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 field of psychosocial health services is an emerging one with considerable development in research on some diseases, such as cancer, arthritis, and diabetes. However, gaps exist throughout psychosocial health research, especially research that applies to the rapidly increasing elderly population. Thus, more research focused on the development and testing of interventions targeting the elderly is needed. In addition, more effective models of service delivery that address patients with multiple chronic illnesses and strained social networks require development.

The evidence base for current approaches to psychosocial interventions in health care has been presented in the previous three chapters. This chapter summarizes directions for research in the psychosocial health services:

• Address the nomenclature challenge.
• Identify effective psychosocial interventions for understudied elderly populations.
• Determine the interventions’ effectiveness in different populations and scenarios.
• Use more robust research methods.
• Develop, test, and disseminate comprehensive models and approaches devoted to illness and wellness management.

The Nomenclature Challenge

One serious impediment to research on psychosocial health services is the lack of a taxonomy and nomenclature for referring to psychosocial services, most of which are also social work services. A recent Institute of Medicine (IOM) report on psychosocial aspects of cancer made an effort to synthesize multiple definitions into a single definition of psychosocial services: “those psychological and social services that enable patients, their families, and health care providers to optimize biomedical health care and to manage the psychological/behavioral and social aspects of illness and its consequences so as to promote better health” (Institute of Medicine [IOM], 2007). Although this lack affects social work practice, it is an even greater impediment in research that attempts to identify and evaluate evidence regarding the effectiveness of psychosocial health services. For example, the National Library of Medicine does not use the term “psychosocial” as a medical subject heading (MeSH) to index publications. Furthermore, none of the dictionaries developed by the various National Institutes of Health (NIH) include a definition of “psychosocial,” and there is no consistent usage in describing health services that might facilitate the development of such a taxonomy.

Attempts to examine the effectiveness of individual psychosocial services also are confounded by imprecise terminology within and across databases. When researchers use the same word, it may not always refer to the same intervention. Inconsistent and misleading results may be the unfortunate outcome of aggregating data obtained from diverse programs. Although the following terms have no agreed-on definitions, they are commonly used to describe psychosocial services. The label “support group interventions” is used to refer to group psychotherapy, to peer support delivered in a group, to group education, and to varying combinations of these terms. The term “illness self-management programs” maps to “self-care.” And in social work, many disease management programs are referred to as psychoeducational or cognitive-behavioral interventions.

Incorporating a more standardized taxonomy and nomenclature for psychosocial health services in the major health databases has been suggested to the NIH and the Agency for Healthcare Research and Quality (AHRQ) as a possible initiative. It would be essential for social work to be strongly represented in such an initiative because different terms do reflect particular skill sets that are often unique to social work.

Identifying Effective Psychosocial Interventions for Understudied Older Populations

The following are examples of areas or populations for whom new interventions are needed:

• Patients with multiple diseases.
• Approaches to coordination of care, such as transitional care and advanced care planning.
• Comparisons of different approaches such as face-to-face medication counseling versus other educational approaches; home visits versus video conferencing with families.
• Interventions with families and other social networks.
• Reimbursement arrangements that facilitate psychosocial care.

Most interventions are developed for single diseases. Because older adults often live with multiple chronic diseases; for example, 20% of Medicare recipients have five chronic conditions (Partnership for Solutions National Program Office, 2004), studies of screening measures, assessment processes, and interventions are needed to identify realistic ways of dealing with the complexity of functions at illness transitions and advanced stages. Such interventions include, for example, better medication and medical management, as well as addressing mental health risks in the context of these conditions.

Comparisons of different intervention approaches may help to clarify their relative value and the mechanisms of change. Although the evidence suggests that families play an important role in patients’ recovery, they are rarely the subject of or included in psychosocial research on health. Family members are a vital support, but they often differ from the patient in their understanding of the patient’s disease and treatment, may be as distressed as the patient, and, in the case of elderly adults, may be medically and emotionally fragile. For a psychosocial intervention to be broadly used, a reimbursement arrangement that facilitates psychosocial care is necessary. Too often, the costs of an intervention are not calculated or reported.

Effectiveness of Interventions in Different Populations and Scenarios

To establish for whom and under what circumstances interventions are effective, the field needs to integrate the following factors:

• More careful consideration of the nature and extent of support networks because the adequacy of supports may affect the effectiveness of an intervention.
• The impact of socioeconomic status; race, ethnicity, and culture; and of mental health on the effectiveness of interventions.
• More careful analysis of the nature of the sample and of the outcome measures that are used.

