Social workers are the unsung heroes of interdisciplinary geriatric care. ...Well-trained geriatric social workers are the glue that holds together care plans and, without a doubt, contribute positively to health and cost outcomes.
—Mark Lachs, MD, founder and co-chief, Wright Center for Aging, 2003
People are living longer because of advances in public health, health care technology and improved treatment and service delivery. At the same time, new directions in health and mental health care delivery have increasingly complicated the ability of individuals and families to navigate health and social services systems. The number of older adults (i.e., those over 65 years of age) in the United States is expected to grow by 53% in the next 20 years1; in addition, older people are living longer. Life expectancy in the United States continues to extend, from age 47 in 1890 to age 75.7 in 1993.2 Those 85 and older constitute the fastest-growing segment of older Americans; their numbers are expected to triple to 8.8 million by 2030.3 And it is significant to note that a 2001 report from the U.S. Department of Health and Human Services indicates that 77.5% of persons 65 years of age or older are living in urban areas.4
Social Workers and the Urban Elderly
Social workers serve older adults and help family members alongside physicians, nurses, and other health professionals in a variety of urban settings where significant numbers of older adults receive care and treatment. These settings include general and specialized hospitals (including mental hospitals), health care clinics, independent physicians’ practices, rehabilitation centers, geriatric care management agencies, home health care or homemaker service agencies, and managed care agencies—and there are several others.5
Key functions of geriatric social workers include providing a wide range of services, and, as part of the interdisciplinary team, evaluating patients’ cognitive, behavioral, and emotional status and their social support networks. Working directly with geriatric patients and their families, social workers deal with social support factors that create or exacerbate problems in living,5 and, as noted in the epigraph that begins this article, they are “the unsung heroes of interdisciplinary geriatric care.”6 This role is especially important in urban areas because of the greater complexity of those environments.
Need for Educational Changes
Aging, especially as the baby boomers begin to turn 65 by the end of this decade, is an important societal trend that is beginning to emerge as a concern in urban settings. The increasing aging population has led to new issues for social workers to address in working with older patients and families, especially in urban areas, and challenges social work educators to assure that students attain necessary practice competencies. Five important interrelated issues that call for educational changes are
- the greater number of older adults with chronic illnesses;
- changing systems of service delivery;
- increased diversity of the urban aging;
- the growing role of families, broadly defined, in the provision of care; and
- the lack of capacity in geriatric social work.
In the rest of this section, we describe these issues.
Greater Number of Older Adults with Chronic Illnesses
As Americans live longer, they will require more health and social services to address the onset of acute and chronic conditions. Gonyea et al.7 reviewed the current statistics on health conditions of the elderly and earlier this year reported that while older people represent only 13% of the population, they account for 25% of all physician visits and 48% of hospitalizations. Chronic illnesses such as diabetes, heart disease, and cancer are enduring and episodic in nature, and often require monitoring and management for extended periods. Approximately 58% of persons age 70 and older have arthritis, 45% have hypertension, 21% have heart disease, 19% have cancer, and 12% have diabetes. Chronic illness is more complicated for people age 75 and older; this cohort of older adults experiences an average of three chronic health problems at any one time and on average uses more than 4.5 prescription drugs per person at any one time. Mental health issues are also prevalent among older adults. One out of every five persons age 55 and older experiences mental health disorders that are not part of the normal aging process. The three most common disorders are anxiety disorders (e.g., phobias and obsessive-compulsive disorders), severe cognitive disorders (e.g., Alzheimer's disease), and mood disorders (e.g., depression). Furthermore, the suicide rate for persons age 65 and older is higher than for any other age group, and the rate for elders age 85 and older is the highest within the 65-and-older group.7 The growing number of elderly persons with chronic disabling illnesses, and the increasing need for rehabilitative services to support independent functioning, means that patients and families will require more care from social workers—such as psychological and social assistance, as well as care coordination—to address their problems effectively.
