Support Specialists Research Articles

Lactation Support for Breastfeeding and Chestfeeding People with HIV: A Call for Research to Examine Telelactation Experience, HIV Knowledge, and Lactation Consultants' Attitudes Related to Infant Feeding with HIV.

Clinical guidelines for infant feeding among people with HIV in the U.S. were updated in 2023 to encourage providers to utilize a shared decision-making approach that includes breastfeeding/chestfeeding (B/CF) when appropriate. Despite this historic shift in policy to support B/CF as an infant feeding choice for people living with HIV, birthing people living with HIV who desire B/CF face many barriers, and there is currently a gap in research identifying best practices for facilitating safe and satisfying B/CF in this population. Lactation support specialists have been identified as a positive factor in successful B/CF and a key resource for supporting B/CF for people with HIV. Recent research has shown that telelactation, the provision of care from a qualified lactation consultant or counselor using telehealth, can increase access to quality lactation support in underserved areas and can effectively improve outcomes, such as increased rates of exclusive breastfeeding and decreased early breastfeeding cessation while maintaining high levels of patient satisfaction. Telelactation is an innovative approach to improving access to B/CF among birthing people living with HIV, but little is currently known about what kind of support lactation support specialists and other perinatal HIV care providers may need to meet the clinical and psychosocial needs of B/CF people living with HIV and their infants. More research is needed to identify possible gaps in knowledge and other needs within the lactation support community so that infant feeding specialists are adequately equipped with evidence-based strategies to support the unique needs of parents living with HIV.

Peer Support Specialists: SAMHSA's designation raises confusion

If you are in recovery from a substance use disorder (SUD), a peer would be another person in recovery from a SUD. At least, that's the purist way of thinking, before the word “peer” came into common usage. For years, the Substance Abuse and Mental Health Services Administration (SAMHSA) has endeavored in various ways to promote the blending of SUDs and mental illnesses, mainly in terms of the recovery workforce. Most recently, SAMHSA's publication, Peer Support Specialists: A Growing Mental Health and Addictions Workforce, adds further confusion to the issue. We asked experts in the field to comment.

Certified peer recovery support specialists and substance use related emergency department visits: A mixed methods study of the patient experience

IntroductionEmergency department (ED) peer-delivered interventions have been implemented across the country to improve outcomes for people who use drugs. In this study we describe what elements patients believe led to a positive interaction with a certified peer recovery support specialist (CPRSS) in the ED and discuss implications when those elements were missing. MethodsThis is a qualitatively driven mixed methods study embedded within a larger longitudinal study. Using a close and open-ended question interview guide, we interviewed 26 participants from 2018 to 2023 who met with a CPRSS in a Nevada ED for a substance use related concern. Interviews were recorded and transcribed verbatim. Thematic analysis was used to code the transcripts and generate themes. Quantitative data (satisfaction, therapeutic alliance, and social support) were analyzed using student-t, Fisher's exact, and one-way ANOVA tests. ResultsParticipants described numerous elements that they believed contributed to being satisfied with their CPRSS interaction, which we grouped into three categories: 1) how the CPRSS interaction felt, 2) how the CPRSS services were delivered, and 3) patient factors that influenced the interaction with a CPRSS. Elements that contributed to their satisfaction, including whether the CPRSS adapted to their current circumstances, if they received personalized referrals, and how their own mental and physical state impacted their receptivity to services. ConclusionsOur findings highlight areas to optimize implementation and increase program uptake for future ED-based CPRSS-delivered interventions, including training CPRSS in the philosophy of harm reduction, following up with the patient post-ED, and tailoring services to the patients' immediate needs.

