Grace Christ, DSW - Columbia University, School of Social Work 

Sadhna Diwan, PhD - San Jose State University, School of Social Work.

Synopsis

Managing chronic illness presents a profound challenge to the social work profession, not only because of the myriad formal and informal services required by the increasing number of chronically ill elders, but also because the caregivers, too, require our support and empowerment. As professionals, social workers experience first-hand the effects of the met and unmet patient needs, which brings with it a responsibility to insure that practice and policy decisions give full recognition to the impact of psychosocial aspects and services that provide total care to chronically ill older adults and their caregivers.

This section describes some of the most recent literature addressing the role of social workers in managing chronic illness care specifically related to conducting biopsychosocial assessments, providing interventions, and in designing and implementing effective models of health services delivery such as care coordination. 

Characteristics of Chronic Illness as They Impact  the Social Work Role 

Three important characteristics of chronic illnesses among older adults need to be considered as they affect the social work role and function.

1. The trajectory for many serious illnesses has changed from an acute terminal course to a much longer chronic period, with episodes of exacerbations and remissions interspersed with extended periods of good functioning.
2. The trajectory of advanced chronic and terminal illnesses has changed from a relatively brief period to a longer period in which both curative and palliative treatments are combined. Research suggests that a long, advanced chronic illness can be highly stressful for both patients and their families.
3. The increase in the total number of older people with advanced chronic and terminal illnesses will require more curative and palliative care being provided in the home, with greater reliance on provision by family members.

 Advances in medical care have changed the illness trajectory in ways that dramatically alter the older adult’s experience of chronic illness. Facilitating and enhancing positive health behaviors at all stages of life as well as effective management of chronic illness is central to the social worker’s role, knowledge, value, and skill base in health care.

The specific role of social workers in health care is to address psychological, behavioral, and social factors by (1) assessing patient and family psychosocial health needs, (2) providing interventions required to address their psychosocial needs and promote their adaptation to illness and disability, and (3) developing and implementing effective models of health services delivery. The following sections provide an overview of issues related to Biopsychosocial Assessment of older persons with chronic conditions; a description of the range of social work interventions relevant to the management of chronic conditions; and a description of the evidence base of one model of service delivery: care coordination for older persons. 

Psychosocial Assessment of Older Adults with Chronic Conditions

Because of the frequency of multiple chronic conditions in older adults, a comprehensive biopsychosocial assessment of needs and resources has become the most important part of service delivery and is the beginning of the intervention process to address the management of chronic conditions among them. The National Association of Social Workers (NASW, 2005) and the American Geriatrics Society (AGS, 2005) recommend a biopsychosocial approach to the assessment of older adults. This section reviews the evidence supporting comprehensive geriatric assessments and, using a biopsychosocial framework, describes the rationale or evidence supporting seven typical domains of psychosocial assessment for social workers in the management of chronic illnesses.

Comprehensive Assessments

• Comprehensive geriatric assessment (CGA) and geriatric evaluation and management (GEMs) programs have shown positive impact on improving or maintaining cognitive and physical function (Urdangarin, 2000).

These programs have shown increased likelihood of patients living at home, decreased likelihood of hospitalization during follow-up, and a reduction in mortality.

• The primary component of CGA and GEM programs is an interdisciplinary team consisting primarily of physicians, nurses, and social workers.

Comprehensive assessment and management programs for the care of older adults in the health care system have been evaluated in the U.S. over the last decade and have shown positive outcomes. For example, the CGA programs without follow-up care and the GEMS programs that incorporate follow-up care and management have reported favorable effects on cognitive and physical functioning, an increased likelihood of living at home, a decreased likelihood of hospitalization during follow-up, and a reduction in mortality (Urdangarin, 2000). The primary component of these programs is an interdisciplinary team consisting mainly of physicians, nurses, and social workers, but also can include specialists from fields, such as occupational and physical therapy, nutrition, pharmacy, audiology, and psychology (Agostini, Baker, & Bogardus, 2001; Wieland & Hirth, 2003).

CGA is more effective when it is targeted to older adults with functional impairments, geriatric syndromes, or high use of hospital and nursing home care. The American Geriatrics Society (AGS) issued the following position statement in 2005: “Comprehensive geriatric assessment has demonstrated usefulness in improving the health status of frail, older patients. Therefore, elements of CGA should be incorporated into the care provided to these elderly individuals” (http://www.americangeriatrics.org). The degree to which those elements have an impact on patients is still being evaluated, but components of CGA have already become an accepted part of geriatric primary care and inpatient consultation services, especially in managed health care programs.

• Comprehensive assessment, however, is not feasible for all older persons; therefore, programs have developed criteria to target individuals most likely to need such assessments.

These criteria include people who have functional impairments in their ability to perform activities of daily living (ADLs); have one or more geriatric syndromes, such as falls, depression, dementia, delirium, or weight loss; or show patterns of high use of hospital or nursing home placements (AGS, 2005).

