Abstract and Keywords
Despite high levels of functioning among older adults, chronic health conditions lead to impairment and the need for help. Family members provide most of the assistance; yet formal services such as in-home personal and homemaker services, congregate and home-delivered meals, adult day services, employment and educational services, transportation, nursing homes, assisted and supportive living facilities, legal and financial services, and case management are available. Even with the growing number and type of services, unequal access and uneven quality persist. In these settings, social workers develop and administer programs, provide clinical care, offer case management and discharge planning, and contribute to policy development.
The population is aging, both in the United States and across the world. Demographers estimate that by the year 2030, 19% of the U.S. population will be over the age of 65 (Administration of Aging, 2011); and those adults over the age of 85 constitute the fastest growing subgroup. Despite the fact that older adults often experience multiple chronic health condition, most older adults are functionally independent. Overall, trends are toward not only longer, but more functional lives (Crimmins, Hayward, Hagedorn, Saito & Brouard, 2009).
Despite high levels of health and functioning in the older population, chronic health conditions lead to functional impairment and the need for assistance. The number of older adults who need assistance with activities of daily living varies by specific age cohort. The rate of limitations in activitis among persons 85 and older is much higher than for prsons age 65-74. For example, 47% of older adults age 85 and older need assistance with walking while only 9% of persons age 65-74 have limitations with walking (Administration of Aging, 2011). Johnson and Wiener (2006) report that about one-quarter of older Americans living outside of nursing homes have a disability that limits functioning including help bathing, dressing, using the toilet, taking medicines, and managing money.
By far, family members provide most assistance to older adults with functional impairments. Most older adults (66%) receive help from informal caregivers without any formal assistance, while 9% get only formal help, and 25% are supported by both informal and formal assistance (Federal Interagency Forum on Aging, 2012). The growing need for caregivers follows the growth of the over-85-year-olds in our population. It is often estimated that between 70% and 80% of all assistance provided to older adults is provided by family members. The care provided by family and friends (referred to as informal care as opposed to formal care provided by paid professionals and paraprofessionals) has been costed at $450 billion a year (AARP, 2011). Females, largely wives and daughters, provide the bulk of the care. The average caregiver is a 49 year old woman, employed outside the home, raising her own children, and providing unpaid care to her mother for nearly 5 years (National Alliance for Caregiving & AARP, 2009). One out of five U.S. households provide care to someone age 50 or older, and 43% of caregivers are 50 years and older (National Alliance for Caregiving, 2005).
Caregiving activities range from hands-on personal care, taking care of household chores, monitoring, managing any paid help, and providing companionship/emotional support. It is well documented that caregiving can result in compromised work lives as well as declining health and mental health. Positive outcomes in terms of satisfaction with doing the job and closer relationships are also documented. Trends that relate to informal caregiving include the evolution of women's role in the workplace, increasing ethnic diversity among the older population, the increase in male caregivers, and club-sandwiched generations where women raising children have both parents and grandparents alive (Crewe & Chipungu, 2006).
Nonprofit and public agencies offer a variety of support and educational programs with little or no charge to caregivers. Programs include online and in-class courses, psychoeducational support groups, telephone helplines, Internet chat rooms, and peer-to-peer counseling programs to the caregivers. Professionals and volunteers staff these programs; and monies come from private funds, some state revenues, and federal grants made through the Older Americans Act.
Most research documents small to moderate statistically significant effects (see findings from the REACH study, Gitlin et al., 2003). The size of the effects vary by intervention and outcome assessed. Biegel (2006) finds that group interventions seem to be less effective than individual in reducing burden; and that caregivers of persons with dementia experience less effect than those for nondemented persons. In general, evidence indicates that mixed interventions, longer interventions, and those targeted to specific groups of caregivers hold the most promise.
The Growth of Formal Services
The use of formal services has increased since 1998, corresponding to caregiver patterns in the workforce and the growth in formal services. Previously, few alternatives to informal care existed. Hospitals and nursing homes constituted the formal care system, with nursing home care being the only source for long-term care. Now, a range of in-home and community-based services can be purchased with private money, and some publicly funded services are offered to functionally impaired, lower-income older adults. These services are often called the continuum of care, reflecting their intended response to a continuum of need.
