workforce Development

Thank you for your participation. Very lively discussion and
great application.

As you know this 1
st
module allows us to set the stage for the
work ahead.

Slide 5

List of discussion questions for participant small groups are
as follows; these will be placed in the breakout session chat
for your reference.

• Name
• Organization
• Title
• Years in Health Care
• 1 Thing You Hope to Gain
from Today/the Program
Introductions
Lecture & Readings Review
Breakout Session – Discussion & Activity
Participants:
• What current investments are you aware of that your organizations
is making to address health inequities?
• How is your organization addressing the social determinants of
health? Is your department or work unit involved in these efforts? If
so, in what capacity?
• Do you discuss social care integration strategies in your workplace?
• Are you or your colleagues in medical social services consulted
during strategic planning on health inequities or social
determinants of health efforts?
• What would you like your health care leadership to know about your
skills, expertise, and/or passions for social care integration work?
110

Slide 6

List of discussion questions for health care leader small
groups are as follows; these will be placed in the breakout
session chat for your reference.

Slide 7

Additionally, you are asked to prepare a visual depiction of
problems/barriers and solutions/ideas related to closing the
health gap, particularly as it relates to social care integration
strategies in your workplace.

Be prepared to provide a ~5 minute report out for the larger
group when we reconvene.

This will also be placed in the breakout room chat for your
reference.

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 45 minutes.

Slide 8

Welcome back.

Let’s get started with Group 1 (participant grouping)
{provide feedback, allow time for questions}

Next, Group 2 (health care leader grouping)
{provide feedback, allow time for questions}

Great working session today!

Last but not least, Group 3 (participant grouping)
{provide feedback, allow time for questions}

Breakout Session – Discussion & Activity
Health Care Leaders:
• What current investments are you and other leaders making to
address health inequities?
• How is your organization addressing the social determinants of
health?
• Are there systematic efforts to promote social care integration
strategies and interventions in your organization?
• Who are your identified experts/leaders in advancing these strategies?
• Are social workers involved in the strategic planning of these efforts?
• What unanswered questions do you have that, if answered, might
motivate you to invest in more widespread social care integration
activities in your organization?
• Are there any current barriers in implementing social care activities in
your organization that you need help solutioning through? If so, what
are they?
Breakout Session – Discussion & Activity
• Upon completion of your breakout group discussion, create a
visual depiction of the problems (or barriers) AND solutions
(or ideas) related to addressing healthcare inequities.
• Specifically highlight actions that are currently working as well
as ideas for future application.
• Prepare a ~5 minute report out for the larger group.
Group Report Out
• Group 1 – Participants
• Group 2 – Health Care Leaders
• Group 3 – Participants
111

Slide 9

Let’s talk next steps:

Thank you for our Health Care Leaders who joined us today.
We look forward to inviting you back during our program
presentations at the culmination of this cohort’s
programmatic journey and encourage you to remain engaged
with your organization’s program participants to provide
feedback or ask questions throughout the duration of the
program. Collaboration is key.

For our Program Participants, please ensure you complete
the required Module 2 readings and asynchronous lecture,
and prepare for synchronous discussion and activities for
Module 2 when we convene live on Wednesday, October 18,
2023.

Slide 10

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
Module 1.

Slide 11

• Health Care Leaders –
• Participant culminating presentations on June 12,
2024 & July 31, 2024 (invitations forthcoming)
• Ongoing engagement and feedback
• Program Participants –
• Module 2 – Practitioner Research next week
• Complete Module 2 readings and asynchronous lecture
• Synchronous session: Wednesday, October 18, 2023
What’s Next?
Questions & Wrap-Up
112

9. INSPIRE Module 2 Asynchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 2.
My name is ____________________ and I will be your
instructor for this module.
Today, we will focus on an essential building block for the
INSPIRE program and the basis for your experiential
learning activities: Practitioner Research.

Slide 2

Specifically, we’ll speak about how we start to form the basis
for our engagement as practice-based experts through
Practitioner Research strategies.

We will cover:
Introduction to Practitioner Research;
Definition/Goals of Practitioner Research
Then we’ll cover How Practitioner Research Works
And spend considerable time discussing the The Practitioner
Research Method.
And last but not least, we’ll cover Practice Problems &
Research Question Development.

Practitioner
Research
Module 2:
Asynchronous Session
Let’s Engage:
Practitioner Research
Introduction to Practitioner Research
Definition/Goals of Practitioner Research
How Practitioner Research Works
The Practitioner Research Method
Practice Problems & Research Question Development
113

Slide 3

Practitioner Research is an entire course or series of courses
standing alone. As part of this program, we will review the
main concepts, tools, and processes of practitioner research
so that you all can put into motion some of your own small
(or large) scale research projects that will form the basis for
this training program.
Do not get overwhelmed. The structure of this training
program includes individual mentorship, additional
resources, and the power of group think to get you over the
finish line.
You can’t improve if you don’t start.
Don’t Let “Perfect” Be the Enemy of “Good”

Slide 4

Practitioner Research is a strategic approach for improving
professional practice.
Practitioner Research consists of empirical studies
conducted by social workers, nurses and other health
professionals to answer questions resulting from their
practices. The research takes place as an interaction between
the practitioner doing the research and his or her colleagues,
patients, or clients. The primary goal of practitioner research
is to improve one’s own practice.
The goal of Practitioner Research is to study professional
practice within its local context for the purpose of generating
knowledge on how to improve services.
Practitioner Research is a systematic, empirical approach
embedded in daily work routines that provides new insights
that in turn serve as a basis for innovation in practice.
In particular, health care organizations expend considerable
time, money, and energy evaluating the quality of their
services. Practitioner research stands in alignment with
these strategies and should be utilized more effectively in
health care practice settings.

Slide 5

Practitioners are empowered to collect & analyze data as an
active part of everyday professional practice.
Learning on the part of professionals in the interest of
improving their practice requires asking questions, making
intentional observations, and sharing ideas and knowledge.
Practitioner Research enables practitioners to learn
systematically from their own experience.
Practitioner research is a form of implementation science:
the study of integrating evidence-based interventions into a
practice setting.
Practitioner research is a strategic approach to advance
professional development through experiential learning.
Experiential Learning:
Kolb’s Learning Cycle:
Concrete Experience
Reflective Observation
Abstract Conceptualization
Active Experimentation

• Module Focus: The main concepts, tools, and processes of
practitioner research so that you all can put into motion some of
your own small (or large) scale research projects that will form
the basis for this training program
• Don’t let PERFECT be the enemy of GOOD
Introduction to Practitioner Research
• Practitioner research:
• Strategic approach for improving professional practice
• Consists of empirical studies to answer questions resulting from
professional practice
• Is a systematic, empirical approach embedded in daily work routines
that provides new insights that serve as a basis for practice innovation
Definition/Goals of Practitioner Research
How Practitioner Research Works
• Practitioners are empowered to collect & analyze data as an
active part of everyday professional practice.
• Experiential Learning – Kolb’s Learning Cycle:
• Concrete Experience
• Reflective Observation
• Abstract Conceptualization
• Active Experimentation
114

Slide 6

Select a practice problem; collect data; analyze the data
according to a detailed research plan. Program participants
will begin this planning process when completing the
Practitioner Research Plan worksheet.
Practitioner research starts with identifying a practice
problem that is perceived to be significant by both the
practitioner and her organization and clientele. This is an
important precondition for developing a sense of ownership
over the research process and the results.
7 Key Components:
Orientation – How is the issue defined? What is the scope of
the problem?
Focusing – In-depth problem analysis based on theoretical
frameworks and empirical data (literature review)
Planning – The research plan; describing and planning the
activities needed for conducting the study.
Data Collection – quantitative & qualitative tools help collect
data
Analysis & Conclusion
Design & Innovation
Documentation & Presentation

Slide 7

Practice Problems
Situations arising in professional practice that may
become a starting point for in-depth studies.
Practice problems arise from REAL-LIFE experiences.
Broadly refers to challenges, opportunities, needs, and
areas that can be improved.
Practice Problem Categories:
Real-life situations in which you may not be confident
how they need to be handled (uncertainty)
Challenging dilemmas that need robust and clear
answers (challenges)
The need to improve the effectiveness and/or quality of
services or develop new components for the
organization (enhancement)
Desired learning outcomes of providers, experts,
management teams, etc. (learning)
Making sure that we are doing the right thing
(validation)
Anticipating future developments (anticipation)
Sustaining resources by satisfying funding agencies’
expectations (sustainability)
Introducing best practices and contributing to
professional practice (dissemination & scalability)
Research Question Development – think about the
processes that take place in your work setting. Where
are there gaps?

Slide 8

You have now completed Module 2.

Please ensure you complete the required Module 2 readings
and prepare for synchronous discussion and activities when
we convene live on Wednesday, October 18, 2023.

