Volume 4, Number 4 - February 2009
In This Issue: Healthcare
Healthcare affects everyone, but older adults bear the brunt of a difficult-to-navigate system while often facing their own declining health. This issue of Aging Times addresses these challenges from the perspectives of public policy and caregiving.
Health Care: Implications for Policy and Practice
Rob Hudson, Boston University
The keynote presenter at the 2008 CSWE APM, Hudson recaps his electrifying talk on reforming healthcare policy and motivating the social work profession to seize the political moment.
Policy Dilemmas in Aging and Chronic Illness
Gunnar Almgren, University of Washington
Almgren details Medicare’s imminent failures and discusses the restructuring challenges confronting President Obama and the 111th Congress.
Elders and Their Caregivers: A Student’s Reflections
Thao Phan, MSW Student, University of Washington
An MSW student discusses her experiences with minority elders and veterans and discovers the difficulties their caregivers face.
Resources on Older Adults and Health Care
MAC Project Resource Reviews on Healthcare
Recommended References: Ascertaining Health Status/Assessing Physical Functioning of Older Clients (MS Word)
Case Study: Hospice Social Work (MS Word)
Case Study: Selecting a Medicare Prescription Drug Plan (MS Word)
List of Suggested Readings: Health and Long-Term Care Policy (MS Word)
Gero-Ed Center Updates
Specialized Gero Funding Applications Due in April
Don’t forget to apply for this new opportunity to develop, implement, and institutionalize a minor, area of emphasis, certificate, specialization, or concentration in gerontological social work.
2009 APM Call for Proposals Now Open
Proposals for the Gero-Ed Track are due by Sunday, March 29 at 11:59 pm.
Events Commemorate GSWI 10th Anniversary
Events at two upcoming conferences will celebrate a new book edited by Nancy Hooyman, co-Principal Investigator of the Gero-Ed Center.
Master's Advanced Curriculum (MAC) Project Celebrates Second Successful Year
The MAC Project looks back on the Gero Innovations Grant, the Resource Reviews, and successful meetings and presentations.
Join AGE-SW or Renew Your AGE-SW Membership
There's still time, says Tracy Schroepfer, AGE-SW Membership Coordinator.
Health Care: Implications for Policy and Practice
By Rob Hudson
A new era for aging and health policy presents both challenges and opportunities for social work practice. The Obama administration will pursue an aggressive health policy agenda, focusing primarily on access and cost tied to acute care needs. While social work can certainly promote and celebrate such initiatives, its more important role is in the arena of community-based long-term care. Millions of care recipients and providers live in a pubic policy netherworld, one principally associated with Medicaid. To avoid an oversight in emerging health care and economic policy initiatives, I propose the following five-point strategy to expand the agenda to include home and community-based services in long-term care (HCBS).
1. Policymakers must address the structural lag in HCBS-related policies, such as Medicaid, the Older Americans Act, and Medicare. Medicaid must continue to move toward supporting community-based alternatives, the aging network must determine how singularly and aggressively to participate in the HCBS arena, and Medicare must move beyond its acute care emphasis. Long-term care must shift from a residual to an institutional element of these policies.
2. Social work must resist continued “risk-shifting” from the public to private and formal to informal sectors. In this vein, long-term care must be recognized as a critical contemporary issue to be directly addressed through a social insurance mechanism. Difficult as it will be, we must extend the relative successes of Medicare and Social Security in addressing age-related income and acute health care needs to long-term care. Such a move augments traditional family efforts and responsibility with an institutionalized and non-means-tested public presence.
3. Although promising “cash and counseling” and consumer-choice innovations serves to promote client autonomy, social work must help assure the protection of other elements of clients’ interests. At the delivery level, these interests center on concerns of fraud, abuse, and services availability; at the policy-level, they focus on not allowing the appearance of consumer choice to be a stalking horse for further risk-shifting onto families. For example, defined-contribution-type Long Term Care/HCBS vouchers can risk the public sector fading away in the wake of cash or voucher delivery. These initiatives also represent a profound paradigm shift in the financing and delivery of in-kind benefits in a manner not previously seen. Social work should take a lead in the design of this new paradigm, where concerns of autonomy, security, accountability, and flexibility are being fundamentally rethought.