Peer navigation intervention for individuals with serious mental illness reentering the community after jail incarceration: a qualitative case study

BackgroundCriminal legal system-involved individuals with serious mental illness (SMI) experience more challenges accessing mental health and other community services than those without a history of criminal legal system involvement. A formative qualitative study was conducted to explore feasibility and acceptability and inform the adaptation of a mental health peer navigation intervention for individuals with SMI reentering the community after jail incarceration.MethodsIn-depth qualitative interviews and focus-group discussions were conducted with mental health peer navigators (i.e., certified mental health peer support specialists, peer recovery coaches) and individuals with lived experience of SMI and criminal legal system involvement (N = 20 total). Data were analyzed using applied thematic analysis.ResultsFour major themes emerged: (1) Feasibility and acceptability of peer-provided services: all participants reported that peer navigation services would be feasible and acceptable for individuals with SMI reentering the community after jail incarceration; (2) roles of peer navigators in addressing barriers to care: peers can address barriers to care experienced during community reentry and contribute towards service linkage/engagement; (3) shared identity and combating stigma: having a shared identity with peer navigators may minimize the impact of stigma and make it easier for clients with multiple marginalized identities to seek support; and (4) peer navigator skills and recommendations for the planned program: essential peer navigation skills include authenticity, reliability, active listening, advocacy, trauma-informed care, motivational interviewing, and empathy. Recommendations for the planned program include initiating services while clients are in custody, emphasizing the voluntary nature of peer support, knowing the limits of a peer navigation intervention, and offering support for peer navigators while on the job.ConclusionParticipants saw peer navigation services for individuals with SMI with criminal legal system involvement as potentially feasible and acceptable. Such programs may enhance their impact by offering supportive supervision, emphasizing the voluntary nature of the service, and acknowledging recovery as a self-directed endeavor.

Supporting Data Discovery: Comparing Perspectives of Support Specialists and Researchers

Supporting Data Discovery: Comparing Perspectives of Support Specialists and Researchers

Implementation of a patient-centered phone line to address non-medical cancer support needs in an integrated health system.

208 Background: From the moment cancer is suspected, patients and their caregivers may feel overwhelmed and not know where to seek help for non-medical questions. Social risks, including financial instability, housing and food insecurity can lead to poor cancer outcomes, and 39% of Kaiser Permanente (KP) cancer patients screened positive for at least one social risk. KP implemented the Cancer Support Line to provide patients and caregivers with a single point of contact to address non-medical concerns, including financial navigation, social health needs, and general cancer information. Methods: Kaiser Permanente partnered with patients, clinicians, and health plan functions supporting member services, social health, and quality to co-design and implement a phone number for cancer members in the KP Northwest market. The Cancer Support Line (‘Line’) is an inbound phone number staffed by Cancer Support Specialists (‘Specialists’), a dedicated team of health plan member services, trained in cancer support skills. Specialists use four co-designed pathways to navigate callers to resources for financial questions, social needs, and general cancer information and support. If clinically appropriate questions arise, Specialists use existing operational channels to connect patients back to their care teams. Results: During the pilot, there were 1,057 interactions with members, patients, and caregivers from March 12 th to May 17 th . Financial questions about payment assistance and insurance benefits/eligibility emerged as the highest call driver. The top call outcomes by volume are shown in the included table. A high majority of calls (94%, n=992) were addressed by the Cancer Support Specialists themselves. Post-call survey results revealed that 96% of callers (n=26) rated their call experience high when asked “How would you rate your overall call experience today?” Conclusions: Effective collaboration across KP’s project teams was a critical driver of the pilot’s success. Workflows were built with all partner teams and departments, Specialist training was designed internally with consultation from the American Cancer Society, team communications were open and consistent, call reporting was robust and adaptable. Furthermore, the Line addresses a critical gap in the cancer patient experience: navigating non-medical needs that busy care teams are unable to address on their own. Though positive, these pilot results are preliminary and focused on one KP market. To evaluate the pilot for scalability, the team will assess process metrics and outcomes on caller, frontline staff, and Specialist experience on an ongoing basis to capture the Line’s broader operational impact. Call transfer destination. Transfer Destination # of calls % No Transfer 992 93.9% KP Community Support Hub Transfer 45 4.3% Clinical Transfer 17 1.6% KP Community Support Hub + Clinic Transfer 3 0.3%

Behavioral Health Support Specialists.