The Practitioner Research Method
• 7 Key Components:
1. Orientation – How is the issue defined? What is the scope of the
problem?
2. Focusing – In-depth problem analysis based on theoretical
frameworks and empirical data (literature review)
3. Planning – The research plan; describing and planning the activities
needed for conducting the study.
4. Data Collection – quantitative & qualitative tools help collect data
5. Analysis & Conclusion
6. Design & Innovation
7. Documentation & Presentation
Practice Problems & Research Question Development
• Practice Problems
• Situations arising in professional practice that may become a starting point for in-depth studies.
• Practice problems arise from REAL-LIFE experiences.
• Broadly refers to challenges, opportunities, needs, and areas that can be improved.
• Practice Problem Categories:
• Real-life situations in which you may not be confident how they need to be handled (uncertainty)
• Challenging dilemmas that need robust and clear answers (challenges)
• The need to improve the effectiveness and/or quality of services or develop new components for the
organization (enhancement)
• Desired learning outcomes of providers, experts, management teams, etc. (learning)
• Making sure that we are doing the right thing (validation)
• Anticipating future developments (anticipation)
• Sustaining resources by satisfying funding agencies’ expectations (sustainability)
• Introducing best practices and contributing to professional practice (dissemination & scalability)
• Research Question Development – think about the processes that take place in your work
setting. Where are there gaps?
115

10. INSPIRE Module 2 Synchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 2
Synchronous Session focused on Practitioner Research.
My name is ____________________ and I will be your
instructor for today.

Slide 2

Today is a 2 hour session, and we have quite a bit to cover.

The Agenda for today is as follows:
• Lecture and Readings Review (this will be a high-level
overview of the module you completed prior to this
session)
• Followed by Large group Discussion
• Next we’ll move to a small group Activity in Breakout
Session
• Then we’ll have our breakout groups report out on key
discussion points before welcoming our
• Guest Speaker: _________________ to provide
insights into their experience conducting practitioner
research in health care seettings
• After that we’ll quickly review what’s next in the
program and
• finish with any questions you may have and a final wrap-
up of Module 2

Practitioner
Research
Module 2:
Synchronous Session -
Wednesday, October 18, 2023
Agenda
Lecture & Readings Review
Discussion Questions
Breakout Session: Activity
Group Report Out
Guest Speaker
What’s Next?
Questions & Wrap-Up
116

Slide 3

Let’s do a quick review of this week’s asynchronous lecture
and reading materials.

Volunteer please to give us one major takeaway from each
lecture topic {engage the participants in lively discussion
about the module material}:
• XXX

Thank you for your participation. Very lively discussion and
great application.

Module 2 is essential to building the requisite knowledge for
you all to engage in your own practitioner research activities
that is the basis for the rest of the program.

Slide 4

• What questions do you have from the asynchronous
lecture and/or readings?
• How might you go about ensuring your topic/practice
problem is important to relevant stakeholders?
• For anyone in the group who may have previously
engaged in practitioner research, what insights can you
provide for the rest of the cohort?

Slide 5

Activity instructions for participant small groups are as
follows; these will be placed in the breakout session chat for
your reference.

Be prepared to provide a ~2 minute report out for the larger
group when we reconvene.

Any questions before I place you in rooms?

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 30 minutes.

Lecture & Readings Review
Discussion Questions
• What questions do you have from the
asynchronous lecture and/or readings?
• How might you go about ensuring your
topic/practice problem is important to
relevant stakeholders?
• For anyone in the group who may have
previously engaged in practitioner research,
what insights can you provide for the rest of
the cohort?
Breakout Session –Activity
• Six techniques are described on pages 43-46 in the Sheikhattari text that
can help you identify potential practice problems in your professional
setting.
• Practice at least one technique and discuss the findings with your team
members.
• Be prepared to summarize your experience and any idea generation with
the larger group (~2 minutes)
117

Slide 6

Welcome back.

Let’s get started with Group 1
{provide feedback, allow time for questions}

Next, Group 2
{provide feedback, allow time for questions}

Great working session today!

Slide 7

Today’s guest speaker is ____________.

{Prepare bio and update slide and speaker notes
accordingly}

___[guest speaker name]__, take it away!

Slide 8

Thank you so much, ___[guest speaker name]_, for sharing
your knowledge and experiences with the group.
We are so pleased to have an example of the types of
experiential learning activities this group has to look forward
to, and it’s important to see how this type of work is
applicable for every day life.

Let’s get another round of applause for ___[guest speaker
name]__.

Now, let’s talk next steps:

Please ensure you schedule your first individual mentorship
meetings.
Also, your Practitioner Research Plan Worksheet is due:
Wednesday, November 1st, which is the date of our next
session which will be our first workshop with a focus on your
Practitioner Research Plan

The rest of this calendar year will be spent focused on your
Practitioner Research planning and execution. I’m looking
forward to seeing your projects develop.

Group Report Out
• Group 1
• Group 2
Guest Speaker
• Schedule Individual Mentorship Meeting |
October 23, 2023 – October 27, 2023
• Practitioner Research Plan Worksheet |
Due: November 1, 2023
• Next Session: Workshop on November 1, 2023
What’s Next?
118

Slide 9

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Module 2 synchronous session.

Thank you.

Slide 10

Questions & Wrap-Up
119

11. INSPIRE Module 2 Workshop Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Practitioner
Research Plan Workshop.

My name is ____________________ and I will be your
instructor for today.

Slide 2

The Agenda for today is as follows:
• We’ll start with an overview of the workshop format
• We’ll quickly jump right in to today’s workshop activity
• After that we’ll take a moment to review what’s next in
the program and
• finish with any questions you may have and a final wrap-
up of today’s Practitioner Research Workshop.

Practitioner
Research
Workshop Session -
Wednesday, November 1, 2023
Module 2:
Agenda
Workshop Overview
Workshop Activity
What’s Next?
Questions & Wrap-Up
120

Slide 3

The focus of today’s Practitioner Research Plan Workshop
Session will be to present and seek feedback on your
individual Practitioner Research Plan Worksheet
development.

Guest mentors who will be available to offer guidance and
share their experiences with you today, so please use this
opportunity to share freely and discuss feasibility of your
projects to ensure your success moving forward.

The main goal of the workshop session is to provide you with
an opportunity to solidify your research plans, which, as you
know, will serve as a basis for INSPIRE program outcomes
and achievements and your ability to engage in knowledge
dissemination activities at the culmination of your program
journey.

Workshops are a good opportunity to test your ideas and also
revise your Practitioner Research Plan Worksheets in
advance of your individual mentorship sessions and actual
engagement in your research projects.

Slide 4

Each breakout group will consist of 2 of you and a guest
mentor.
You’ll have 40 minutes today, so I recommend splitting time
between each of your projects (~20 minutes each)

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after 40 minutes.

Slide 5

Welcome back! I hope that was helpful for you. Please
remember, the support of your cohort participants will be
key throughout this process. Lean on each other and
remember, you have your mentors, your fellow cohort
participants, and now your guest mentors to lean on with any
questions or issues that may arise.

Let’s talk next steps now:

Please ensure you schedule your next individual mentorship
meetings and be prepared to share any Practitioner Research
Plan Worksheet revisions and to come with questions you
may have.

On Wednesday, November 29
th
we’ll have both your
Practitioner Research Checkpoint and an Activity Session, so
come prepared to share updates with the larger group
regarding your progress at that time.

Workshop Overview
• Participants will present and seek feedback on their
Practitioner Research Plan Worksheets
• Small group cohort & guest mentor guidance and
feedback is available.
• Workshop goal: opportunity to solidify your research
plans to ensure readiness for implementation
• Reminder – your projects will serve as a basis for
program outcomes and achievements; it’s important to
feel confident about feasibility and applicability of your
projects within the timeframes allotted.
Workshop Activity
• Breakout Rooms – 2 participants, 1 guest mentor
• 40 minutes total (20 minutes each)
• Schedule Individual Mentorship Meeting |
November 6, 2023 – November 17, 2023
• Practitioner Research Checkpoint|
November 29, 2023
• Next Session: Practitioner Research Activity on
November 29, 2023
What’s Next?
121

Slide 6

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Practitioner Research Workshop session.

Thank you.

Slide 7

Questions & Wrap-Up
122

12. INSPIRE Module 2 Activity Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Practitioner
Research Activity Session.

My name is ____________________ and I will be your
instructor for today.

Slide 2

The Agenda for today is as follows:
• We’ll start with an overview of today’s activity format
• We’ll quickly jump right in to today’s breakout session
where we will spend the bulk of our time today
• After that we’ll take a moment to review what’s next in
the program and
• finish with any questions you may have and a final wrap-
up of today’s Practitioner Research Activity Session.

Practitioner
Research
Activity Session -
Wednesday, November 29, 2023
Module 2:
Agenda
Activity Overview
Breakout Session Activity
Report Out
What’s Next?
Questions & Wrap-Up
123

Slide 3

In the Practitioner Research Activity Session, you will
provide updates on your research project statuses, seek
ongoing feedback, and ensure projects align with
overarching program goals and timelines.

Remember, this is your time to ensure you are on the right
track, and an opportunity to seek assistance or feedback as
might be helpful during this stage of the program.

Slide 4

While in your 40 minute breakout sessions, you can use the
prompts on the screen as a basis for your update report outs.

This will also be placed in the breakout room chat for your
reference.

Be prepared to provide a ~2-3 minute report out for the
larger group about any themes among your group members
or any questions that may arise that can be answered in the
large group when we reconvene.

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 40 minutes.

Slide 5

Welcome back.

Let’s get started with Group 1
{provide feedback, allow time for questions}

Next, Group 2
{provide feedback, allow time for questions}

Next, Group 3
{provide feedback, allow time for questions}

Next, Group 4
{provide feedback, allow time for questions}

Great working session today!