Changing Systems of Service Delivery
There are ongoing persistent and dramatic changes in health care delivery stimulated by advances in technology and new approaches to the financing of health care. One major change in the health care delivery system for elders, particularly under managed care, is the creation of more community-based services. Health care delivered in community-based ambulatory settings is provided by a large array of medical specialists. Patients with chronic conditions move in and out of health care systems more rapidly than in the past, and their interactions with all health care professionals are likely to be time limited and episodic.8 The decentralization of expensive diagnostic services to out-of-hospital sites and the use of ambulatory care for procedures that were once done only on an inpatient basis increasingly complicate the ability of elderly patients and their families to decipher the eligibility requirements of different programs; this eligibility information is needed to access and utilize the system of care effectively.8,9 Social workers are often the members of the interdisciplinary team who must accept the challenging task of understanding these complex systems and financing programs, to help older adults and their families use these systems and programs effectively.
Increased Diversity of the Urban Aging Population
The older adult population is increasingly diverse in terms of age, race, ethnicity, gender, and socioeconomic status. By 2050, about one-third of the elderly population will be composed of blacks, Latinos, Asians, and members of other U.S. minority groups.10 In the next 50 years, the proportion of Latino individuals age 65 or older is expected to triple to become an estimated 16% of the population.11 Emotional reactions of the elderly, related to physical and mental health issues, are interrelated with personal and culturally bound perceptions that influence the individual's access to, acceptance of, and utilization of health care services. Social workers and other health care professionals are challenged to be especially aware of the cultural diversity of those they serve as those persons confront serious physical and mental health problems. This is particularly important for elders because there are greater disparities in health care delivery and access to care in later life among diverse groups.12
Increased Family Responsibilities
An individual's aging occurs primarily within a family context. An individual's experience of physical and mental illness profoundly influences and is influenced by his or her reciprocal relationships (or lack of relationships) with family members and other caregivers.13 Changes in longevity and in health care have led to changes in the expectations for family involvement in care of older adults.14,15 Families are increasingly expected to be responsible for home care needs. More than nine million people in the United States are informal caregivers.16 At the same time, there are fewer family members available to provide care because of geographic distances and increased workforce participation.17 In addition, families may not have the psychological or financial resources needed to provide such care, and the potential risk for elder mistreatment associated with increased burden of family care-giving cannot be overlooked. As with other types of family violence, elder abuse is believed to be underreported and underdiagnosed.18 Help is needed to support both patients and family caregivers. Individuals without identifiable families are at particular risk if their improved status and subsequent return to participation in the community depend on this outside support.
Finally, older adults are not only receiving care, they are providing it. Half of all people caring for elderly family members are themselves older that 60 years of age, and there are 2.5 million families in the United States that are maintained by one or more grandparents.19 A growing number of older women have assumed the role of custodial grandparents, due most often to the biological parents’ substance abuse, incarceration, physical disability, or death.
In a health care system that views the older individual as the unit of care, social workers are challenged to identify and address the psychosocial needs of family members and other caregivers, as well as communicate their concerns to other health care professionals. Social workers must also support and be advocates both for families as they try to adequately attend to the health and long-term care needs of their elder kin, and also for those older adults who provide care for family members.
Lack of Capacity in Geriatric Social Work
The need for professionally trained social workers with expertise in aging has been projected to grow as the population ages20; given the situation reviewed above, this is not a surprise. Labor force projections indicate that approximately 60,000 to 70,000 social workers, trained to work with older adults, will be needed within the next 20 years.21 However, this projected need for social workers trained in the needs of the aging is in sharp contrast to trends in social work education. Only 2.3% of social work graduate students currently select aging as a field of practice,21 and only 3% of masters-level students have graduated with a specialization in aging or geriatric social work.15 Yet, as long ago as 1990, 62% of National Association of Social Workers members reported that geriatrics knowledge is required in their professional work22; the percentage is undoubtedly higher now. Indeed, at the precise moment when social workers are becoming more essential to address the complex social, functional, psychological, and environmental service needs of older people and their caregivers—especially in urban areas—social work education is challenged to increase the numbers of social workers who have the knowledge and skills necessary to serve not only the elderly but also other populations in our current health, mental health, and social service systems.