Behavioral Health Support Specialists.

Obstacles and enablers for using telehealth services online in nursing practice: A systematic review

Background: Comprehensive reporting on the barriers and enablers to telehealth adoption in industrialized nations has identified a wide range of significant factors. We aimed to get the important research information on the elements that nurses found most beneficial and hindering when using online telehealth services for nursing practice, we conducted a systematic review study. Method: This systematic review study was conducted in accordance with PRISMA principles. We searched for articles that discussed the aspects of using telehealth services for nursing practicum that nurse practitioners found most helpful and inconvenient. The international electronic databases that were used were Web of Science, Scopus CINAHL, and PubMed. The search was conducted for articles published in the period from 2011 and 2023. Only research that were written in English and published were considered. Results: We considered 7 articles in our systematic review analysis, totaling 3729 participants. Inadequate resources (time, money) were mentioned as barriers relevant to both organizational and patient issues. Negative attitudes, a lack of telehealth experience, and inadequate training and support were considered to be impediments to the use of telehealth (3). According to the findings of the Kleib et al., 2018 study, the following variables affect user competency and proficiency: age; Prerequisites for qualifying include prior knowledge of information technology and a sufficient, early, and continual informatics education. Conclusion: Numerous facilitators and obstracles were identified. In addition to administrative support, health professionals and information technology specialists must come to local agreements when transitioning from traditional face-to-face nursing practice to telehealth utilization.

Peer Intervention to Link Overdose Survivors to Treatment (PILOT): Protocol for a Multisite, Randomized Controlled Trial Conducted Within the National Institute on Drug Abuse Clinical Trials Network.

The increase in opioid-related overdoses has caused a decrease in average life expectancy, highlighting the need for effective interventions to reduce overdose risk and prevent subsequent overdoses. Peer support specialists (PSSs) offer an appealing strategy to engage overdose survivors and reduce overdose risk, but randomized controlled trials are needed to formalize peer-led interventions and evaluate their effectiveness. This National Institute on Drug Abuse Clinical Trials Network (CTN) study is a multisite, prospective, pilot randomized (1:1) controlled trial (CTN protocol 0107) that aims to evaluate the effectiveness of an emergency department (ED)-initiated, peer-delivered intervention tailored for opioid overdose survivors (PeerIntervention to Link Overdose survivors toTreatment [PILOT]), compared with treatment as usual (TAU). This study evaluates the effectiveness of the 6-month, PSS-led PILOT intervention compared with TAU on the primary outcome of reducing overdose risk behavior 6 months after enrollment. Adults (aged ≥18 years; N=150) with a recent opioid-related overdose were identified and approached in the ED. Participants were screened and enrolled, either in the ED or within 7 days of ED discharge at research offices or in the community and then asked to complete study visits at months 1, 3, 6 (end of intervention), and 7 (follow-up). Participants were enrolled at 3 study sites in the United States: Greenville, South Carolina; Youngstown, Ohio; and Everett, Washington. Participants randomized to the PILOT intervention received a 6-month, PSS-led intervention tailored to each participant's goals to reduce their overdose risk behavior (eg, overdose harm reduction, housing, medical, and substance use treatment or recovery goals). Participants randomized to TAU received standard-of-care overdose materials, education, and services provided through the participating EDs. This paper describes the study protocol and procedures, explains the design and inclusion and exclusion decisions, and provides details of the peer-led PILOT intervention and supervision of PILOT PSSs. Study enrollment opened in December 2021 and was closed in July 2023. A total of 150 participants across 3 sites were enrolled in the study, meeting the proposed sample size for the trial. Primary and secondary analyses are underway and expected to be published in early 2025. There is an urgent need to better understand the characteristics of overdose survivors presenting to the ED and for rigorous trials evaluating the effectiveness of PSS-led interventions on engaging overdose survivors and reducing overdose risk. Results from this pilot randomized controlled trial will provide a description of the characteristics of overdose survivors presenting to the ED; outline the implementation of PSS services research in ED settings, including PSS implementation of PSS supervision and activity tracking; and inform ED-initiated PSS-led overdose risk reduction interventions and future research to better understand the implementation and efficacy of these interventions. ClinicalTrials.gov NCT05123027; https://clinicaltrials.gov/study/NCT05123027. DERR1-10.2196/60277.

