Topics
Grace Christ, DSW—Columbia University, School of Social Work
Gunnar Almgren, PhD—University of Washington, School of Social Work
Victoria Rizzo, PhD—Columbia University, School of Social Work
Sadhna Diwan, PhD—San Jose State University, School of Social Work.
The goal of the present review of research and curricula is to provide current, empirically based information on social work in health and aging that can be taught in the advanced MSW curriculum on health and health-related topics. In this way we aim to promote greater attention to and inclusion of the older adult population’s health issues in social work health curricula. Preparing such a resource review is no easy task because of the sheer breadth of the topic and the paucity of organizational schemas characterizing the role and function of social work across diseases and sites of care. As presented in this review, such schemas are now gradually evolving. We have adapted two of them as frameworks through which practice can be analyzed and taught across diseases.
The first framework consists of the psychosocial health needs of patients and families or caregivers and the related psychosocial health services that address those needs. The second framework, consisting of approaches to coordination of care, describes and analyzes emerging health delivery systems. Despite the challenges of teaching social work practice in health and aging, the subject is a critical area for inclusion in the social work curricula because older adults are a large proportion of the clients who use health care. Therefore, it is vital for the profession to be knowledgeable and take a leadership role in defining and giving voice to the biopsychosocial needs of these clients and the services in the emerging American health care system that will be required to treat them.
As the U.S. aging population has continued to grow, the health care system has been confronted with a dramatic increase in the numbers of people who have complex chronic medical conditions. More than three-fourths of adults aged 65 years and older are diagnosed with at least one chronic condition that requires ongoing care and management. What is particularly important to social work is that more than 20% of Medicare beneficiaries have five or more chronic conditions (Institute of Medicine [IOM], 2008). This information is important for the profession, because, as the resource reviews will confirm, the special needs of these burdened individuals require services that virtually define social work’s role.
Today’s health care system currently treats both single and multiple chronic conditions but has not yet fully adapted its acute-care-focused models of service delivery to models focused on comprehensive management of these chronic, longer-term conditions. In fact, the American health care system is commonly described as becoming overwhelmed, and as a consequence, care for many is described as fragmented. Unfortunately, studies show that the health care system has also been largely ineffective in reducing health disparities among minority and marginalized groups of all ages (Rust & Cooper, 2007).
While the health care system is becoming overwhelmed, its costs are mushrooming as well. Fee-for-service reimbursements are widely believed to contribute not only to fragmentation of the system of care but also to the rapidly increasing costs. The imminent growth in the number of patients with complex conditions will require further innovations with regard to financing and delivery of care as the need for more effectively coordinated care becomes more pressing. Thus, it is crucially important for social work to use its unique knowledge of individuals, families, and systems to inform the development of currently emerging models of patient care. Students who have acquired that knowledge are prepared to assume leadership roles in the care of older adult patients and their families and in innovative changes in the current system.
Although the health system’s current problems affect people of all ages, the elderly are especially challenged. For example, those who suffer from a range of conditions, such as hypertension and congestive heart failure, are often complex to treat, because each condition requires ongoing care and active management from multiple providers simultaneously. In addition, older patients may suffer from mental health problems that are reactions to functional losses and cognitive impairments. Furthermore, the social support networks of vulnerable elderly people may be weakened and severely strained.
The American health care system is in transition. In a recently published consensus report, the Institute of Medicine (IOM) (2008) listed three principles designed to guide changes in the health care system’s care of older adults:
The idea that biopsychosocial assessments and interventions should be an integral part of health care has always struggled for acceptance and integration within physical disease and treatment-oriented medical systems. None of the National Institutes of Health focuses specifically on psychosocial aspects of medical disease to facilitate the development and integration of this knowledge base. Instead, the research and related psychosocial evidence base have emerged largely within specialized areas of disease, with limited generalizability or attempts to apply information across diseases or sites of care. The problem with an approach that deals exclusively with a single disease is that complex and multiple conditions require more integrated and comprehensive approaches to education and coordination of care than is permitted with single-disease models. Even young people can become overwhelmed by a disease like diabetes, the treatment of which can compromise the treatment of another disease. Unfortunately, it is the elderly population and their elderly supports that are affected most by the limited approaches to integrated and comprehensive coordination of care.