The Major Challenge for Social Work Education
A study conducted at The New York Academy of Medicine (NYAM) identified the aging population as a major recipient of social work services and articulated recent shifts in social work practice needs that result from the trends just described. The study examined what all social work graduates need in order to be prepared to meet the emerging needs of clients and families who use health and mental health services.23 In the rest of this article, we address one major challenge identified in that study: the need for integration of the field practicum experiential knowledge with classroom-based training.
The field practicum is a significant component of social work training; at the graduate level, it includes a minimum of 900 hours of practice in myriad community-based and institutional settings. Practitioners who provide this practicum instruction receive no compensation for carrying out this educational responsibility, but historically have found the mentoring role gratifying and prestigious. However, in the current fiscal environment, field instructors are also expected to carry very heavy caseloads as part of efforts to increase revenues and reduce the cost of health care for both insured and uninsured clients. Thus, previously available time for field instruction in agencies and health care settings that serve the elderly is diminishing, resulting in reduced levels of supervision and field-based formal education for students.
The NYAM study clearly identified the need for increased synergy between field experience and instruction in the classroom. Integration of field realities and classroom instruction, and infusion of aging content throughout the social work curriculum, can work together to provide social work graduates with the new competencies needed to address the demographic and health care trends affecting health care practice.24 Members of the practice community are the first to experience needs of clients and changes in service delivery and, as a result, have much to contribute to the educational content and structure. Medical and nursing schools have already begun to reform their course offerings and training in the field, entering into collaborative agreements with new health care delivery systems, including managed care organizations. Behavioral health educators have lagged behind, continuing to struggle with how best to educate students about new requirements for practice.25
As the NYAM report indicated, preparing future social work practitioners to work with older adults requires both the educational and practicum systems to examine the potential for change:
- There is a need for shared recognition, between field practicum and school, that care for the elderly changes rapidly, requiring new knowledge and practice skills in order for social workers to function effectively. Offering special aging-content may need to be a shared responsibility of the field sites and school.
- The conceptual gaps between classroom education and practice in the field are often exacerbated by physical separation. Focus on integrating, or at least strengthening, the coordination between field and class is an important first step toward greater synergy between practice needs and classroom content.
- Field instructors (preceptors) report that they have not been given the ongoing training they need. What is lacking is a current conceptual framework underpinning practice methods, skills to support adult-style student learning, and clear competency expectations agreed to by school-based instructors and field instructors.
The value placed on field education varies from school to school. Few resources are dedicated to developing field education and to elderly-rich field sites or to promoting the leadership role of field educators. This is an important area in need of change, and the NYAM study identified a number of concrete steps that can be taken to create greater synergy between the classroom and the field:
- Create incentives for practicum sites and for the universities to commit time on activities that link field and classroom.
- Include field instructors in graduate seminars and discussions of course content and sequencing.
- Create financial incentives to allow for release time of field instructors for continuing education.
- Create opportunities for academic faculty to have experience in the field.
A Promising Educational Model
One educational model that may better integrate practicum and classroom teaching has been implemented and tested at six sites across the country. The Practicum Partnership Program (PPP), which has developed and pioneered this model, is a national initiative—one of five programs * funded through the John A. Hartford Foundation's (JAHF) Geriatric Social Work Initiative—to address the shortage of social workers trained in geriatrics. The PPP model was implemented by six university–community partnerships, † with three years of foundation funding for implementation following a one-year planning grant. This national program is coordinated by NYAM staff. The goal of the six PPP partnerships is to increase the number of students trained to work with older adults by developing elderly-rich field practicum sites as a key component of the university–community partnership. The model is designed to strengthen geriatrics fieldwork education by creating greater synergy between fieldwork agencies and graduate schools of social work. By increasing resources dedicated to the field and by promoting field leadership, the field practicum experience is enhanced, thus creating increased interest among students to work with older adults.