4. Social work can play a critical role in mobilizing caregivers to be an active constituency in long-term care policy reform. The 34 million caregivers to frail older adultsrepresent a latent social movement of immense potential. Most caregivers, for understandable reasons, have not mobilized politically and lack awareness of legislative possibilities to change the conditions they face. Social work is better prepared than any other profession to move these individuals and their concerns onto the political agenda.
5. The social work profession must apprise and seize the political moment. The magnitude of potential change represented by the simultaneous appearance of a new administration and an economic crisis may be a once in a lifetime occurrence. This unprecedented reshuffling of the political deck means that alternatives that were pipe dreams a year ago might now be viable policy options. As an example of major policy breakthroughs occurring at the most unlikely times and places, mental health parity provisions were enacted as part of the $700 billion financial bailout in December. Even in these circumstances, major new long-term care initiatives will be a tough sell. But if not now, when?
At the very least, gerontological social work must ensure that age-related issues are not seen as already having had their day. Economically stressed agencies and caregivers should work to be part of a national stimulus package in which caregiving is defined as both an economic and health-related contribution to national well-being.
Rob Hudson is professor and chair, Department of Social Welfare Policy, Boston University School of Social Work. He has written widely on aging policy and politics, and his book The New Politics of Old Age Policy is used widely in social work and allied programs around the country. He also serves as editor of The Public Policy and Aging Report and chairs the John A. Heinz Dissertation Award Committee for the National Academy of Social Insurance.
Policy Dilemmas in Aging and Chronic Illness
By Gunnar Almgren
By the year 2020, nearly 160 million Americans will have one or more chronic conditions, which will account for 80% of health care expenditures (Anderson and Knickman 2001). Because of the relationship between number of years lived and the accumulation of chronic health conditions, older adults are disproportionately represented in health care utilization for chronic and disabling conditions and the resultant health care expenditures. With the aging of the U.S. population, expenditures have escalated to the point where the fiscal sustainability of the public programs essential to the care of persons with chronic illness and disability are in jeopardy. The Obama administration now confronts projections that Medicare’s Hospital Insurance Trust Fund will be exhausted by the year 2019 (Social Security and Medicare Boards of Trustees 2008).
This policy dilemma is often mischaracterized as an entitlement crisis—there are simply too many older adults becoming eligible for Medicare relative to its fiscal resources. The reality, however, is far more complex, and has as much to do with the organization of the U.S. health care system and the culture of American medicine as with social and biological processes of aging and the age distribution of the national population. Two distinct policy challenges are embedded in the Medicare’s fiscal sustainability. One challenge is directly tied to the dramatic increase in Medicare enrollments as an ever larger share of the Baby Boom generation crosses the Medicare age eligibility threshold of 65. The financial structure of the Medicare program, from its very beginning, has failed to adequately account for the growth of enrollments tied to population aging (CRS 2008).
The other very different policy challenge has to do with Medicare’s antiquated benefit structure—one designed nearly 50 years ago to insure against expenditures for the treatment of acute illness within a system of unfettered medical free enterprise. This made sense in the demographic context of 50 years ago, when acute and infectious diseases were the dominant threats to health and reasons for seeking medical care. However, the largest share of Medicare expenditures today is for the management of chronic diseases. Despite this fact, the Medicare program’s benefit structure and criteria for provider payment remain enmeshed in the acute care paradigm of 1965—with all of its embedded inefficiencies and inflationary incentives.
The Obama administration and Congress now confront three basic policy choices: 1) dramatically reduce Medicare benefits and provider payments, 2) raise Medicare payroll taxes, or 3) reform the Medicare program’s benefit and payment structures in ways that promote more effective and cost-efficient approaches to the care and management of chronic disease. For a variety of reasons, the latter choice is far preferable, but how realistic is it?
Clinically, it is quite realistic to reform Medicare, particularly if one considers the striking regional variations in Medicare’s average lifetime expenditures per enrollee to achieve identical health outcomes. In Miami, these expenditures are $50,000 more per typical enrollee than in Minneapolis (Wennberg 2002). The question is not one of clinical efficacy, but one of political choice. Shall we bail out the Medicare Trust fund with dollars that might be allocated to education, health care for children, or roads and bridges? Shall we instead shift a significantly larger share of health care expenditures to the Medicare program’s beneficiaries? Or shall we shape Medicare’s benefit and provider payment structures in ways that accommodate a chronic disease paradigm?