Another problem in developing the knowledge base regarding the biopsychosocial aspects of geriatric health is that elderly people are often excluded from or underrepresented in randomized clinical trails and clinical studies of both medical and psychosocial interventions. For many reasons, those interventions that do demonstrate some effectiveness among older adult populations are not readily disseminated within the larger health care system. Even in the cancer field, only recently has the lack of translation of evidence-based psychosocial interventions into the larger system been highlighted as a major cause of a broad range of medical and quality-of-life problems (IOM, 2007).
Despite these challenges, our search was aided by several new developments in the literature. As mentioned above, reviews of the evidence base for models of disease management and care coordination provided a structure for analyzing new delivery systems in different diseases and populations. Although many studies have reported positive outcomes, no single model has been recommended for broad dissemination as yet. Instead, recent reviews highlight approaches used across studies that have sufficient promise to be included in future studies. Evidence-based approaches for use with elderly adults that show promise strongly emphasize factors that clearly involve the social work role. These factors include interdisciplinary team care, care management, chronic disease self-management programs, preventive home visits, proactive rehabilitation, caregiver education and support, and transitional care (IOM, 2008). These approaches include, for the most part, interventions for which social workers have the expertise, knowledge, skills, and value base. Therefore, we included these models as interventions for teaching in both the chronic illness and palliative care modules (IOM, 2007). The excellent social work texts and handbooks we used and cite in the health, health and aging, and palliative care modules were published between 2000 and 2008 (Berkman, 2006; Berzoff & Silverman, 2006; Gehlert & Browne, 2006; Hooyman & Kiyak, 2008; Kane & Kane, 2000; Almgren, 2007). These publications, in combination with an increasing number of articles on social work health practice and research published in health journals, document the profession’s emerging sophistication and contribution to the creation of much-needed conceptual frameworks and resources for teaching in the field. The recent publication of multiple government-supported evidence reviews and consensus reports on clinical practice addressing psychosocial needs within and across diseases demonstrates the growing importance of this knowledge base. A consensus panel formed by the IOM on the psychosocial care of cancer patients provides a framework for describing the needs regarding psychosocial health and health services that we adapted for use across diseases and conditions in this review (IOM, 2007).
The content is presented in three modules titled “Chronic Illness in Aging,” “Health Promotion,” and “Palliative Care.” Each module addresses current health areas that are critically important to the rapidly expanding elderly population. In each area, the social work role and expertise is central to addressing the broad range of the psychosocial health needs of families, caregivers, and the wider local and national communities. Palliative care addresses the care of patients with advanced illnesses, whereas health promotion can occur before illness is diagnosed and often is required at the community level as well as at the patient and family level.
The topic of the first module is chronic illness because chronic diseases are emerging as the major organizing framework for health care and its financing. Learning about chronic illness brings students and teachers into the 21st century in relation to the vast changes that have occurred in health care over the past 10 years. Because of its size and complexity, the module is divided into six sections:
Section 1: The demographic imperative, the evidence base, and service delivery structures
Section 2: The role of social work in addressing chronic illness.
Section 3: A framework for understanding family care.
Section 4: Cancer as an example of a chronic, life threatening illness.
Section 5: Osteoarthritis as an example of a disease that affects functional capacity and quality of life, but is not life threatening.
Section 6: Current issues regarding health policy and advocacy that are critically important for social workers involved in the health care of chronically ill elderly adults.
In addition to the references cited in the text, the section provides a bibliography of highly recommended texts and articles for student assignment, useful websites, and other resources, such as PowerPoint slide presentations and a case example with an accompanying discussion guide for instructors.
The second module on promotion of health emphasizes the major challenge of health care in the 21st century—the shift in focus from illness to wellness, from treatment to health promotion, from chronic illness to compression of morbidity. This change requires the established health care system not only to treat illness but also to emphasize healthy living in old age. It challenges health care providers to shift from focusing exclusively on the treatment of individual diseases to focusing on care that encompasses promotion of health as well as prevention of disease—even in the face of multiple chronic conditions.