Activity Overview
• Participants will:
• provide updates on their research project statuses
• seek ongoing feedback, and
• ensure projects align with overarching program goals and
timelines
Breakout Session Activity
• 4 breakout groups
• 40 minute breakout session
• Answer the following prompts:
• Provide a brief summary/review of your research project details
• What actions have you taken thus far?
• What is working?
• What challenges are you facing?
• What changes have you made or do you anticipate may need to be made to
your project goals, approach, or outcomes measurement?
• Are you on schedule to conduct and wrap your project by the stated timelines?
• Prepare a ~2-3 minute report out for the larger group
Report Out
• Group 1
• Group 2
• Group 3
• Group 4
124

Slide 6

Let’s talk next steps:

Please ensure you schedule your next individual mentorship
meetings.

Continue working diligently on your projects the rest of the
year.

We will reconvene on January 3, 2024 with our second
Practitioner Research Checkpoint and Module 3 on
Knowledge Dissemination, so come prepared to give updates
on your progress as well as ensure that you complete the
required Module 3 asynchronous lecture & readings in
preparation for our live session.

Slide 7

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Practitioner Research Activity session.

Happy Holidays!

Slide 8

• Schedule Individual Mentorship Meeting |
December 4, 2023 – December 15, 2023
• Practitioner Research Checkpoint|
January 3, 2024
• Next Session: Module 3 – Knowledge
Dissemination on January 3, 2024
What’s Next?
Questions & Wrap-Up
125

13. INSPIRE Module 3 Asynchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 3.
My name is ____________________ and I will be your
instructor for this module.
Today, we will focus on an essential building block for the
INSPIRE program and the basis for your skill based activity
engagement: Knowledge Dissemination.

Slide 2

Specifically, we’ll speak about how we start to form the basis
how we share with others and build the evidence base
through knowledge dissemination strategies.

We will cover:
What is Knowledge Dissemination?
Why is Knowledge Dissemination Important?
Types of Knowledge Dissemination Activities
Getting Started, and
How To Guides

Knowledge
Dissemination
Module 3:
Asynchronous Session
Let’s Share:
Knowledge Dissemination
What is Knowledge Dissemination?
Why is Knowledge Dissemination Important?
Types of Knowledge Dissemination Activities
Getting Started
How To Guides
126

Slide 3

• Knowledge Dissemination refers to “a planned
process that involves consideration of target audiences
and the settings in which research findings are to be
received and, where appropriate, communicating and
interacting with wider policy and…service audiences in
ways that will facilitate research uptake in decision-
making processes and practice”
• In other words, dissemination of research findings
involves careful planning, thought, consideration of
target audiences, and communication with those
audiences. Writing up results from your research and
having others take notice are two entirely different
propositions. In fact, the general rule of thumb is that
people will not take notice unless you help and
encourage them to do so.
• Disseminating your findings successfully requires
determining who your audience is, where your
audience is, and how to reach them. When considering
who your audience is, think about who is likely to take
interest in your work. Your audience might include
those who do not express enthusiastic interest but
might nevertheless benefit from an awareness of your
research.
Slide 4

• Bridging the gap between research and practice has
been a long-standing problem in the social work
profession.
• This is at least partially, if not largely due to lack of
adequate knowledge dissemination among and
between social workers and other interdisciplinary
collaborative disciplines.
• It goes without saying that social workers, especially
those on the frontlines, are often overburdened with
day-to-day work to consider that their work is valuable
and worth sharing, let alone trying to carve out the
time to engage in such activities. However, the impact
that this knowledge dissemination can and does make
cannot be overlooked.
• The importance of knowledge dissemination lies in the
ability to represent social work voices in public
discourse to achieve greater impact and influence
decision making across fields.
• Knowledge dissemination also provides a pathway for
social workers to remain engaged in lifelong
professional learning, to ensure practices are in
alignment with best practices and are adequately
adapted for use in specific practice settings.
• Knowledge dissemination conducted in a variety of
methods, including by way of leveraging technology,
offers social workers a practical and socially just way to
professionally engage with a variety of stakeholders to
address the research-to-practice gap.
• In addition, practitioner research without knowledge
dissemination lacks value, and furthermore, leaves a
large opportunity to advance the field on the table.

• Knowledge Dissemination refers to “a planned process that
involves consideration of target audiences and the settings in which
research findings are to be received and, where appropriate,
communicating and interacting with wider policy and…service
audiences in ways that will facilitate research uptake in decision-
making processes and practice”
What is Knowledge Dissemination?
• The importance of knowledge dissemination lies in the ability to
represent social work voices in public discourse to achieve
greater impact and influence decision making across fields.
• Knowledge dissemination also provides a pathway for social
workers to remain engaged in lifelong professional learning, to
ensure practices are in alignment with best practices and are
adequately adapted for use in specific practice settings.
Why is Knowledge Dissemination Important?
127

Slide 5

• Peer-Reviewed Journal Articles
• Researchers commonly submit manuscripts to peer-
reviewed academic journals. These journals are
commonly read by other researchers, students, and
practitioners. Peer review is a formal process in which
other scholars review the work to ensure it is a high
quality before publication.
• While perhaps not feasible for the bounds of this
program, this is an important knowledge
dissemination activity you can and should consider in
the future.
• Informal and Formal Professional Presentations
• Consider opportunities to share your work with your
immediate work groups – let’s say, in a staff meeting,
quarterly in-service, or research fair. If opportunities
are not readily available, consider whether you could
initiative such a setting/platform in your work setting.
• Formal professional presentation opportunities
abound. Despite the seemingly daunting task of
engaging in this type of activity, there are available
options. Consider following key professional
organizations like: The Society for Social Work
Leadership in Health Care, National Association of
Social Workers, The Case Management Society of
America, The American Gerontological Society, and
more who have national and local conference
opportunities for both experienced and novice
presenters.
• Presenting at a conference can take the form of podium
(large presentations) as well as poster presentations.
• The use of technology in networking and sharing
knowledge: Complex social problems require
collaboration and innovative thinking from nimble and
engaged researchers and practitioners. Technology
offers a new avenue to connect those interested in
complex social problems. Frequently working in
multidisciplinary settings, social workers can
potentially use technology reach across professional
boundaries, contribute to public conversations that
inform policy and practices, and help overcome
research-to-practice gaps. Practice connections
mediated by social media can increase researchers’
ability to connect with people who can help them
understand and address factors that affect the uptake,
use, and sustainability of evidence-based interventions
in the practice setting. Social work researchers are
taught the importance of disseminating their research
findings to practitioners, community-based settings,
and other researchers, but often traditional outlets like
peer-reviewed publications and conference
presentations are insufficient in transferring research
to practice. Digital and social technologies provide new
opportunities for professional engagement and sharing
across disciplines and geography.
Slide 6

• Disseminating findings involves the following 5 steps:
o Who: Determine your audience
o What: What does your audience want or
need to know?
o Where: Identify where to reach your
audience
o Why: Why is it important to reach this
audience?
o How: Discover how best to reach your
audience
• Sharing your research with the wider world (let’s say,
beyond your immediate work group or setting) can
seem daunting. But sharing your practitioner research
findings with professional audiences is designed to
bring your work to the attention of other social workers
or professionals who practice in areas related to your
research. Remember, professional social workers will
want to hear about the practice and policy implications
of your research.

Types of Knowledge Dissemination Activities
• Peer-Reviewed Journal Articles
• Information & Formal Professional Presentations
• Leveraging Technology for Networking and Sharing Knowledge
Getting Started
• Who: Determine your audience
• What: What does your audience want or need to know?
• Where: Identify where to reach your audience
• Why: Why is it important to reach this audience?
• How: Discover how best to reach your audience
128

Slide 7

• Non-Scientific Articles, Blog Posts, Social Media
• Peer-Reviewed Journal Articles – may not be feasible
for this program, but could evolve over time. Set out to
conduct a search on call for journal abstracts.
• Conference/Presentation Abstract Submissions
• Submissions usually require you to include the
following elements (not an exhaustive list):
o Title
o Topic
o Target Audience
o Learning Objectives
o Abstract/Summary
• Your reading for this module includes examples of
abstract submissions and can be used as a guide as you
think about developing your own knowledge
dissemination strategies and plans.
• Poster Presentation Development
o What Elements Do I Include?
o Standard Poster Sizes
o What questions should I be prepared to
answer?
• Public Speaking Tips
o Practice
o Talking Points
o Choose what you are passionate about!
o Take a leap – you can do this

Slide 8

You have now completed Module 3.

Please ensure you complete the required Module 3 readings
and prepare for synchronous discussion and activities when
we convene live on Wednesday, January 3, 2024.

How To Guides
• Peer-Reviewed Journal Articles
• Non-Scientific Articles, Blog Posts, Social Media
• Conference/Presentation Abstract Submissions
• Public Speaking Tips
129

14. INSPIRE Module 3 Synchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 3
Synchronous Session focused on Knowledge Dissemination.
My name is ____________________ and I will be your
instructor for today.

Slide 2

Today is a 2 hour session, and we have quite a bit to cover.