Gunnar Almgren holds a PhD in Sociology (Demography/Medical Sociology) from the University of Washington, an M.S.W. from Portland State University, and an M.A. from Pacific Lutheran University. He is an associate professor and director of the PhD Program in Social Welfare at the University of Washington. His primary research and teaching interests are in social stratification, health, and health care policy.
References
Anderson, G., & Knickman, J. R. (2001). Changing the chronic care system to meet people's needs. Health Affairs, 20(6), 146-160.
Social Security and Medicare Boards of Trustees. (2008). Status of the Social Security and Medicare Programs: A Summary of the 2007 Annual Reports. Retrieved February 11, 2008, from http://www.socialsecurity.gov/OACT/TRSUM/trsummary.html
Congressional Research Service. Medicare Part A: History of Trust Fund Insolvency Projections. Report Order Code RS20946. Library of Congress, Washington D.C. March 28, 2008
Wennberg. 2002. Geography and the debate over Medicare reform. Health Affairs. Suppl Web Exclusives: W96-114.
Elders and Their Caregivers: A Student’s Reflections
By Thao Phan
I began my journey in working with older adults and their health care at Asian Counseling and Referral Services in Seattle. In the Aging and Adult Services department, I saw many Vietnamese elders in the community who needed in-home care services and case management because their families were too busy and/or did not speak English to advocate for them through the complex systems of hospitals, nursing homes, Medicare, and Medicaid. This showed me that there was a great need for social workers to work with elders, especially those who did not speak English.
It also made me aware that for my professional development, I needed to learn about different settings and environments, such as nursing homes, assisted living facilities, and hospitals serving elders with complex health care needs. This would allow me to see the full picture of what elders may experience and the kinds of advocacy needed when navigating through health care systems. I next sought out the opportunity to acquire the experience in working with a new population in the Department of Veterans Affairs (VA).
My advanced practicum placement is currently at the VA Puget Sound Health Care Geriatric Research Education and Clinical Center (GRECC). The GRECC seeks to integrate psychiatry, primary care, and research to provide comprehensive care for older veterans. I work with patients who are using primary care and/or psychiatry. The veterans benefit from doctors and psychiatrists who are knowledgeable in geriatrics and who work together for the patient’s care.
At the VA, I have learned about not only the inner workings of a hospital and the latest research on diseases and other issues related to aging, but also the connection between policy and patient services and care. For example, because of ongoing budgetary issues, the primary care clinic is being phased out, which will negatively affect both veterans and their caregivers. I believe that policy makers in the future will likely recognize the importance of having this primary care clinic and may want to re-open it. I have also benefited at the VA from the different ways of communicating and connecting with patients who are not similar to me.
One of the things that I often notice is how caregivers of veterans do not identify themselves as caregivers. They focus so much on the veterans that they put themselves second. For example, when I call caregivers to ask how they are doing, the conversation shifts back to the care and well-being of the veterans. I believe this is an unbalanced partnership.
Social workers, care providers, and caregivers need to recognize that caregivers themselves need care. Without caregivers, many care plans for elders would easily unravel. I hope that in the future, I will have a chance to be involved in a program that recognizes the importance not only of elders, but also of their informal caregivers - family, friends, neighbors—who are central to their care and that will conduct comprehensive assessments of the family unit instead of only the individual.
Thao Phan is a current MSW Advance Standing student at the University of Washington School of Social Work. She is in the direct practice concentration specializing in gerontology. She is completing her practicum placement at the VA Puget Sound Health Care in Seattle, WA.
Specialized Gero Funding Applications Due in April
The Friday, April 10, 2009 deadline to apply for the Specialized Gerontology Program, the newest funding opportunity from the CSWE Gero-Ed Center, is only two months away!
The Specialized Gero Program, a 2-year program starting July 1 2009, provides funding to BSW, MSW, and BSW/MSW programs to develop, implement, and institutionalize a minor, area of emphasis, certificate, specialization, or concentration in gerontological social work. Applications will be accepted from CSWE-accredited BSW, MSW, and combined BSW/MSW programs that have gero content currently infused in foundation courses.