Creating Recovery-Ready Communities.

This article explores the transformative impact of peer support specialists in creating communities where recovery is not only possible but probable. It focuses on the innovative approach of Wilkes Recovery Revolution, Inc.in addressing substance use disorders and the critical integration of harm reduction services to enhance current recovery efforts.

Модель компетенций, в том числе цифровых, специалистов сопровождения образовательных проектов (тьюторов) в системе дополнительного профессионального образования на примере АНО ВО «Университет Иннополис»

The study aims to design, develop, and test a Competency model, including digital competencies, for educational project support specialists (tutors) in the system of additional professional education. The paper examines the organization of tutoring support in the context of additional professional education. The study identifies the stages of tutoring support, determines the specifics of the work of tutors in an additional professional education organization, and highlights the clusters and spheres of competencies for tutors. The scientific novelty lies in the fact that the developed Competency model for the first time includes Digital Competencies and Self Competencies, alongside Hard and Soft Competencies. As a result of the study, the specifics, features, and possibilities of tutoring in additional professional education in the context of digital transformation of education are identified, clusters and spheres of competencies for tutors are highlighted, and the levels of competence mastery are determined. The conducted analysis of tutoring activities allowed for the development of the Competency model, including digital competencies, for educational project support specialists (tutors) in the additional professional education system.

Personalized Support for Participants of the Educational Space in the Resource Model of Supporting Family of an Early Age Child

Introduction.The aim of the work was the theoretical and methodological substantiation, development and implementation of the resource model of early support to the family of a child with disorders in the education system. Methodology. The article presents the results of a long-term empirical study of families raising early aged children with disorders, describes the author’s resource approach to their psychological and pedagogical support. The importance of a personalized approach in the interaction of all participants in the educational space (support specialists, children and their parents) in the triad is emphasized. Results. The resource field of the family, including internal and external resources, is designated. A resource model of early assistance to a child with disabilities and his family is presented. Variable strategies of such a model have been developed and tested depending on the request and resource capabilities of parents: patronage, accompanying, advisory. The events and areas of activity that were part of the personalized support process are listed. Conclusions. The importance of training and advanced training of personnel for the implementation of early support associated with professional theoretical and practical deficiencies is emphasized.

EP290 - Is the Breast Multidisciplinary Meeting Dying?

Abstract Introduction Care by a multidisciplinary team (MDT) is the gold standard for patients with cancer. It is mandated by the National Cancer Plan in 2000. However, the concept has been hampered by the increasing workload, shortage of radiologists and pathologists and changing patterns of working since the Covid-19 pandemic. Method We carried out a prospective study of the Breast MDT in a single unit looking at the workload and attendance between April 2022 and August 2023. Percentage absences of key specialists were recorded and workload was calculated by using an online statistics software. Results There was a total of 72 MDT meetings over the 17 months. Percentage absences were oncology (2.8%), Pathology (2.8%), and radiology (15%). The median number of patients increased from 58 from April to December 2022 to 68 from January to August 2023. Conclusion There are several headwinds affecting the breast MDT including shortage of ancillary support specialists and increasing workload. To remain effective, Breast MDTs would need to evolve to continue providing excellent care to breast cancer patients

A brief descriptive analysis of a pilot study of peer support training and supervision for Texas firefighters