In the United States, these services developed under various federal initiatives. Although Social Security does not pay for services directly, this income source is critical to the financial well-being of the older population, and as such, enables some to purchase services privately out of their own pockets. In 1965, federal legislation established three programs that undergird these services, namely, Medicare, Medicaid, and the Older Americans Act. Medicare, the health insurance program, covers acute medical services, both inpatient and outpatient, short-term rehabilitation in institutions or at home, prescription medication coverage and hospice care for the terminal stage of illnesses. Medicare does not cover the long-term care services that are more often needed when chronic conditions lead to disability. With only 12% of total patient days in skilled nursing facilities being covered by Medicare (Medicare Payment Advisory Commission, 2011), these funds are only available for short-term rehabilitative services. Medicaid offers health insurance for low-income people, and for older adults, it supplements Medicare to cover premiums for Part B, copays for Part A, and medicines for Part D. Medicaid will also cover long-term care. In fact, 48% of nursing home costs are covered by Medicaid (Federal Interagency Forum on Aging, 2012). A smaller part of the Medicaid budget covers long-term care in the community, including in-home supportive services, day care, and some forms of residential care.
In 1965, the Older Americans Act (OAA) created the Administration on Aging (AoA) and provided grants to states to plan, develop, and provide services to older adults. This establishes supportive services, senior centers, congregate and home-delivered meals, training and research, supportive employment, protective services, and grants for older Native Americans. Monies provided through the act flow through State Units on Aging to Area Agencies on Aging, which are mandated to assess, plan, organize, and deliver services to meet local needs. Services cannot be allocated by income, but are targeted to those in greatest social and economic need. These administrative structures and the organizations providing services funded in part by OAA monies are called the “aging network,” consisting of 56 State Units on Aging, 629 Area Agencies on Aging, 244 Tribal and Native organizations, and 2 organizations that serve Native Hawaiians (Administration of Aging, 2010). AoA supports the Eldercare Locator, a national toll-free service to help callers find local resources (1-800-677-1116) (http://www.eldeldercare.gov/EldercareNET/Public/Index.asp).
The aging network undergoes ongoing changes to incorporate new initiatives. For example, the National Family Caregiver Support Program was funded in 2000 to focus on caregivers, not older adults. Money is authorized to provide education, respite, and counseling for caregivers and custodial grandparents. The 2006 OAA reauthorization (Older Americans Act Amendments of 2006, H. R. 6197) calls for the recognition and support of the civic engagement of older adults. It requests the development of a comprehensive strategy for utilizing older adults to address community needs and to fund programs that expand critical volunteer services. Despite renewal efforts, the aging network is criticized for being disconnected from many older adults and weak advocates in regard to advancing long term care services and supports in the community (Applebaum, 2012; Sanderson, 2012). Further, it is faulted by some for being a nonnetwork heavily relying on an agency rather than a consumer directed model.
Types of Formal Services in the Continuum of Care
Both health and social service agencies offer in-home services to maintain people in the least restrictive environment. Home health care is medically oriented and requires a physician's order for nursing, therapies, social work, or personal care services provided under nurse supervision. Home health care is usually ordered to transition a patient out of the hospital and has an average duration of 2–3 months. Homemaker and personal care services are usually provided for longer periods of time and are supportive rather than medically oriented. Chore workers provide assistance with instrumental activities of daily living (that is, meal preparation, housekeeping). Personal-care aides assist with activities of daily living, such as grooming, bathing, transfers, and ambulation. Funding sources include Medicare, Medicaid, private insurance, Social Service Block Grants, the OAA, Veterans Administration (VA), and TriCARE. Most nonpublic providers are for-profit agencies, but some nonprofit agencies offer sliding scale fees. Most research demonstrates that homecare services address unmet need for assistance and are satisfying to clients; but only a few studies indicate homecare substantially delays nursing home admissions (Gaugler, Kane, Kane, & Newcomer, 2005). For social work services, literature is mostly descriptive, indicating clinical relevance, yet results for effectiveness are inconclusive (Lee & Gutheil, 2003; Simons, Shepherd & Munn, 2008).
Congregate and Home-Delivered Meal Programs
Federal government, the primary financier for meal programs, emphasizes serving low-income and disadvantaged older adults without using means tests. Congregate meals sites provide at least one meal in a social setting, 5 or more days a week. They are served in church basements, schools, apartments, senior centers, or other multipurpose centers, with an average daily census between 20 and 60 older adults. Home-delivered meal programs (for example, Meals on Wheels) provide either one or two meals per day, generally 5 days a week, to home-bound older adults. Over 40% of programs have waiting lists (Wacker & Roberto, 2008). Evaluations indicate that the programs provide nutritious meals; yet there is still an unmet need for many low-income, older adults (Colello, 2010).