• With increasing numbers of elders with chronic illness living in the community, screening and assessment has become increasingly important to the provision of continuity of care to identify those with biopsychosocial needs.

Social workers provide health and mental health services to the elderly in a variety of settings across the continuum of care (Berkman, Maramaldi, Breon, & Howe, 2002). They help older people who are active and healthy, as well as those who have poor health, and address the needs of the elderly who live in the community, as well as those hospitalized or in long-term care institutions. Many people are not aware of available social services, and families with serious social problems are not finding the community resources and services they need. Regardless of site, screening and assessment of need for psychosocial help are still the most important part of service delivery and mark the beginning of the intervention process (Berkman et al., 2002).

Process of Conducting Geriatric Assessments

Conducting comprehensive geriatric assessments involves using general social work clinical interviewing skills as well as knowledge of special conditions that may apply to working with specific populations. Geron (2006) and Berkman and colleagues (2002) summarize these skills and processes as: 

o Establishing rapport with the respondent
o Explaining the purpose of assessment
o Using observation and clinical judgment
o Assessing the client’s preferences (Kane & Degenholtz, 1997)
o Knowing human behavior and caregiver dynamics
o Demonstrating cultural competency in addressing and understanding diverse groups of older persons

For a review on the social work processes involved in conducting geriatric assessments and a discussion of special issues in working with older persons, see Geron (2006).

Biopsychosocial Framework for Seven Domains of Assessment

• The conceptual framework that supports comprehensive geriatric assessment, evaluation, and management is a biopsychosocial approach to understanding chronic illness care.
• These domains of assessment along with the rationale or evidence supporting specific areas of assessment are adapted from Diwan & Balaswamy, (2006) and presented in Table 1. 
• To develop a substantive understanding of an older adult’s needs and resources there are seven typical domains of assessment that are important for social workers.

1) Physical wellbeing and health
2) Psychological wellbeing and mental health
3) Cognitive capacity
4) Ability to perform basic ADLs and instrumental activities of daily living (IADLs)
5) Social Functioning
6) Physical environment
7) Assessment of family caregivers

Biopsychosocial Needs and Services for Chronic Illness Care

• Aging populations require diverse biopsychosocial services from both formal and informal sources.

Biopsychosocial services are defined as those psychological, social, and health care services that enable patients, their families, and health care providers to manage the psychological, behavioral and social aspects of illness and its consequences and thus promote better health (Institute of Medicine, 2007). When informal support is insufficient to address a patient’s needs, more formal services are needed.  Table 2  lists the common biopsychosocial health needs of elders with chronic illnesses together with typical community-based services that can be helpful in meeting these needs (Institute of Medicine, 2007). 

• The evidence supporting the effectiveness of various biopsychosocial services is mixed.

In a comprehensive review of the literature on the effectiveness of psychosocial health services for patients with cancer, the Institute of Medicine (2007) notes that there is generally good evidence (through meta analyses of randomized controlled trials) of the effectiveness of psychotherapeutic services, especially cognitive behavioral therapy, that help ameliorate emotional distress that co-occurs with many chronic illnesses. A similar level of evidence exists for behavioral interventions that help individuals manage their symptoms and improve their overall health. However, many interventions, such as the provision of transportation, financial assistance, and medication assistance, have not been examined specifically for effectiveness but are widely accepted as humanitarian services necessary to address basic needs. Many of the services and studies reviewed in this report address not just cancer, but a number of other chronic illnesses as well. 

Coordination as a Model of Health Services Delivery: The Evidence Base

What Is Care Coordination?

• Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services (McDonald et al., 2007).

This overarching construct includes programs of intervention that have been referred to by such terms as disease management, case/care management, multidisciplinary team management, and patient navigation. Social workers are increasingly called on to participate in the development and implementation of these programs because they often incorporate many social work functions and provide major opportunities to improve the quality and effectiveness of patients’ health care, a core social work commitment.

The Need for Care Coordination

• The structure of the health care delivery system in the U.S. is marked by fragmentation, complexity, pervasive deficiencies, and remarkable variation in patient safety and healthcare quality (McDonald et al, 2007).
• Additionally, older patients are more vulnerable to the negative consequences of this fragmentation as they often have complex management regimens for their chronic conditions, strained or reduced family support, and lower health literacy (McDonald et al, 2007).
• The range of psychosocial services described earlier that are useful in improving the health and quality of life of elders are located in various delivery systems in the community, making it difficult for elders and families to access these services.
• The following summary statement characterizes the view of many health professionals about current challenges to the health care system.