For program and application details, download the Request for Proposals (RFP) and Frequently Asked Questions (FAQ) from the Specialized Gero Program Web Page.
2009 APM Call for Proposals Now Open
The CSWE Gero-Ed Center encourages you to submit your aging-related proposal to the 2009 CSWE Annual Program Meeting (APM) Gero-Ed Track. Proposals are due by Sunday, March 29 at 11:59 pm, EST. Only online proposals will be accepted. To have your proposal considered for the Gero-Ed Track, select the “Gero-Ed (Aging and Gerontology) Track” option. We recommend that you review the updated Gero-Ed Track description when considering your proposal.
The 55th APM will be held in San Antonio, TX, November 6-9. The Gero-Ed Center will continue its tradition of hosting several special sessions and exciting events, including the popular Film Festival. For more information on the Gero-Ed Track, visit the APM Gero-Ed Track Page.
Events Commemorate GSWI 10th Anniversary
Since 1998, the John A. Hartford Foundation has invested $64.5 million in the Geriatric Social Work Initiative (GSWI). CSWE Press is publishing Transforming Social Work Education: The First Decade of the Hartford Geriatric Social Work Initiative, a book edited by Nancy Hooyman in recognition of the Hartford Foundation's 10 year commitment to gerontological social work through the GSWI.
The book will be released at The National Association of Deans and Directors of Schools of Social Work (NADD) Spring Conference with a luncheon sponsored by the Hartford Foundation on Monday, March 16 from 12:00 pm -1:30 pm.
GSWI will further celebrate the book release at The Association of Baccalaureate Social Work Program Directors (BPD) Annual Conference during the Workshop and Special Session for the Mit Joyner Gerontology Award on Saturday, March 21 from 3:00 pm – 4:15 pm.
For more information on this milestone, read History of Hartford GSWI at CSWE, published in the June 2008 issue of Aging Times.
Master's Advanced Curriculum (MAC) Project Celebrates Second Successful Year
The MAC Project achieved remarkable goals in its second year, which ended December 31, 2008. Through two initiatives, the Gero Innovations Grant (GIG) and the Resource Reviews, social work educators and researchers across the country have worked successfully to enhance the advanced curriculum areas of mental health, substance use, and health with aging-related competencies.
The 14 GIG grantees continued to create and implement innovative curricular resources for the three MAC Project specialty areas, which will be widely disseminated in the future. A paper session at the 2008 CSWE Annual Program Meeting (APM) showcased a selection of the innovations including videos, case studies, and other pedagogical resources that will be posted on the MAC Project Web site.
At the same time, national experts in health, mental health and substance use joined forces to review the available resources in the three MAC specialty areas. The results of their work are available as Web-based Resource Reviews that include evidence-based curricular resources such as teaching modules, case studies, lecture notes, PowerPoint presentations, and annotations of teaching videos and online curricula. The MAC Project also sponsored a Faculty Development Institute at the CSWE APM with SAMHSA, showcasing these resources and demonstrating how faculty can include the evidence-supported content in their courses.
Now in its third and final year, MAC Project grantees, faculty, and staff look forward to disseminating and publicizing their work on advanced content areas and gerontological competencies. More resources will be launched at the 2009 APM!
Join AGE-SW or Renew Your AGE-SW Membership
There is still time to renew your The Association for Gerontology in Social Work (AGE-SW) membership for 2009 or sign up as a new member and receive the new membership benefit: 8 issues of the Journal of Gerontological Social Work (JGSW). In addition, you will also have access to the new “members only” section of the AGE-SW Web site, which contains a membership database, information on aging-related funding sources, and a job site where programs seeking faculty with aging relate backgrounds can post their job announcements for viewing by doctoral students on the job market.
Along with these exciting new benefits, two changes have been made concerning membership renewals. AGE-SW’s membership cycle will now be January through December and dues have increased slightly: $65 for new and renewing members, $35 for renewing student members, and $25 for new student members.
To renew your AGE-SW membership, please download and send in the membership form. For questions about membership, E-mail Tracy Schroepfer, Membership Coordinator for AGE-SW, or call her at +1.608.263.3837.