Adult Day Services
Adult day services (that is, adult day care or adult day health care services) are group programs that offer individualized care plans for adults with physical and cognitive functional impairments in a protective setting during part of a day but less than 24 hours. As a structured and comprehensive program offering respite to caregivers, it includes personal care, therapeutic, nutritional, social, nursing, rehabilitation, and transportation services. Programs are mostly nonprofit (78%) and affiliated with other medical or social services. Medicaid, VA, private pay, long-term care insurance, and voluntary contributions are funding sources (O'Keeffe & Siebenaler, 2006). Adult day services are underutilized, yet caregiver and client satisfaction is high (Malone Beach & Langeland, 2011). Mixed results remain for reducing caregiver burden and delaying nursing home placement (Gaugler, Yu, Krichbaum & Wyman, 2009).
Respite services are aimed at caregivers who need release time from caregiving duties. The services must meet the needs of the care recipient and can be supervisory, personal, or medical. Both for-profit and nonprofit programs offer respite services. As the most common form, in-home respite is provided by companions, homemakers, home-health aides, or nurses for several hours at a time. Medicaid and a limited amount of OAA monies are available for in-home respite. Some programs offer overnight services; yet most overnight respite occurs in long-term care facilities and is paid out-of-pocket by caregivers. Respite services can decrease caregiver distress, yet overnight respite may hasten nursing home placement and temporarily alter the frequency of disruptive behaviors (Kim & Hall, 2003; Neville & Bryne, 2005).
Hospice offers holistic care and pain control that “affirms life while neither hastening nor postponing death” for persons with terminal illness (Waldrop, 2006). An interdisciplinary team of medical, social service, and spiritual guidance professionals offers individualized treatment for the patient and family, most often in the home but also in hospitals, nursing homes, assisted living and hospice houses. The team provides direct care and coordinates auxiliary services, bereavement and family counseling, and medical supplies. Medicare, Medicaid, and private insurance cover hospice. Eligibility requires a physician-certified terminal prognosis of 6 months and the forgoing of most curative treatments. Over half of hospice patients die in their own home (National Hospice and Palliative Care Organization, 2012). Hospice decreases hospitalizations and intensive medical procedures. Hospice had quality of care outcomes comparable to usual care, thus emphasizing patient choice in opting for hospice. When compared to usual care, significant differences include the following: hospice resulted in a lower percentage likely to experience persistent pain, patient and family members were more satisfied with care, and hospice facilitated grief resolution for surviving spouses (Rhodes, Mitchell, Miller, Connor & Teno, 2008).
Case Management Services
Case management is the act of identifying, securing, and coordinating services to cost effectively meet the needs of older adults with functional impairments and their families (Wacker & Roberto, 2008). It includes the steps of casefinding (conduct outreach, eligibility determination, intake), assessment (current status, problem identification), care planning (develop plan based on needs), coordination (arrange delivery of services), follow-up (monitor client and services), and reassessment (reevaluate). The assessment and care arrangements ensure the continuity of care between acute care and residential, in-home, community, and informal care systems. Case managers (mostly licensed social workers or nurses) are often based in public agencies, Medicaid waiver programs, managed care organizations, medical groups, hospitals, private companies, or as self-employed businesses (Hyduk, 2002; Naleppa, 2006). Funding for case management is provided by the OAA, federal waivers in over 40 states, and private pay from family members (Centers for Medicare & Medicaid Services, n.d.; Naleppa, 2006; Wacker & Roberto, 2008).
For more than two decades, case management has received mixed results. The first demonstration project, the National Long Term Care Channeling Project, identified benefits such as increased use of homecare, reduction in unmet health care needs, and increased client confidence and satisfaction. However, the Kemper study (Kemper, 1988) demonstrated that case management did increase the costs of overall care. A growing evidence-base for case management is available in general (Boult et al., 2009; Counsel et. al., 2006), as well as it being a key component within integrated mental health care models (Katon, Unutzer, Wells & Jones 2010) and care transition interventions to decrease re-hospitalizations (Coleman et al., 2006). These contradictory results persist because of variations in services used, variables studied, and client populations (Gensichen et al., 2005; Hyduk, 2002; Leutz, 1999).