The Agenda for today is as follows:
• Lecture and Readings Review (this will be a high-level
overview of the module you completed prior to this
session)
• Next we’ll move to a small group Activity in Breakout
Session
• Then we’ll have our breakout groups report out on key
discussion points before welcoming our
• Guest Speaker: _________________ to provide
insights into their experience engaging in knowledge
dissemination activities in different contexts and
mediums.
• After that we’ll quickly review what’s next in the
program and
• finish with any questions you may have and a final wrap-
up of Module 3

Knowledge
Dissemination
Module 3:
Synchronous Session -
Wednesday, January 3, 2024
Agenda
Lecture/Readings Review & Discussion
Discussion Questions
Breakout Session: Activity
Group Report Out
Guest Speaker
What’s Next?
Questions & Wrap-Up
130

Slide 3

Let’s do a quick review of this week’s asynchronous lecture
and reading materials.

Volunteer please to give us one major takeaway from each
lecture topic {engage the participants in lively discussion
about the module material}:
• XXX

Thank you for your participation. Very lively discussion and
great application.

Module 3 is such an exciting piece in this program where we
begin to see your projects come together into wonderful
works of art that are worthy of sharing with the larger
community. I hope you are all looking forward to your
culminating activities and sharing your findings and work
with your professional colleagues and other key
stakeholders.

Slide 4

Activity instructions for participant small groups are as
follows; these will be placed in the breakout session chat for
your reference.

Be prepared to provide a ~2 minute report out for the larger
group when we reconvene.

Any questions before I place you in rooms?

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 30 minutes.

Slide 5

Welcome back.

Let’s get started with Group 1
{provide feedback, allow time for questions}

Next, Group 2
{provide feedback, allow time for questions}

Great working session today!

Lecture & Readings Review
Breakout Session –Activity
• Research Poster Presentation Activity: How to
Plan Your 1 Minute Pitch
Group Report Out
• Group 1
• Group 2
131

Slide 6

Today’s guest speaker is ____________.

{Prepare bio and update slide and speaker notes
accordingly}

___[guest speaker name]__, take it away!

Slide 7

Thank you so much, ___[guest speaker name]_, for sharing
your knowledge and experiences with the group.
We are so pleased to have an example of the types of
knowledge dissemination activities this group has to look
forward to, and it’s important to see how these activities are
feasible and impactful for ongoing innovation in the field.

Let’s get another round of applause for ___[guest speaker
name]__.

Now, let’s talk next steps:

Please ensure you schedule your next individual mentorship
meetings.

We’ll convene next on February 7
th
for your Knowledge
Dissemination workshop.

Also, your Knowledge Dissemination Plan Worksheet is due
Friday, February 9, 2024, which is a couple days after our
next session which will be our workshop. This will give you a
couple days to make any necessary edits needed from cohort
feedback before submission.

The rest of this calendar year will be spent focused on
wrapping up your Practitioner Research projects and
planning for sharing your knowledge with others. I’m
looking forward to your culminating presentations and
knowledge dissemination activities.

Slide 8

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Module 3 synchronous session.

Thank you.

Guest Speaker
• Schedule Individual Mentorship Meeting |
January 8, 2024 – January 19, 2024
• Next Session: Workshop on February 7, 2024
• Knowledge Dissemination Plan Worksheet |
Due: February 9, 2024
What’s Next?
Questions & Wrap-Up
132

Slide 9

133

15. INSPIRE Module 3 Workshop Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Knowledge
Dissemination Plan Workshop.

My name is ____________________ and I will be your
instructor for today.

Slide 2

The Agenda for today is as follows:
• We’ll start with an overview of the workshop format
• We’ll quickly jump right in to today’s workshop activity
• After that we’ll take a moment to review what’s next in
the program and
• finish with any questions you may have and a final wrap-
up of today’s Knowledge Dissemination Workshop.

Knowledge
Dissemination
Workshop Session -
Wednesday, February 7, 2024
Module 3:
Agenda
Workshop Overview
Workshop Activity
What’s Next?
Questions & Wrap-Up
134

Slide 3

The focus of today’s Knowledge Dissemination Plan
Workshop Session will be to present and seek feedback on
your individual knowledge dissemination plans.

Guest mentors who will be available to offer guidance and
share their experiences with you today, so please use this
opportunity to share freely and discuss your knowledge
dissemination plans and strategies to ensure your success
moving forward.

The main goal of the workshop session is to provide you with
an opportunity to solidify your knowledge dissemination
plans, which, as you know, will serve as your culminating
activities in the INSPIRE program.

Workshops are a good opportunity to test your ideas and also
make last minute revisions to your Knowledge
Dissemination Plan Worksheets in advance of the upcoming
deadline, your individual mentorship sessions and
engagement in your knowledge dissemination activities.

Slide 4

Each breakout group will consist of 2 of you and a guest
mentor.
You’ll have 40 minutes today, so I recommend splitting time
between each of your projects (~20 minutes each)

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after 40 minutes.

Slide 5

Welcome back! I hope that was helpful for you. Please
remember, the support of your cohort participants will be
key throughout this process. Lean on each other and
remember, you have your mentors, your fellow cohort
participants, and now your guest mentors to lean on with any
questions or issues that may arise.

Let’s talk next steps now:

Your Knowledge Dissemination Plan worksheets are due in 2
days, on February 9
th
.

Please also ensure you schedule your next individual
mentorship meetings.

On Wednesday, March 6
th
we’ll have both your Knowledge
Dissemination Checkpoint and an Activity Session, so come
prepared to share updates with the larger group regarding
your progress at that time.

Workshop Overview
• Participants will present and seek feedback on their
Knowledge Dissemination Plans
• Small group cohort & guest mentor guidance and
feedback is available.
• Workshop goal: opportunity to solidify your
knowledge dissemination plans to ensure feasibility of
completion
Workshop Activity
• Breakout Rooms – 2 participants, 1 guest mentor
• 40 minutes total (20 minutes each)
• Knowledge Dissemination Plan Worksheet |
Due: February 9, 2024
• Schedule Individual Mentorship Meeting |
February 12, 2024 – February 23, 2024
• Knowledge Dissemination Checkpoint |
March 6, 2024
• Next Session: Knowledge Dissemination Activity
on March 6, 2024
What’s Next?
135

Slide 6

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Knowledge Dissemination Workshop session.

Thank you.

Slide 7

Questions & Wrap-Up
136

16. INSPIRE Module 3 Activity Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Knowledge
Dissemination Activity Session.

My name is ____________________ and I will be your
instructor for today.

Slide 2

The Agenda for today is as follows:
• We’ll start with an overview of today’s activity format
• We’ll quickly jump right in to today’s breakout session
where we will spend the bulk of our time today
• After that we’ll take a moment to review what’s next in
the program and
• finish with any questions you may have and a final wrap-
up of today’s Knowledge Dissemination Activity Session.

Knowledge
Dissemination
Activity Session -
Wednesday, March 6, 2024
Module 3:
Agenda
Activity Overview
Breakout Session Activity
Report Out
What’s Next?
Questions & Wrap-Up
137

Slide 3

In the Knowledge Dissemination Activity Session, you will
provide updates on your knowledge dissemination plans,
seek ongoing feedback, and ensure your plans align with
overarching program goals and timelines.

Remember, this is your time to ensure you are on the right
track, and an opportunity to seek assistance or feedback as
might be helpful during this stage of the program.

Slide 4

While in your 40 minute breakout sessions, you can use the
prompts on the screen as a basis for your update report outs.

This will also be placed in the breakout room chat for your
reference.

Be prepared to provide a ~2-3 minute report out for the
larger group about any themes among your group members
or any questions that may arise that can be answered in the
large group when we reconvene.

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 40 minutes.

Slide 5

Welcome back.

Let’s get started with Group 1
{provide feedback, allow time for questions}

Next, Group 2
{provide feedback, allow time for questions}

Next, Group 3
{provide feedback, allow time for questions}

Next, Group 4
{provide feedback, allow time for questions}

Great working session today!

Activity Overview
• Participants will:
• provide updates on their knowledge dissemination plans
• seek ongoing feedback, and
• ensure knowledge dissemination plans align with
overarching program goals and timelines
Breakout Session Activity
• 4 breakout groups
• 40 minute breakout session
• Answer the following prompts:
• Provide a brief summary/review of your knowledge dissemination plans
• What actions have you taken thus far?
• What are your next steps?
• Are there key deadlines that you need to work toward?
• What challenges are you facing?
• Are you on schedule to engaged in your knowledge dissemination activities by
the stated timelines?
• Prepare a ~2-3 minute report out for the larger group
Report Out
• Group 1
• Group 2
• Group 3
• Group 4
138

Slide 6

Let’s talk next steps:

Please ensure you schedule your next individual mentorship
meetings.

You should begin to wrap up your research and ensure you
are on schedule to engage in your knowledge dissemination
activities by the end of the program.

We will reconvene on April 10, 2024 with Module 4 on
Building a Business Case, so please ensure that you complete
the required Module 4 asynchronous lecture & readings in
preparation for our live session.

Slide 7

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Knowledge Dissemination Activity session.

Slide 8

• Schedule Individual Mentorship Meeting |
March 11, 2024 – March 22, 2024
• Next Session: Module 4 – Building a Business
Case on April 10, 2024
What’s Next?
Questions & Wrap-Up
139

17. INSPIRE Module 4 Asynchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 4.
My name is ____________________ and I will be your
instructor for this module.
Today, we will focus on how to close the deal on
demonstrating value of social care integration investments
through, Building a Business Case.