Background Peer support has been shown to reduce the incidence and severity of mental health disorders among firefighters. This pilot project had two aims: (1) to assess training satisfaction and knowledge, self-efficacy, and skills development of Texas firefighters participating in the International Association of Fire Fighters (IAFF) Peer Support Training, and (2) to determine if newly trained peer support specialists would use monthly phone supervision. Methods The study included 14 Texas firefighters who enrolled in the IAFF Peer Support Training. Pre- and post-tests were administered to evaluate training satisfaction, skills development, self-efficacy, and behavioral health knowledge of participants. Use of phone supervision over 6 months following the training was also recorded. Results Overall, participants reported high satisfaction with the training provided. While self-efficacy regarding detection of mental health issues and therapeutic empathy skills significantly improved following the training, participants did not show a significant improvement in knowledge regarding mental health. Attendance of participants to supervision calls was less than expected, although 71% attended at least one supervision call. Conclusions This project was successful in increasing firefighters’ self-efficacy and therapeutic empathy skills, and participants were highly satisfied with the training. However, further research on follow-up supervision of peer support trainees is needed.

Experiences of Certified Peer Support Specialist Providing Formal Peer Support in Mental Health Services: ASystematic Review and Meta-Synthesis.

Peer support specialists (PSSs) in mental healthcare services are individuals recovering from mental health conditions and providing formal peer support to clients with similar conditions. Despite evidence of the benefits of this modality and the increasing demand for it, little is known about the PSSs' experiences in mental healthcare services. This review systematically synthesises available qualitative data on the certified PSSs' experiences in providing formal peer support in mental healthcare services. A search was performed across six electronic databases and one grey literature database for all published and unpublished qualitative studies in English between 2014 and 2022. Mixed-methods studies were included if their qualitative data were extractable. This review included PSSs who provided formal peer support to clients with similar mental health conditions. The included studies were appraised through the Critical Appraisal Skills Program Qualitative checklist, while data extraction was done through a customised tool. Our meta-synthesis revealed an overarching theme on certified PSSs' journey in mental healthcare services, alongside four main themes: (i) emotional impacts of being PSSs, (ii) struggle to justify their roles, (iii) complex roles of PSSs and (iv) sources of support. The review has provided an insightful understanding of the PSSs' roles and needs, for which there is a need to cultivate a supportive working environment. Given the difficulties in adopting the PSSs' roles, as demonstrated by our findings, future research should explore how mental healthcare organisations can address their work-related challenges and cultivate a supportive working environment.

A Guide to Innovation in Physician Associate/Assistant Education: Using Instructional Technology for Improved Engagement.

For physician associate/assistant (PA) educators, the path of least resistance often is to focus our cognitive energies on topics with which we are most comfortable and to deliver content in the style in which we are most accustomed. The consequence of this approach is that many didactic curricula are delivered in a traditional, lecture-based format, which then aligns with how the faculty were taught. Studies show that lecture-based teaching may not be the most effective and that blending teaching modalities can improve knowledge acquisition. In addition, scheduling several classroom lectures week to week can be challenging, especially in a program that uses numerous guest lecturers to deliver the curriculum. One solution to this problem may be through innovative, engaging resources that enable faculty to deliver content asynchronously. Developing and implementing such tools can be challenging to PA faculty because they are often not formally trained in education nor are they up to date on the most current innovations in educational technology. Furthermore, change can be difficult, and it could seem an insurmountable feat to step outside the comfort zone of a traditional lecture. This work describes a collaboration between PA faculty and a University Instructional Support Specialist where the Analysis, Design, Develop, Implement, Evaluate ADDIE model, a widely used system for developing training tools, was used to create an asynchronous lecture for students in the form of an interactive series of modules to replace a traditional classroom lecture.

Scarce perinatal social support for women with OUD: Opportunities for doula services