The essential components of the PPP partnerships were defined through a consensus process of the principal investigators of the six PPPs. They identified five essential components of the model: (1) a university–community partnership, (2) competency-driven education, (3) an integrated field-rotation internship across multiple programs and diverse aging populations, (4) an expanded role for field instructors, and (5) focused recruitment to geriatric social work supported by student scholarships.
The PPP has concluded its third year and the preliminary results are encouraging: (1) A total of 303 social workers have been successfully trained and plan to work with older adults and their families, (2) students’ knowledge and skills regarding older adults have increased, (3) students gave a very high rating to the experience, (4) students report acquiring knowledge and skills to prepare them to work with older adults, (5) the number of students recruited to service for the aging has increased, and (6) the diversity of the students trained reflected the diversity of the populations of older adults.26
The PPP model has the potential to benefit universities, social work practice sites, and their clients and students. Anecdotal reports and focus groups at the six sites indicate that the universities involved have taken an expanded leadership role and have developed more focused contacts with the community. They also report that the combination of providing scholarships with the innovative programming attracts more student interest in geriatrics. The six sites, from the outset, were required to match grant funds provided by the JAHF. Attention to the importance of perfecting fund-raising skills was required. This early recognition coupled with the success of the community–university partnerships have resulted in each site's ability to institutionalize the programs beyond the funding period.
Recognizing the importance of interdisciplinary practice, field-rotation internships were designed to give students experience working as members of the care team. At one site, over 40 students were assigned to the Geriatric Interdisciplinary Team Training program, where the original intent was for social work students, medical students, and nursing students to form parallel student teams to deliver patient services.27,28 Because scheduling among students from different university programs made this unmanageable,29 students in the PPP work primarily with established interdisciplinary professional and health care teams.
Community agencies also report that having the opportunity to work with academia to shape curricular and field experiences has the effect of increasing the qualified pool of future employees. As agencies collaborate with other community aging agencies on “neutral issues” and in a noncompetitive way, they report increased collaboration that leads to program improvements, better-coordinated services and, ultimately, higher quality of care for older adults and their families. Students also benefit—their educational experiences are strengthened by the careful selection of community agencies that parallel the continuum of services available for older adults, field and classroom experiences are integrated through active collaboration and shared responsibilities, and students increase their knowledge and skills to work with older adults.24 Members of the interdisciplinary health care team benefit because these social workers are skilled at early identification of the needs of older adults, know the importance of supporting the care plan, and can add important information about older adults and their families that will improve the potential for successful treatment and follow-up.
As the need for social work services with the older adult population increases, the challenge confronting social work educators and their communities is to develop and sustain new and innovative models of field education and institutionalize these programs as a permanent and ongoing part of universities and communities. The six PPPs described here are being sustained. Because of the demonstrated success of these innovative programs, the partners continue to be successful in raising support. This is one model used to address the shortage of trained, competent practitioners and to focus educators on the importance of skilled practitioners in aging. Developing these innovative educational models and promoting the infusion of geriatrics content throughout social work curricula in programs at all levels will be essential if we are to be successful in producing a social work labor force qualified to meet the urban challenge of an aging population.
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*The Faculty Scholars Program, the Practicum Partnership Program, the Doctoral Fellows Program, the Faculty Development Institute Program, and the Geriatric Enrichment Program (GeroRich).
†The demonstration sites for these six programs are (1) Hunter College School of Social Work/Brookdale Center on Aging of Hunter College, New York, New York; (2) School of Social Welfare, University at Albany, State University of New York, Albany, New York; (3) University of California, Berkeley, School of Social Welfare, Berkeley, California, with additional sites at San Francisco State University School of Social Work, San Francisco, California, and San Jose State University College of Social Work, San Jose, California; (4) University of Houston Graduate School of Social Work, Houston, Texas; (5) University of Michigan School of Social Work, Ann Harbor, Michigan; and (6) Partners In Care Foundation, Burbank, California, with additional sites at the University of California, Los Angeles, Department of Social Welfare, Los Angeles, California, the University of Southern California School of Social Work, Los Angeles, California, California State University at Long Beach Department of Social Work, Long Beach, California, and California State University at Los Angeles School of Social Work, Los Angeles, California.