Slide 2

Specifically, we’ll speak about how we generate buy-in and
ongoing investments in social care integration strategies by
building a business case.

We will cover:
Introduction to Social Care Business Cases
What is Known About the Impacts of Social Care
Interventions?, and
How to Develop a Business Case

Building a
Business Case
Module 4:
Asynchronous Session
Generating Buy-In:
Building a Business Case
Introduction to Social Care Business Cases
What is Known About the Impacts of Social Care
Interventions?
How to Develop a Business Case
140

Slide 3

• Healthcare organizations understand that SDOH
factors can improve health outcomes and minimize
medical costs. However, many still miss the
opportunity to maximize investments in social care
interventions.
• Many health care leaders still do not understand how
to effectively use the insights derived from the
integration of social care interventions.
• This is where you come in. As direct practice health
care social workers, you have the power to craft the
narrative around what you do, why you do it (i.e. what
problems you are seeking to solve) and how it benefits
the organizations where you work, as well as the larger
community, and of course, individual
members/patients/clients.
• The goal of “building a business case” for social care
integration strategies, programs, and interventions is
to connect your specific use case to a return on
investment, in order get leadership and other
stakeholder buy-in.
• A business case is a formal document submitted to
decision makers for approval and/or funding of a
service development initiative
• A convincing business case must link the proposed
service improvement to local, regional and national
priorities and constraints.
• The financial section of a business case will be analyzed
closely, so costs and benefits need to be made clear (if
available).
• If social workers learn to articulate the needs of their
services in the language of health care leadership, they
have a good chance of securing support and ongoing
investments in social care integration activities.
Slide 4

• There is mounting evidence that addressing social
needs of complex patients can reduce costly forms of
health care utilization and result in savings.
• More research is being produced in this area as more
attention is given to social care integration work.
• The Commonwealth Fund has compiled an evidence
guide that helps tie specific interventions, programs, or
strategies to return on investment for health care
organizations.
• During the past three years, they have spoken with
leaders of health care and community-based
organizations interested in developing partnerships to
address social determinants of health for the high-
need, high-cost populations they serve. They’ve
concluded that leaders need information on what
works and the expected impact from investments.
• They focus on health care utilization and cost impact
for adults with complex needs, with an intention of
helping organizations make a business case for
delivering social services.
• They also published and maintain a Return on
Investment (ROI) Calculator to inform program
planning and in negotiating financially sustainable
contractual relationships.
• In their work with the ROI Calculator, they learned
that decision-makers often lacked benchmarks on
program impact and costs,
• Therefore, the opportunities are ripe for you to craft
your story, to develop a business case for your work
withing your host workplaces/organizations, and
beyond.

• Opportunity: Crafting the Narrative
• Mechanism: Building a Business Case
• Business Case: “a formal document submitted to decision makers for approval
and/or funding of a service development initiative”
• A convincing business case must link the proposed service improvement to local,
regional and national priorities and constraints
• The financial section of a business case will be analyzed closely, so costs and
benefits need to be made clear (if available)
• The “why” for social workers in health care
Introduction to Social Care Business Cases
• Evidence that Integration of Social Care = Reduces Costs (health
care utilization)
• Commonwealth Fund Evidence Guide
What is Known About the Impacts of Social Care Interventions?
141

Slide 5

• Financial Impact: Calculating financial impact for
defined populations does not mean that social need
interventions should be undertaken only when they
yield a positive ROI for the health care sector. The
human impact on access to services, health outcomes,
and economic opportunity can justify the investment to
meet community benefit and health equity goals. Even
so, it is useful to know the financial impact.
• Quality Impact: Qualitative data about quality of care,
patient and/or provider satisfaction can be used to
develop robust quality data for business case
development.
• Health Care Outcomes Impact: Of course, if there are
clinical outcomes data related to social care
interventions or strategies, these are also a great source
or ROI to be used in business case development.
• Societal Impact: Considering how a social care
intervention or program impacts the greater
community or society is also important to include in
any business case proposal.
• Writing a business case can be frustrating. It is made
easier by engaging decision makers from the outset to
ensure the proposal is in alignment with organizational
goals and strategies. Involving patients and getting
qualitative feedback to support the quantitative data
will enhance your proposal.

Slide 6

You have now completed Module 4.

Please ensure you complete the required Module 4 readings
and prepare for synchronous discussion and activities when
we convene live on Wednesday, April 10, 2024.

How to Develop a Business Case
• Financial Impact
• Quality Impact
• Health Care Outcomes Impact
• Societal Impact
• Alignment with Organizational Goals and Strategies
142

18. INSPIRE Module 4 Synchronous Session Slides & Instructor Notes

Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Module 4
Synchronous Session focused on Building a Business Case.
My name is ____________________ and I will be your
instructor for today.

Slide 2

Today is a 2 hour session, and we have quite a bit to cover.

The Agenda for today is as follows:
• Lecture and Readings Review (this will be a high-level
overview of the module you completed prior to this
session) and Discussion
• Next we’ll move to a small group Activity in Breakout
Session
• Then we’ll have our breakout groups report out on key
discussion points before welcoming our
• Guest Speaker: _________________ to provide
insights into their experience engaging in knowledge
dissemination activities in different contexts and
mediums.
• After that we’ll quickly review what’s next in the
program and
• finish with any questions you may have and a final wrap-
up of Module 4

Building a
Business Case
Module 3:
Synchronous Session -
Wednesday, April 10, 2024
Agenda
Lecture/Readings Review & Discussion
Breakout Session: Activity
Group Report Out
Guest Speaker
What’s Next?
Questions & Wrap-Up
143

Slide 3

Let’s do a quick review of this week’s asynchronous lecture
and reading materials.

Volunteer please to give us one major takeaway from each
lecture topic {engage the participants in lively discussion
about the module material}:
• XXX

Thank you for your participation. Very lively discussion and
great application.

Module 4 allows us to delve deeper into the impacts we can
make and represents the final piece of the puzzle on ensuring
that the value of social care integration innovation is
understood by key stakeholders including decision-makers
and funders.

Slide 4

Activity instructions for participant small groups are as
follows; these will be placed in the breakout session chat for
your reference.

Be prepared to provide a ~2 minute report out for the larger
group when we reconvene.

Any questions before I place you in rooms?

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after about 30 minutes.

Slide 5

Welcome back.

Let’s get started with Group 1
{provide feedback, allow time for questions}

Next, Group 2
{provide feedback, allow time for questions}

Great working session today!

Lecture & Readings Review
Breakout Session –Activity
• Speaking the Right Language: Practitioners are
often confused about how to effectively engage
and connect with health care decision-makers
and leaders. This activity will explore the
language nuances practitioners must learn to
make effective business case pitches that result in
value propositions of their work and that help to
secure ongoing investments in these strategies.
Group Report Out
• Group 1
• Group 2
144

Slide 6

Today’s guest speaker is ____________.

{Prepare bio and update slide and speaker notes
accordingly}

___[guest speaker name]__, take it away!

Slide 7

Thank you so much, ___[guest speaker name]_, for sharing
your knowledge and experiences with the group.
We are so pleased to have an example of the types of
knowledge dissemination activities this group has to look
forward to, and it’s important to see how these activities are
feasible and impactful for ongoing innovation in the field.

Let’s get another round of applause for ___[guest speaker
name]__.

Now, let’s talk next steps:

Please ensure you schedule your next individual mentorship
meetings.

We’ll convene next on May 8
th
for your Business Case
Development workshop.

Also, your Business Case Development Worksheet is not due
until May 22, 2024.

I hope your projects are wrapping up, you have plans for
knowledge dissemination – please reach out with questions
or concerns.

Slide 8

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Module 4 synchronous session.

Thank you.

Guest Speaker
• Schedule Individual Mentorship Meeting |
April 15, 2024 – April 26, 2024
• Next Session: Workshop on May 8, 2024
• Business Case Development Worksheet |
Due: May 22, 2024
What’s Next?
Questions & Wrap-Up
145

Slide 9

146

19. INSPIRE Module 4 Workshop Session Slides & Instructor Notes
Slide 1

Welcome to the Institute on Social Practice Integration
Research & Education (INSPIRE) Program – Business Case
Development Workshop.

My name is ____________________ and I will be your
instructor for today.

Slide 2

The Agenda for today is as follows:
• We’ll start with an overview of the workshop format
• We’ll quickly jump right in to today’s workshop activity
• After that we’ll take a moment to review what’s next in
the program and
• finish with any questions you may have and a final wrap-
up of today’s Business Case Development Workshop.

Slide 3

The focus of today’s Business Case Development Workshop
Session will be to present and seek feedback on your
business cases that you are working on (worksheets).

Guest mentors who will be available to offer guidance and
share their experiences with you today, so please use this
opportunity to share freely and discuss your business cases
and return on investment strategies to ensure your success
moving forward.

The main goal of the workshop session is to provide you with
an opportunity to solidify your business cases, which, as you
know, will support implementation and sustainability of your
projects and future activities.

Workshops are a good opportunity to test your ideas and also
make last minute revisions to your Business Case
Development Worksheets in advance of the upcoming
deadline.