Often a specific intervention demonstrates effectiveness, but no evidence is available regarding whether it would generalize to a broader spectrum of patients and to their families and support networks. For example, in the field of cancer, most psychosocial research has focused on one of two groups: patients who have early stage breast cancer and those who have middle- or upper-class incomes.

More Robust Research Methods

Although the effectiveness of services is often measured by using aspects of quality of life, the many different instruments used to measure quality of life make it difficult to compare outcomes across studies. In addition, to address the efficacy of an intervention, such as testing different types of psychotropic drugs for the medically ill, relatively long-term follow-up of study participants is required. However, the duration of patient follow-up called for in many research protocols is inadequate. Furthermore, too few comparison studies, such as outcomes of interventions involving medications administered with and without counseling, have been conducted. Finally, many research designs have lacked adequate scientific rigor. Improvements in research design, such as the following, would increase the strength and generalizability of the evidence generated by research on psychosocial health services:

• Selection and testing of highest quality standardized instruments developed to measure the outcomes of interventions as well as screening and assessment (Lorenz et al., 2004).
• Longer-term follow-up of study participants.
• Studies in which the outcomes of different interventions are compared.
• Improved research designs that require randomized controlled trials and larger patient cohorts obtained by including multiple centers.

Development, Testing, and Dissemination of Comprehensive Models and Approaches

Over the past two decades, research on health services has begun to develop and test alternative models of service delivery that would better serve the needs of the growing elderly population and the challenges posed by chronic illness and co-morbid conditions, often in the context of a strained support network. These models also can be referred to as “care coordination” models. Care coordination is defined as “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. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care” (Owens, 2007, p. 18). The models show promise for shaping a new health system that provides elderly people with comprehensive care (e.g., coordinating services are not normally reimbursed), and efficient and cost-effective care (through coordination of medical and social services and shifting providers’ traditional responsibilities); and that engages older persons as active partners in their own care (IOM, 2008).

Despite the evidence that patient care can be improved by implementing many of these approaches, only recently have such approaches been applied to services for older adults. Dissemination of effective approaches has been limited, in part, because of insufficient funding or reimbursement mechanisms for these types of services. As a consequence, improved dissemination of models shown to be effective as well as continued development of research and demonstration programs that promote the creation of new models of more comprehensive care are a critical future direction in health research.

A recent review of 128 such private- and government-supported comprehensive models that have been developed for and used specifically with frail elderly adults identified features across models that have shown positive outcomes at least in some circumstances (IOM, 2008). The report recommends incorporating some of these features in future research. Important for social work is that most of these recommended features are psychosocial in nature and draw on social work’s knowledge, skill, and value base. Such features include interdisciplinary team care, care management, self-management programs for patients with chronic diseases, preventive home visits, proactive rehabilitation, caregiver education and support, and transitional care. Clearly, this is an important area of research in which social work can make a substantial contribution.

Health Policy and Future Research

The declining state of the American health care system, in particular the fiscal viability of the Medicare program and the fragile condition of community care systems for older adults, must inevitably result in significant reforms of the system over the next decade. Within this inevitability, there is the possibility of significant progress toward greater fiscal sustainability and health care equity—and also great danger of a move toward a system of health care for elderly adults that not only replicates but also expands the disparities in access to high-quality health care that are so prevalent in younger clients. Therefore, future research in health care policy, as it pertains to the older population, should place a high priority on three domains of policy research:

• Monitoring and reduction of disparities in access to high-quality health care, disparities in health outcomes across the life span because disparities in access to quality health care in earlier stages of the life course result in greater disparities in health and economic security as the years advance.
• Monitoring and reduction of the particular disparities in access to high-quality health care that are associated with old age—especially the disparities that arise from various forms of ageism in the health care system.
• Fostering and evaluation of innovative approaches to health care delivery, in particular innovations that integrate health and mental health care as well as acute and long-term care and generate optimal outcomes at lower cost.

Fortunately, all three of these priority areas are interdependent: Gains in one area will foster progress in another.

References

Institute of Medicine. (2007). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: The 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

Lorenz, K., Lynn, J., Morton, S. C., Dy, S., Mularski, R., Shugarman, L., et al. (2004) End of Life Care and Outcomes. Rockville, MD: Agency for Healthcare Research and Quality.

Owens, D. (2007, June). Care coordination. In K. Shojania, K. McDonald, R. Wachter, & D. Owens (Eds.), Closing the quality gap: A critical analysis of quality improvement strategies (Vol. 7, Tech. Rept. 9, AHRQ Publication No. 04[07]-0051-7. ). Rockville, MD: Agency for Healthcare Research and Quality.

Partnership for Solutions National Program Office. 2004. Chronic conditions: Making the case for ongoing care: September 2004 update. Baltimore, MD: Johns Hopkins University.