Social Work with Older Adults in Health Care Practice Course: Health Care Adelphi University School of Social Work

Acknowledgements The development of this gerontology teaching module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center's Master's Advanced Curriculum (MAC) Project and the John A. Hartford Foundation. Adelphi University Project Team: Judy Fenster (Principal Investigator), Philip Rozario, Patricia Joyce, and Bradley Zodikoff.

Acknowledgments (Continued) Source material for this module was adapted from the course assigned reading:  Diwan, S., & Balaswamy, S. (2006). Social work with older adults in health- care settings. In S. Gehlert & T. Browne (Eds.). Handbook of Health Social Work (pp ). Hoboken, NJ: John Wiley & Sons, Inc.

Growth in Older Adult Population  Growth in Elderly Population 1900 – 4% of U.S. population was age – 13% of U.S. population was age % predicted  Number of people aged 85+ will DOUBLE by 2030

Health and the Aging Population  Co-morbidity: majority of older adults live with one or more chronic conditions  Most frequently occurring conditions among older adults  Hypertension (49.2%)  Arthritis (36.1%)  Heart disease (31.1%)  Cancer (20%)  Diabetes (15%)

Activities of Daily Living  Among community residing older adults 65-74, one in five report difficulties in activities of daily living (ADLs)  Among community residing older adults 85+, over half report difficulties with ADLs

Health Care Utilization of Older Adults  In 2002, hospital discharge rate for adults 65+ was over three times the rate for adults  Older adults have more doctor visits than their younger counterparts  Older Americans spend 12.8% of their total expenditures on health  High out-of-pocket expenditures, particularly for prescription drugs, remains a critical issue for policy and practice

Implications of Demographic Trends  Older adults will continue to comprise a growing proportion of patients in all sectors of the health care system  In many health care settings, social workers will have the opportunity to work with a large and growing proportion of older adult patients.  Health social workers must possess specialized knowledge to work effectively with older adults and their caregivers in health settings

Implications of Demographic Trends  Employment opportunities for social workers with background in health and aging include:  hospitals  primary care practices  home care agencies  assisted-living and senior housing  long term care facilities  hospice

Implications of Demographic Trends  Shortened length of stays in hospitals and in post-acute rehabilitation facilities:  continued emphasis on discharge planning and on the development of community-based care models  critical opportunities for health social workers to participate in the development and provision of community-based health care models  culturally competent models of care needed to address minority older adult populations

Comprehensive Geriatric Assessment (CGA)  Older adults often experience complex problems in multiple domains - physical, social, psychological - resulting in unmet health needs  Many problems experienced by older adults require an assessment beyond the initial diagnostic exam performed by a physician  CGA is performed ideally by a multidisciplinary or interdisciplinary team:  Physicians, nurses, social workers, occupational and physical therapists, nutritionists, pharmacists, audiologists, speech language pathologists, psychologists

 Per American Geriatrics Society, CGA should address (at minimum):  Mobility  Continence  Mental Status  Nutrition  Medications  Personal, Family and Community Resources  Integrated assessment plan: all disciplines involved in care provision participate in CGA  Ideally, older adult patient and family also participate in developing the care plan that emerges from the CGA Comprehensive Geriatric Assessment (CGA)

 CGA is useful in diagnosis and assessing complex problems, but CGA does not guarantee that team recommendations and care plan will be followed  Research has shown that care plan recommendations from CGAs are not consistently followed by either primary care physicians or by patients, at times resulting in poor outcomes  CGAs are not provided routinely to older adults across all settings due to the current structure of the health care system: limited reimbursement, lack of trained geriatricians, lack of interdisciplinary teams Comprehensive Geriatric Assessment (CGA)

Geriatric Evaluation and Management (GEM)  Geriatric evaluation and management (GEM), developed by the Veterans Affairs (VA) system, explicitly connects comprehensive assessment with the management of care. In the GEM approach to inpatient and ambulatory care, the interdisciplinary team conducts the assessment and follows through by implementing the entire care plan  Social work functions in GEM: providing psychosocial counseling to patients and caregivers, referring patients to financial, social, and psychological services, planning for post-hospital discharge when required