Business Case
Development
Workshop Session -
Wednesday, May 8, 2024
Module 4:
Agenda
Workshop Overview
Workshop Activity
What’s Next?
Questions & Wrap-Up
Workshop Overview
• Participants will present and seek feedback on their
Business Cases.
• Small group cohort & guest mentor guidance and
feedback is available.
• Workshop goal: opportunity to solidify your business
case worksheets to ensure readiness for
proposal/presentation to health care leaders and other
stakeholders.
147

Slide 4

Each breakout group will consist of 2 of you and a guest
mentor.
You’ll have 40 minutes today, so I recommend splitting time
between each of your projects (~20 minutes each)

Ok, I’ll place you in breakout groups now; I’ll bring you back
into the main room after 40 minutes.

Slide 5

Welcome back! I hope that was helpful for you. Please
remember, the support of your cohort participants will be
key throughout this process. Lean on each other and
remember, you have your mentors, your fellow cohort
participants, and now your guest mentors to lean on with any
questions or issues that may arise.

Let’s talk next steps now:

Your Business Case Development worksheets are due on
May 22
nd
.

Please also ensure you are on track to engage in your formal
knowledge dissemination activities between June 1
st
and
July 31
st
. Your final deliverables will be due on July 31
st
.

On June 12
th
we’ll have both your Rapid Fire Practitioner
Research presentations to your cohort and will have our final
session on July 31
st
.

Slide 6

Are there any lingering questions, concerns, comments?

{field questions from the group}

This brings us to the end of today’s session, and a wrap up of
our Business Case Development workshop session.

Thank you.

Workshop Activity
• Breakout Rooms – 2 participants, 1 guest mentor
• 40 minutes total (20 minutes each)
• Business Case Development Worksheet |
Due: May 22, 2024
• Target Formal Knowledge Dissemination
Activities| June 1, 2024 – July 31, 2024
• Final Knowledge Dissemination Deliverables |
Due: July 31, 2024
• Upcoming Sessions:
• Rapid Fire Practitioner Research Presentations on
June 12, 2024
• Rapid Fire Business Case Presentations, Program
Wrap-up, & Post-Survey on July 31, 2024
What’s Next?
Questions & Wrap-Up
148

Slide 7

149

Appendix D - Data Collection Strategy
Topic or Stakeholder Group Rationale Format
Health care disparities Understand the broad problem landscape from a
historical and current context.
Assist with identification of related key issues and
stakeholder groups.
Literature Review – Peer-reviewed periodicals; online
news articles; books and book chapters; governmental and
non-governmental reports and white papers; and, social
media and online blog posts.
Populations most affected by
health care disparities
Understand the broad problem landscape from a
historical and current context.
Literature Review – Peer-reviewed periodicals; online
news articles; books and book chapters; governmental and
non-governmental reports and white papers; and, social
media and online blog posts.
Health equity Understand the broad problem landscape from a
historical and current context.
Literature Review – Peer-reviewed periodicals; online
news articles; books and book chapters; governmental and
non-governmental reports and white papers; and, social
media and online blog posts.
Social Determinants of Health
interventions / Interventions or
initiatives aimed at integrating
social care into health care
delivery
Understand the broad solution landscape from a
historical and current context.
Narrow the focus to workforce solutions.
Literature Review – Peer-reviewed periodicals; online
news articles; books and book chapters; governmental and
non-governmental reports and white papers; and, social
media and online blog posts.
Workforce development strategies
to integrating social care into
health care delivery, including
those specifically targeted toward
professional social workers or
other social care experts
Understand the narrower solution landscape focused
on workforce solutions from a historical and current
context.
Seek an understanding of the role professional social
workers and other social care experts have historically
and currently play in these solutions, as well as what
might be proposed as a future state.
Literature Review – Peer-reviewed periodicals; online
news articles; books and book chapters; governmental and
non-governmental reports and white papers; and, social
media and online blog posts.

150

Frontline professional social
workers in health care
environments and adjacent social
services sectors.
Understand the current frontline professional social
work experience in the midst of growing awareness of
the social determinants of health/greater emphasis on
addressing non-medical social care needs in health
care.
Individual Interviews
See interview questions – Frontline professional social
workers.
Social work and other professional
leaders working in health care
environments /
Population health leaders

Understand the current social work leadership
experience in the midst of growing awareness of the
social determinants of health/greater emphasis on
addressing non-medical social care needs in health
care.
Learn more about how health care leaders understand
the issue of health disparities and how they plan and
execute programs and initiatives to address this issue,
including staffing and expertise considerations.
Individual Interviews
See interview questions – Leaders.

Frontline health care
professionals/public health
practitioners (nurses, physicians,
community health workers, etc.)
Understand the current frontline health care
professional experience in the midst of growing
awareness of the social determinants of health/greater
emphasis on addressing non-medical social care needs
in health care. Attention will be paid to their
perception of the role social workers play in achieving
health equity or SDOH-related initiatives in their
workplace(s)
Individual Interviews
See interview questions – Frontline health care
professionals/public health practitioners.

Professional case managers Professional Case Managers include nurses, social
workers, occupational/physical therapists, and other
affiliated health care providers.
With a focus on coordination/integration of care and
improvement of health outcomes while managing
costs, this professional sector may have valuable
insight into how the health gap is understood/defined
and current and potential solutions.
Conference Presentations (live and recorded)
See interview questions – Professional case managers.

151

Master’s level social work students
or recent (past 1-3 years) graduates
interested in health care related
social work practice.
Understand the current educational preparation (or
lack thereof) of master’s level social work students
seeking to enter the field of medical or health care-
related social work.
Individual Interviews
See interview questions – Master’s level social work
students/recent graduates

Health care organization human
resource professionals
This stakeholder group may hold key information
about how health care organizations characterize the
scope of responsibility as well as requisite skills and
experience of health care social workers that can help
to inform gaps in understanding.
Individual Interviews
See interview questions – HR professionals.

Public Health Researchers and
Practitioners
Learn more about current research, evidence-based
practices, and policy focused on improving population
health, addressing health disparities, and achieving
health equity from the field of Public Health.
Specifically seek to find perspectives of the role social
workers play/might play in these efforts.
Trainings & Conference Presentations (live or recorded)
Target organization(s)/events:
• The American Public Health Association: Advancing
Racial Equity Webinar Series, APHA’s Policy Action
Institute Conference

Individuals and population groups
affected by health care disparities
(beneficiaries) & frontline
professionals in health & human
services (users)
Seeking to learn more from mainstream contemporary
voices/perspectives on the issue of health disparities
and health equity.
Novels/Essays/Poems
• Patients Come Second: Leading Change by Changing
the Way You Lead by Paul Spiegelman
• Doing Harm: The Truth About How Bad Medicine
and Lazy Science Leave Women Dismissed,
Misdiagnosed and Sick by Maya Dusenberry
• Biased by Jennifer L. Eberhardt
• Black and Blue by John Hoberman
• Just Medicine by Dayna Bowen Matthew
Health care policymakers and
advocates
Seek greater understanding of local, state, and federal
policy activity surrounding workforce preparation and
development in the growing field of health equity.
Trainings & Conference Presentations (live or recorded).
Twitter/LinkedIn posts and conversations will also be a
key source of information to gain perspective from this
stakeholder group and current work in the field.
152

Interview Questions by Stakeholder Group
Frontline professional social workers
1. Tell me about your role and the types of interventions you provide on a daily basis.
2. In your own words, what do health care social workers do? What are your specialized skills or expertise?
3. How do you advocate for your patients/clients? Are there barriers to effective advocacy in this sector?
4. Tell me about a time you were involved in the development of a program, initiative, or intervention in your work environment
that dealt with addressing non-medical social care needs.
5. Do you feel you have a voice or chance to impact how your organization goes about addressing health equity?
6. In a perfect world, what would you need to do your job (addressing the SDOH) more effectively/what needs to change?
7. What do you want other people (patients/family members, health care professionals, public) to know about what you do as a
health care social worker?
8. Do you consider yourself to be an expert in non-medical social care needs and interventions? Why or why not?
9. In your opinion, are you adequately compensated for the work that you do? Why or why not?
10. How long have you been practicing in the area of health care social work?
11. Do you intend to remain in the field of health care social work? Why or why not?
12. Tell me about your training and education and whether you feel this adequately prepared you to work in the field of health care
social work.
13. What else would you like me to know about your work?

Leaders
1. Tell me about the role your social work staff members play and the types of interventions they provide on a daily basis.
2. In your own words, what do health care social workers do? What are their/your specialized skills or expertise?
3. Tell me about a time you were involved in the development of a program, initiative, or intervention in your work environment
that dealt with addressing non-medical social care needs.
4. In general, when you or your organization are/is making decisions about initiatives or programs addressing the social
determinants of health or non-medical social care needs, who do you involve/who is “at the table”? What role does each
member serve? Is there anyone missing, and if so, who and why?
5. Do you feel you have a voice or chance to impact how your organization goes about addressing health equity?
6. In your opinion, are your social work staff members adequately compensated for the work that they do? Why or why not?
What factors drive compensation for professional staff in your organization?
153

7. How do you know if you are making strides/meeting your goals to address health care disparities? What outcomes do you track
(if any), and how would you rate your organization overall?
8. How do you recruit, train, and/or incorporate new social work professionals in your organization?
9. What else would you like me to know about your work?