ProblemPersons with opioid use disorder (OUD) often lack social support, which is associated with improved recovery outcomes. BackgroundIn the last two decades, the rate of opioid use disorder (OUD) among pregnant people has quadrupled. QuestionThis study aimed to describe the prenatal and postpartum social support networks and needs of persons with OUD and assess perceived acceptability of community-based social supports such as doulas. MethodsThis mixed methods study utilized quantitative and qualitative data to understand social support structures and needs. Data was collected through surveys –demographics and social mapping; Adverse Childhood Experiences (ACE) tool; Connor Davidson Resilience 25-item (CDRS-25) scale– and a semi-structured interview. A total of 34 participants from a single urban opioid treatment program consented to participate. FindingsParticipants were on average 34.9 years old, White (64.7%), and unemployed (91.2%). Participants described small perinatal social support networks, which decreased in size from the prenatal to postpartum period. Only half (52.9%) reported adequate prenatal and postpartum social support. Doulas and peer recovery support specialists were perceived as valuable in perinatal health, social support, and recovery domains, with interest in doulas seen particularly amongst those with fewer reported supports. Discussion: The scarcity of prenatal and postpartum social support among persons with OUD is critical to address, given the increased risk of relapse during the postpartum period which has implications for the maternal child dyad. Conclusion: Due to multiple disparities in prenatal and postpartum social support (small networks, inadequate support), doulas represent a trusted community-based support to be integrated into healthcare teams to address maternal morbidity/mortality associated with opioid use.

Substance use approaches among peer support specialists in community mental health early psychosis programs.

Substance use (SU) is common among adolescents and young adults, including those experiencing early psychosis. Coordinated Specialty Care (CSC), a community-based multidisciplinary team-based service model, is increasingly used to support people experiencing first-episode psychosis. In addition to prescribers, clinicians, and vocational specialists, CSC includes peer support specialists who use their own living/lived experience with mental health and treatment to engage and support young people with their recovery goals. Peer support is also foundational in SU recovery. However, little is known about how peer support specialists navigate client SU in CSC. The purpose of this article is to detail CSC peer support SU practice. Informed by community-based participatory research methods, a PhD-level qualitative researcher and a former peer support specialist conducted virtual interviews with 20 CSC peer support specialists. A multidisciplinary team including researchers with lived mental health experiences thematically coded interview transcripts. A spectrum of CSC peer support specialist SU responses emerged: (a) leverages lived SU experiences; (b) does not explore SU with clients; (c) shares client SU information with the CSC team; (d) educates, mentors, and advocates; (e) shares SU consequences and/or challenges substance use; (f) nonjudgmental, nondirective SU exploration; and (g) promotes harm reduction. CSC peer specialist SU practice is influenced by several contextual tensions that must be better understood and addressed in future research to improve peer SU practice. Study findings speak to practice nuances that are helpful for CSC peer support training and supervision. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Quality of participants’ relationships to peer recovery support specialists as a function of perceived similarities: An exploratory analysis

BackgroundA growing evidence base supports the value of peer recovery support specialists (PRSS), particularly due to shared lived experience with participants (recipients of PRSS services). However, little research has examined whether congruence on certain aspects of “peerness” (e.g., demographics, experiences) matters for PRSS-participant relationships. MethodsThrough a pilot study under the NIDA-funded Initiative for Justice and Emerging Adult Populations (JEAP), adults who had recently received PRSS services (N=100) were interviewed. Participants completed a modified version of the Scales for Participant Alliance with Recovery Coach (SPARC), a measure of PRSS-participant relationship quality, and rated themselves as different/similar to their PRSS in several domains using a six-point scale. ResultsParticipants had met with their PRSS for a median of 10 sessions over two months. SPARC scores were unrelated to participant demographics or lived experiences. However, better-quality relationships were reported by participants who believed their PRSS was similar to them in relationships with family (p=.004), spirituality/religion (p=.001), age (p<.001), and overall recovery pathway (p<.001). Total SPARC scores were not significantly correlated with perceived PRSS-participant similarities on gender, race/ethnicity, substances of choice, and history of incarceration or substance use treatment. DiscussionResults from this pilot study suggest that PRSS-participant alignment on past experiences (e.g., prior incarceration, choice of drugs) may not be needed to establish good-quality working relationships. However, similarities on factors related to current life stage (e.g., age, family relationships) and/or recovery process (e.g., overall pathway, spirituality) may be more important. Future research should employ mixed-methods approaches to elucidate these unique findings.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. Two-arm, randomized trial. Two EDs in Rhode Island, USA. ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9years, 68.2% were male and 68.5% were White. Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.