Because effective interventions promoting health are an inherent part of social work’s person-in-environment paradigm, social workers should assume a leading role in the design and delivery of health promotion programs. This role is not a new one for the profession. It is a traditional role that began during the 1890s in Chicago with the pioneering work of social workers at Hull House, who created effective maternal and child health programs under the auspices of the federal Children’s Bureau well in advance of the medical profession’s development of similar prevention and health promotion activities as a domain of medical practice. The health promotion module is divided into three sections:
Section 1: The demographic imperative for infusing promotion of health at all levels of intervention with elderly adults.
Section 2: Current conceptual frameworks for health promotion that are integrative with social work’s systems concepts.
Section 3: Examples of social work interventions that promote adequate nutrition and activity among the elderly at both the individual and community levels.
The third module, “Palliative Care with Older Adults,” addresses the reality that although a natural death from functional decline of body organs is the goal, many elderly people die after a lengthy period of advanced illness, during which the aim of treatment is to maximize quality of life. Transcending the illness-based paradigm of diagnosis and treatment is the most profound challenge that advanced disease poses for health care providers. Social work’s broad psychosocial perspective accomplishes this transcendence and defines a social work philosophy and approach that is multilevel and holistic and that encompasses the patient, the family, and their larger environment.
The palliative care module follows an outline similar to the outline for the chronic illness module but is more circumscribed. It includes three sections:
Section 1: The demographic imperative, specific challenges and trajectories of advanced illness among older adults, service delivery structures including similarities and differences between hospice and palliative care.
Section 2: The social work role in addressing advanced illness in older adults, assessment of needs and preferences for palliative care in the U.S. population, current practice with patients and families, intervention models and evidence based approaches.
Section 3: Health policy issues that are critically important for social workers in palliative care.
To assemble the information for the three curriculum resource reviews, we used literature databases, Internet searches, the IOM, and evidence reviews produced through the Evidence-Based Practice Centers of the Agency for Healthcare Research and Quality (AHRQ). In addition, we evaluated other governmental and organizational reviews of particular areas of health; and textbooks and handbooks on health, health and aging, and palliative care authored by social workers. We included meta-analyses and literature reviews focused on empirical studies. The consensus reports and evidence reviews we used were published by the IOM and AHRQ between 2001 and 2008. The IOM reports included workshops and consensus panel reports on aging, cancer and aging, workforce issues in aging, cancer survivors, quality of health care, and psychosocial care of patients with cancer. The AHRQ reports included reviews in care coordination and other reviews produced in the “Closing the Quality Gap” series. The social work textbooks and handbooks were published between 2006 and 2008, which reflects a growing sophistication and integration of social work expertise and knowledge in health care. These books contain excellent bibliographies and reviews of research and clinical studies on a broad range of topics related to disease, service-delivery systems, and the social work role. Using multiple sources helped us to cope with the size and fragmentation of the knowledge base. The degree of agreement or disagreement across resources was used to assure adequate comprehension and depth of the literature within the three modules.
Our searches were conducted within categories relevant to the topics in the modules. The search included several hundred categories related to aging, elderly, older adults, geriatrics, and so on in relation to specific illnesses, assessments, interventions, and service models (conducted on PubMed, PsychInfo, CINAHL, Medline, Abstracts in Social Gerontology, Social Work Abstracts, and Google Scholar). Although we initially restricted our searches to the years between 1997 and 2007, we later searched for updates through August 2008.
Almgren, G. (2007). Health care politics, policy, and services: A social justice analysis. New York: Springer Publishing.
Berkman, B. (2006). Handbook on social work in health and aging. New York: Oxford University Press.
Berzoff, J., & Silverman, P. (2006). Living with dying. New York: Columbia University Press.
Gehlert, S., & Browne, T. A. (Eds.). (2006). Handbook of health social work. New York: John Wiley & Sons, Inc.
Hooyman, N. R., & Kiyak, A. H. (Eds.). (2008). Social gerontology: A multidisciplinary perspective. Boston: Allyn & Bacon.
Institute of Medicine. (2007). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: National Academies Press. Retrieved August 8, 2008, from: http://www.nap.edu/catalog/11993.html
Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press. Retrieved August 8, 2008, from: http://www.iom.edu/?ID=53452
Kane, R. L., & Kane, R. A. (2000). Assessing older persons: Measures, meaning, and practical applications. New York: Oxford University Press.
Rust, G., & Cooper, L. A. (2007). How can practice based research contribute to the elimination of health disparities, Journal of the American Board of Family Medicine, 20(2), 105-114.