Frontline health care professionals/public health practitioners & Professional case managers
1. Do you feel competent to identify, assess, and address the social determinants of health? Why or why not?
2. Who on your team do you consider to be an expert in non-medical social care needs and interventions and why?
3. When making decisions about initiatives or programs addressing the social determinants of health or non-medical social care
needs, who do you involve/who is “at the table”? What role does each member serve? Is there anyone missing, and if so, who
and why?
4. How do you know if you are making strides/meeting your goals to address health care disparities? What outcomes do you track
(if any), and how would you rate your organization overall?
5. Do you work with or employ social workers? If so, how do you recruit, train, and/or incorporate these professionals in your
organization?
6. In your own words, what do health care social workers do? What are their specialized skills or expertise?
7. Tell me about any questions you have about what health care social workers do or what capacity they have to address health
equity in your organization.
8. What else would you like me to know about your work?

HR professionals
1. In your own words, what do health care social workers do? What are their specialized skills or expertise?
2. Do you work with or employ social workers? If so, how do you recruit, train, and/or incorporate these professionals in your
organization?
3. Tell me about how social workers are characterized in your organization (job descriptions, pay grades, etc.) in relation to case
managers/nurses in non-clinical roles.
4. What factors drive compensation for professional staff in your organization?
5. Tell me about any questions you have about what health care social workers do or what capacity they have to address health
equity in your organization.

154

Appendix E - Design Criteria
Design Criteria Category Detailed Criteria
1. Promote Diversity
Because lack of diversity in the health care workforce has been
identified as a contributing factor toward health care disparities,
the solution should:
• Allow adaptability for culturally competent interventions
tailored for target beneficiary and user population
• Increase diversity of the health care workforce to reflect
the beneficiary populations served
2. Evidence-Based
Because there is lack of consensus of how best to integrate and
implement social care activities in health care delivery, the
solution should:
• Include strategies for advancing the evidence-base
• Consider practitioner-based research strategies, where
appropriate and feasible
3. Sustainable
Because stakeholders are concerned about how to fund and
support innovative strategies to integrate social care in health
care delivery, the solution should:
• Align with macro-level policy change required for long-
term sustainability of the solution
• Be fiscally sustainable / have an identified funding
source
• Be replicable for ease of implementation across the
United States
4. Demonstrate Value/
Reduce Costs
Because key stakeholders including health care
systems/executives and policymakers are concerned about rising
health care expenditures, the solution should:
• Demonstrate a return on investment
• Demonstrate reduction of health care utilization and
associated costs
155

Appendix F - Communication/Marketing Materials
Problem Infographic:

156

Program Logo:

Program Infographic:

157

PROTOTYPING & PILOTING
DEVELOPMENT PHASE
Fall 2022-Summer 2023
Key Participants/Stakeholders
Fall
2022
Winter
2022/23
Spring
2023
Summer
2023
Fall
2023
Winter
2023/24
Spring
2024
Summer
2024
Fall
2024
Winter
2024/25
Spring
2025
Summer
2025
Fall
2025
Winter
2025/26
Spring
2026
Summer
2026
Develop, Pilot/Test, and Iterate
Curriculum & Certification
Program Model
Curriculum Content/Subject Matter
Experts; Key Stakeholders: Users
(social workers), Gatekeepers
(health care leaders, professional
organizations/certifying bodies),
Capstone Faculty, Capstone Peer
Evaluators, Capstone External
Design Partner
Establish Initial Health Care
Organization Sites
Health Care Organizations
employing social workers (Targets:
Sharp Healthcare; Blue Shield of
California)
Engage Initial Professional
Organization Partners
Key Social Work & Health Care
Professional Organizations (Targets:
CMSA, NASW, NSWM, RISE)
Complete & Submit Final Capstone
Project Deliverables [Including Initial
Pilot Feedback & Evaluation from Key
Stakeholders]
Capstone Faculty, Capstone Peer
Evaluators, Capstone External
Design Partner
COHORT 1 PROGRAM
IMPLEMENTATION PHASE
Fall 2023-Summer 2024
Key Participants/Stakeholders
Fall
2022
Winter
2022/23
Spring
2023
Summer
2023
Fall
2023
Winter
2023/24
Spring
2024
Summer
2024
Fall
2024
Winter
2024/25
Spring
2025
Summer
2025
Fall
2025
Winter
2025/26
Spring
2026
Summer
2026
Cohort 1 Program Implementation
• Curriculum instruction
• Practitioner research implementation
• Business case development
• Dissemination of knowledge
1-2 Health Care Organization Sites;
1-2 Professional Organization
Partners, Curriculum
SMEs/Instructors, Program
Participants (social workers &
health care leaders)
Cohort 1 Presentation or
Publication Target (Knowledge
Dissemination)
Program Participants (social
workers), Professional Organization
Partners, Curriculum
SMEs/Instructors
Summer
2024
6/1/24-
7/31/24
Cohort 1 Evaluation
• Conduct Programmatic and Outcomes
Evaluation of Cohort 1 Implementation
Phase
Program Evaluator, Stakeholders
(Users & Gatekeepers], Health Care
Professional Organization Partners,
Health Care Organization Sites,
Curriculum SMEs/Instructors,
Program Participants (social
workers & health care leaders)
Summer
2024
6/1/24-
7/31/24
P
H
A
S
E

1
P
H
A
S
E

2
Fall 2022-
Spring 2023
10/28/22-
4/29/23
Fall 2022-
Spring 2023
10/28/22-
4/29/23
Fall 2022-
Summer 2023
10/28/22-8/4/23
Spring 2023-
Summer
2023
4/29/23-
8/4/23
Fall 2023-Summer 2024
10/1/23-7/31/24
Appendix G - Project Timeline & Phases

158

COHORT 2 PROGRAM
EXPANSION PHASE
Fall 2024-Summer 2025
Key Participants/Stakeholders
Fall
2022
Winter
2022/23
Spring
2023
Summer
2023
Fall
2023
Winter
2023/24
Spring
2024
Summer
2024
Fall
2024
Winter
2024/25
Spring
2025
Summer
2025
Fall
2025
Winter
2025/26
Spring
2026
Summer
2026
Cohort 2 Program Implementation
• Curriculum instruction
• Practitioner research implementation
• Business case development
• Dissemination of knowledge
3-5 Health Care Organization Sites;
3-5 Professional Organization
Partners, Curriculum
SMEs/Instructors, Program
Participants (social workers &
health care leaders)
Cohort 2 Presentation or
Publication Target (Knowledge
Dissemination)
Program Participants (social
workers), Professional Organization
Partners, Curriculum
SMEs/Instructors
Summer
2025
6/1/25-
7/31/25
Cohort 2 Evaluation
• Conduct Programmatic and Outcomes
Evaluation of Cohort 1 Implementation
Phase
Program Evaluator, Stakeholders
(Users & Gatekeepers], Health Care
Professional Organization Partners,
Health Care Organization Sites,
Curriculum SMEs/Instructors,
Program Participants (social
workers & health care leaders)
Summer
2025
6/1/25-
7/31/25
COHORT 3 PROGRAM
SCALE-UP & SOCIAL
ENTERPRISE PHASE
Fall 2025-Summer 2026
Key Participants/Stakeholders
Fall
2022
Winter
2022/23
Spring
2023
Summer
2023
Fall
2023
Winter
2023/24
Spring
2024
Summer
2024
Fall
2024
Winter
2024/25
Spring
2025
Summer
2025
Fall
2025
Winter
2025/26
Spring
2026
Summer
2026
Cohort 3 Program Implementation
• Curriculum instruction
• Practitioner research implementation
• Business case development
• Dissemination of knowledge
10 Health Care Organization Sites; 5-
8 Professional Organization
Partners, Curriculum
SMEs/Instructors, Program
Participants (social workers &
health care leaders)
Cohort 3 Presentation or
Publication Target (Knowledge
Dissemination)
Program Participants (social
workers), Professional Organization
Partners, Curriculum
SMEs/Instructors
Summer
2026
6/1/26-
7/31/26
Cohort 3 Evaluation
• Conduct Programmatic and Outcomes
Evaluation of Cohort 1 Implementation
Phase
Program Evaluator, Stakeholders
(Users & Gatekeepers], Health Care
Professional Organization Partners,
Health Care Organization Sites,
Curriculum SMEs/Instructors,
Program Participants (social
workers & health care leaders)
Summer
2026
6/1/26-
7/31/26
Establish Social Enterprise
Business partners, legal advisors
Fall 2025-Summer 2026
10/1/25-7/31/26
P
H
A
S
E

4
Fall 2025-Summer 2026
10/1/25-7/31/26
P
H
A
S
E

3
Fall 2024-Summer 2025
10/1/24-7/31/25
159

Appendix H - Implementation Framework
EPIS Implementation Framework for the INSPIRE Program

Inner Context Outer Context
EPIS Phase Barriers Facilitators Barriers Facilitators
Exploration

Organizational
Characteristics
Organizational Climate

-Consideration of the
readiness of health care
organizational sites
(where target program
participants practice) is
important. Some
organizations are less
prepared to invest in
workforce development
and social care integration
strategies.
Organizational
Characteristics
Absorptive capacity

-The awareness of health
care organizations, health
care leaders, and especially
social care experts of
existing evidence-based
strategies for successful
social care integration sets
the stage for a healthy
exploration and
consideration of the
INSPIRE program as a
viable workforce
development solution for
change.
Interorganizational
Networks
Direct networking

-Health care delivery system
networks are often siloed in
the current medical model
of health care that persists in
the United States today.
This can lead to low
readiness to consider
workforce solution
strategies to improving the
integration of social care in
health care delivery.
Sociopolitical Context
Legislation & Policies

-The health care policy
context sets a guidepost for
innovative practice and
workforce development
strategies around improving
social care integration and
the ability to address the
social determinants of
health and eliminate health
care disparities. Health
Equity is a national agenda
that paves the way for the
INSPIRE program
implementation.