Outcomes of GCA and GEM  Positive outcomes associated with both CGA and GEM models include: decreased mortality rates, improvements in physical and cognitive functioning, decreased probability of hospitalization post-follow- up, and increased likelihood of living at home

Biopsychosocial Assessment Domains (see Table 14.1 in Diwan & Balaswamy, 2006)  Physiological well-being and health  Psychological well-being and mental health  Cognitive capacity  Ability to perform ADLs  Social functioning  Physical environment  Assessment of family caregivers  Economic resources  Values and preferences  Spiritual assessment

Physiological Well-Being and Health  Health social workers must understand and assess the relationship between an older adult ’ s health status and how the individual functions and copes with daily life.  Chronic health conditions in later life may decrease psychological well-being, may limit functional ability, and may lower quality of life  Example: arthritis, diabetes  Social workers address how older adults cope with health and illness  Polypharmacy: receiving different prescriptions from different doctors without proper coordinated management of all drug interactions and side effects

Psychological Well-Being and Health  Mental health problems in older adults are frequently under-diagnosed  Many symptoms of mood disorders (e.g., sleeplessness, fatigue) may be misattributed to health problems  Stereotypical attitudes of health providers, families, and older adults themselves re: belief that depression is a normal part of aging

Cognitive Capacity  3% of older adults have Alzheimer’s disease; nearly half of older adults 85+ may have Alzheimer’s disease (AD)  Small declines in memory, selective attention, information processing and problem-solving ability may occur with normal aging, though change in cognitive capacity varies greatly among older adults  Social workers assist persons with AD and their families: provide caregiver support groups, behavior management training, counseling, home care, long term care arrangements

Functional Ability  Activities of Daily Living (ADLs): personal care activities such as bathing, eating, grooming, toileting, getting in and out of bed or chair, urinary and bowel incontinence  Instrumental Activities of Daily Living (IADLs): community-setting activities such as cooking, cleaning, shopping, money management, transportation, telephone, medication administration

Social Functioning  social support: help received  social networks: persons in individual’s circle  social activities: attendance at events and frequency of contacts  social roles: volunteer and employment, grandparent, caregiver

Physical Environment  Assess the fit of the home environment with capabilities of the individual  Lighting, flooring, carpeting, access to bathtub and toilet and sink, access to kitchen, heating and cooling, neighborhood conditions, personal safety  Fall prevention

Assessment of Family and Informal Support  Number and relationship of family helpers  Amount and type of help provided  Strain or burden experienced by caregivers  Positive aspects of caregiving  Definition of who is a family member  Elder abuse assessment

Economic Resources  Income  Pension  Health insurance  Other assets  Critical to determine eligibility for public benefits and programs

Values and Preferences (R.A. Kane, 2000 cited in Diwan & Balaswamy, 2006)  Preferences for end-of-life care  Preferences for post-hospital care  Preferences about housing arrangements  Preferences about how routines of daily life are conducted

Values and Preferences (R.A. Kane, 2000 cited in Diwan & Balaswamy, 2006)  Preferences for religious practices  Preferences re: privacy  Preferences re: safety vs. freedom and the right to take risks  Preferences related to exercising control over one’s own care

Spiritual Assessment  Religious and spiritual activity are known to influence individual’s psychological and social functioning, ability to cope with stress, and quality of life  Religious beliefs may influence community-based and institutional long term care plans/choices for the individual older adult and family

Social Work Practice Skills in Health-Care Settings (see Table 14.2 in Diwan & Balaswamy, 2006)  Screening  Assessment  Communication skills  Interpersonal engagement skills  Clinical skills  Group Facilitation  Mediation/Negotiation  Documentation

Social Work with Older Adults in Health-Care Settings  Primary health care settings  Inpatient hospital settings  Home health-care settings  Nursing home settings

In-Class Case Discussions  Learning Exercise 14.1 in Diwan & Balaswamy (2006), p. 439 “Mr. & Mrs. C”: hospital d/c  Learning Exercise 14.2 in Diwan & Balaswamy (2006), p. 440 “Mr. & Mrs. C”: home health care