Providers and decision makers at the health service delivery level are caring for patients with increasing needs for coordination services in a system that is progressively becoming more fragmented. Physicians report that time constraints are a major barrier to patient care. Coordinating care for patients takes time; time that is typically not reimbursed. As the population ages, as the number of people with multiple chronic medical problems increases, and as patients see more doctors and receive care at a greater number of healthcare settings, the need to coordinate care will continue to increase. This increase in need is occurring in an environment in which cost containment efforts result in decreased access to social support services. While the need for coordination increases, healthcare providers frequently lack the infrastructure and resources to respond to their patient’s needs. (McDonald et al., 2007, p. 32)

These new challenges to the health care system have led to widespread interest in ways to improve the effectiveness and efficiency of medical care for chronic conditions. In the last decade, one intervention has received increasing attention in work with older adults with chronic illnesses: coordination of care.

In 2003, the IOM identified care coordination as among the key strategies to deal with escalating problems in the treatment of chronic conditions (IOM, 2003). In 2007, the Agency for Health Care Research and Quality (AHRQ) issued a review and synthesis of the evidence base for the effectiveness of these approaches to intervention (McDonald et al., 2007). It provided a working definition of care coordination programs, identified the range of components, provided a critique of their effectiveness, and made suggestions for future program development and research.

Models of Care Coordination Programs

• The need for care coordination is critical at several points in the health care delivery system and several models of care coordination programs have been developed to address specific needs.

Table 3 outlines some of the major models of care coordination and, for each model, provides an example of an evidence-supported care coordination program and its specific outcomes. Many of these models of care coordination include social workers in the intervention. Readers are referred to the 2008 Institute of Medicine (IOM) report, the National Registry for Evidence-based Programs (NREPP), the Centers for Disease Control and Prevention (CDC), and Care Transitions.Org for more details on each program.

 Features of Innovation Care Coordination Models

The IOM (2008) committee report did not attempt to rank the models described above or to recommend one model of care over another. In fact, little evidence exists that one might use to rate the relative effectiveness of these different approaches. Typically, evaluations focus on whether a single model proved to be successful rather than identifying which of several models produced the strongest results.

• The committee concluded that no single one of the models described above would be sufficient to meet the needs of all older adults. The health care needs of the older population are diverse, and addressing those needs requires varying models of care to meet their specific requirements.

For example, preventive home visits may be too costly to expand to all older persons, the majority of whom may not even require that level of care. Similarly, caregiver-support programs may not be sufficient for older adults with more intensive needs. The models described above have generally been successful in enrolling mainly those older adults who would best benefit from the particular expanded services.

• After reviewing the evidence on a number of different models of care, the IOM committee concluded that some of the models with the strongest evidence of success in improving care quality, health-related outcomes, or efficiency have common features that may contribute to their success.

Common components of care coordination programs include the following:

1. Essential care tasks (e.g., assess client and develop a care plan)
2. Associated coordination activities (e.g., service arranging, psycho-education)
3. Common features of interventions to support coordination activities (e.g., standardized protocols and      manuals, multidisciplinary teams).

Key aspects of these care coordination interventions are thoroughly integrated in the social work profession’s knowledge, skill, and value base:

1. Patient education
2. Self management
3. Provider education
4. Provider reminders to patients (e.g., regarding appointments, procedures)
5. Audit and feedback
6. Relay of clinical data
7. Organizational change (e.g., adding staff, changing or adding programs)
8. Financial and regulatory incentives (e.g., compensated time for patient education).

Evidence for the Relative Efficacy of Various Care Coordination Programs

• The evidence base for the effectiveness of various care coordination is substantial but not sufficient, and the comparative usefulness of various programs is unknown.

Although there is substantial evidence for the effectiveness of care coordination programs, it currently is not adequate to determine the relative effectiveness of any particular strategy compared to other strategies in improving patient outcomes. Because few intervention studies have clearly identified their component parts, the specific aspects of these interventions that are most effective also are unknown.

The AHRQ’s examination of 75 systematic reviews provides an up-to-date evaluation of the evidence base for care coordination interventions (McDonald et al., 2007). From these reviews, 20 different interventions were identified that had been implemented in multiple settings and that covered 12 clinical populations spread across the settings. Specific components of care coordination were clarified to support the analysis. Overall, this synthesis found that care coordination interventions improved important patient outcomes in different diseases across a broad spectrum of clinical settings.

The AHRQ report (McDonald et al., 2007) included the following overall benefits of care coordination:

• Care coordination strategies for older adults have resulted in reduced numbers of hospital admissions.
• Interventions by multidisciplinary teams have improved continuity of service for severely mentally ill patients, reduced mortality and hospital admissions for heart failure patients, reduced symptoms for terminally ill patients, and reduced mortality and dependency for stroke patients.
• Disease management programs have reduced severity of depression and improved adherence to treatment in patients with mental illness, reduced mortality and hospital admissions in patients with heart failure, and improved glycemic control in patients with diabetes.
• Case management programs have shown reduced rates of rehospitalization among patients with mental health problems, and improved glycemic control among patients with diabetes.  

Despite the above findings, unclear definitions and descriptions of the specific components used in most care coordination interventions make it difficult to determine which specific components were affecting the outcomes. Therefore, continued well-designed research in this area is needed.

References

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