Preparation

Leadership
Championing adoption

-Vital to the INSPIRE
program implementation
is securing key health
care leader champions.
The curriculum involves
health care leader
engagement and
educational strategies, but
overcoming this barrier is
essential in the
preparation phase.
Organizational
Characteristics
Knowledge/skills/expertise

-Health care organizations
that have engaged in quality
improvement activities will
be better prepared in the
preparation phase.
Funding
Support tied to federal and
state policies

-Initial integration does not
require significant funding;
however, the current federal
and state political climate
offers opportunities,
particularly in the State of
California under CalAIM
and the health care
workforce development
budget. However, securing
this funding is a barrier that
must be overcome for
successful preparation.
Interorganizational
Networks
Organizational linkages

-National organizational
networks and coalitions
focused on the integration
of social care in health care
provide a pathway for
improved preparation
across the health care
delivery system. This
includes networks like:
NASEM and SIREN.
Implementation

Organizational
Characteristics
Culture/climate

-Success is dependent on
health care leaders
successfully championing
the program.

Organizational
Characteristics
Structure

-INSPIRE program
participants will be able to
conduct their experiential
learning tasks within their
direct practice environments;
thus, structure of the
organizational environment
facilitates implementation.
Interorganizational
Networks
Cross discipline translation

-The current siloed nature of
the health care delivery
system may slow uptake
and should be considered
when engaging cross
discipline stakeholders
(social workers and health
care leaders).
Funding
Sustained fiscal support

-The ability to establish
strong professional
organizational partnerships
and to keep fees reasonable
in comparison to other
workforce development and
continuing education
programs support the
implementation of the
INSPIRE program.
Sustainment

Organizational
Characteristics
Embedded EBP culture

-Success is dependent on
a culture of continuous
quality improvement and
seeking the most
innovative interventions
and programs.
Fidelity monitoring
Fidelity support system

-Strong outcomes
measurement components
address leadership concerns
regarding fidelity of the
program as a facilitating
factor.
Funding
Workforce stability

-The ability to secure or
generate increased funding
is essential to program
implementation and
sustainability.
Public-Private
collaboration
Ongoing positive
relationships

Ensuring ongoing
collaboration & valuing
multiple perspectives across
local and national contexts
will support the sustainment
of the INSPIRE program.
160

Appendix I - Implementation Strategies
ERIC Implementation Strategies, Mechanisms, and Outcomes of the INSPIRE Program

PHASE I STRATEGY:
Cultivate & Maintain a
Partnership between the
INSPIRE program and
National Professional
Organizations (i.e. CMSA)
- Develop professional
partnerships
- Identify & prepare champions
MECHANISMS:
Champions will disseminate
information, train, answer questions,
and overcome indifference or
resistance both internally and externally
with key stakeholders.
OUTCOME:
Acceptability
-increased
acceptability of the
INSPIRE program
among key
stakeholders
PHASES II & III STRATEGY:
Develop INSPIRE Program
Health Care Leader & Social
Work Participant Interest
- Identify early adopters
- Stage implementation scale-up
MECHANISMS:
Invested early adopters will effectively
guide other health care leaders and social
workers toward participation in INSPIRE
program and will help to address
barriers encountered during the start-up
year implementation phase, steadily
expanding program capacity.
OUTCOME:
Adoption
-increased adoption
among Health Care
Organizations in the
local and national
context
PHASE IV STRATEGY:
Secure State &/or
Federal Funding
- Access new and existing
funding sources to establish a
non-profit social enterprise to
administer the INSPIRE program
long-term
MECHANISMS:
Program creator and organizational
partners will secure and maintain
adequate permanent funding which will
facilitate INSPIRE program
implementation by institutionalizing the
program into ongoing, stable operations
of a non-profit social enterprise venture.
OUTCOME:
Sustainability
-permanent funding
and transition into a
social enterprise will
support long-term
sustainability of the
INSPIRE program
161

Appendix J - Start-Up Budget
INSPIRE Program
START-UP BUDGET (Pilot Implementation)
Fiscal Year July 1, 2023 - June 30, 2024
Category $ Comments

REVENUE
Health Care Organization Partner
Fees (x2) $ 10,000.00 $5000 per partner, 2 partners
Training Fees (x10) $ 4,000.00
$400 per participant (encourage use of employer-
based CE benefits), 10 participants
Certificate Issuance Fees (x10) $ 1,000.00 $100 per participant certification, 10 participants

Total REVENUE $15,000.00

EXPENSES

Personnel Exp
Program Instructor (x1) - Contracted $ 10,000.00 Flat rate contract fee/honorarium, 1 instructor
Other Operating Exp
Occupancy/Rent, Furn & Eqpt $ - *Virtual; no occupancy fees or rent required
Communications/Marketing Materials $ 500.00
Offset costs of host Professional Organization
partner
Continuing Education/Accreditation
Fees $ 500.00
Offset costs of host Professional Organization
partner
Program Administration & Evaluation $ 4,000.00
Offset costs of host Professional Organization
partner

Total EXPENSES $15,000.00

SURPLUS/DEFICIT $ -

162

Appendix K - First Full Year of Operations Budget
INSPIRE Program
FIRST FULL YEAR OF OPERATIONS (FFYO) BUDGET
Fiscal Year July 1, 2024 - June 30, 2025
Category $ Comments

REVENUE
Health Care Organization Partner
Fees (x5) $ 25,000.00 $5000 per partner, 5 partners
Training Fees (x25) $ 10,000.00
$400 per participant (encourage use of employer-
based CE benefits), 25 participants
Certificate Issuance Fees (x25) $ 2,500.00 $100 per participant certification, 25 participants

Total REVENUE $37,500.00

EXPENSES

Personnel Exp
Program Instructor (x2) - Contracted $ 20,000.00
$4000 flat rate contract fee/honorarium, 2
instructors
Other Operating Exp
Occupancy/Rent, Furn & Eqpt $ - *Virtual; no occupancy fees or rent required
Communications/Marketing Materials $ 2,500.00
Offset costs of host Professional Organization
partner
Continuing Education/Accreditation
Fees $ 5,000.00
Offset costs of host Professional Organization
partner
Program Administration & Evaluation $ 10,000.00
Offset costs of host Professional Organization
partner

Total EXPENSES $37,500.00

SURPLUS/DEFICIT $ -

Abstract (if available)

Abstract The Grand Challenges for Social Work initiative to Close the Health Gap promotes systemic solutions to address health care inequities and the social determinants of health across the United States (Barth et al., 2022). National health care policy priorities and evidence-based research have identified the ability to successfully integrate social care within health care delivery as key to closing this health gap (Fichtenberg et al., 2020; Horwitz et al., 2020; Kelley, 2022; NASEM, 2019). Unfortunately, health care organizations have struggled with effectively integrating social care interventions into practice. This is driven in part by the underutilization of social care experts like social workers in integrated health care practice and program development, despite evidence that successful social care integration requires an adequately trained specialized workforce (NASEM, 2019; Velásquez, 2019). The Institute on Social Practice Integration Research and Education (INSPIRE) program is an innovative solution for improving social care integration implementation through a targeted workforce development strategy. The INSPIRE program is an experiential learning and certification program for health care social workers to develop skills in practitioner research, knowledge dissemination, and building a business case for social care integration activities that simultaneously engages health care leaders around the importance and benefits of increasing investments in social care integration activities and in a specialized social care workforce. The INSPIRE program is innovative because of its mezzo-level workforce development approach focused on generating new models of care in local contexts intended for wide dissemination across local and national settings for maximum impact and sustainability.

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Asset Metadata

Creator Arndt-Couch, Raine McKenna ‘Āpuakea (author)

Core Title Institute on social practice integration research and education (INSPIRE): a workforce development solution to close the health gap

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-08

Publication Date 07/28/2023

Defense Date 07/24/2023

Publisher University of Southern California. Libraries (digital)

Tag close the health gap,experiential learning,OAI-PMH Harvest,social care integration,Social workers,workforce development

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ronald (committee chair), Jackson, Wiara (committee member), Singh, Melissa (committee member)

Creator Email arndtcou@usc.edu,rainearndt@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113290630

Unique identifier UC113290630

Identifier etd-ArndtCouch-12162.pdf (filename)

Legacy Identifier etd-ArndtCouch-12162

Document Type Capstone project

Rights Arndt-Couch, Raine McKenna ‘Āpuakea

Internet Media Type application/pdf

Type texts

Source 20230728-usctheses-batch-1075 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA

Repository Email cisadmin@lib.usc.edu