Health and Mental Health Care Settings
Social workers have traditionally assumed roles in hospitals, home health care, nursing homes, hospices, and other outpatient medical clinics, where they encounter older adults with comorbid medical needs and functional impairments. Medicare and Medicaid often include social services (that is, case management, discharge planning, interdisciplinary teamwork, and other psychosocial services) within its reimbursement to these settings. Increasingly, social workers are developing, delivering, and evaluating health promotion, cultural competency, and wellness initiatives (Wacker & Roberto, 2008).
With older adults mostly seeking mental health services from primary medical care providers (Gallo & Wittink, 2006), social workers offer supplemental services in detection, assessment, psychotherapy, and care management for issues such as depression, anxiety, caregiver distress, and grief. Medicare and Medicaid reimburse diagnostic evaluations, pharmacotherapy, and outpatient psychotherapy when deemed medically necessary (although current reimbursement rates are low and the bureaucratic process are often labor intensive). Social work involvement in collaborative care treatment models in primary care, supportive housing, and homecare services has a strong evidence base (Ciechanowski et al., 2004; Trivedi et al., 2013; Unützer et al., 2002).
Legal and Financial Services
Since 1981, the OAA funded legal assistance programs for older adults. As of 1992, these services are augmented and overseen by states through the Vulnerable Elder Rights Protection Activities Program. Services include telephone hotlines, lawyer information and referral services, and voluntary panels for pro bono or reduced fees. Problems include divorce, grandparents’ rights, estate plans, income assistance or other benefit plan problems, age discrimination, insurance problems, advanced directives, powers of attorney, consumer fraud, and crime (Wacker & Roberto, 2008).
Safe, reliable, and affordable transportation is critical, and older adults with cognitive, sensory, or mobility limitation face many challenges in getting around the community. Older adults drive their own cars, rely on informal caregivers, use routine public transportation, and obtain formal transportation services. Due to concerns over safety and the difficulty of determining when to cease driving, the American Association for Retired Persons, government offices, occupational therapists, or health centers may offer formal assessments and drivers’ education programs. Demonstrations are exploring how driver safety assessments, transit share, highway design, vehicle design, use of adaptive equipment and educational programs can improve safety and ease the process of driving cessation (Transportation Research Board, 2012).
Transportation alternatives include (a) fixed-route services such as buses, trains, or trolleys that follow predetermined routes with preset stops; (b) service routes buses or vans that circulate a confined distance within a neighborhood to reach shopping centers and medical facilities, and (c) demand-responsive services (that is, para-transit, dial-a-ride, or call-a-ride) for older, disabled, and/or low-income persons to schedule rides to medical or social services. Even with the Federal Department of Transportation and the OAA providing funding, many communities lack these services, and transportation remains one of the largest unmet needs among older adults.
Senior centers are designated focal points in a community where older adults may come together for a broad array of services and activities, including but not limited to nutrition, recreation, social, educational, information and referral, and fitness programs (Hostetler, 2011). An estimated 15,000 senior centers are located in old schools, community centers, churches, or housing projects. They are predominantly nonprofit organizations with funding from public sources and in-kind contributions. Senior centers may ask participants to voluntarily contribute, but no fees can be charged, as per OAA regulation (Rozario, 2006). Cross-sectional survey research has identified benefits as access to nutritious food, to socialization opportunities, and to physical fitness activities (Del Santo, 2009).
Nevertheless, senior centers participants constitute only 15% of the aging population, and they tend to be healthier and minimally diverse. With decrease in participation rates (Malone Beach & Langeland, 2011), senior centers are being challenged to reenvision their roles and attractiveness to the upcoming boomer generation. There is movement toward centers that offer life planning services and other programs with concepts such as vital and creative aging (Rozario, 2006).
Employment and Volunteerism
Older adults are extending their work lives and are seeking ways to stay longer and transition more slowly out of the workforce (Pitt-Catsouphes, 2007). With the Age Discrimination in Employment Act (ADEA) of 1987 and the Older Workers Benefits Protection Act in 1990, workers age 40 and above (with a few exceptions) are protected from age discrimination in hiring, terminations, promotions, wages, and health care coverage. The federal government also provides employment and training programs for older adults through the Experience Works program (formally called Green Thumb), Senior Community Service Employment Program, and other demonstration projects.
With over 24% of older adults in the United States engaged in volunteer activities, this is one prominent activity demonstrating the ongoing productivity of older adults (Administration on Aging, 2011). Aging services coordinate volunteer opportunities and use volunteers in many services. Private and federally supported programs exist such as Retired Senior and Volunteer Program (RSVP), Senior Companions, Foster Grandparent Program, and Senior Corps or Retired Executives (SCORE).
The desire for and benefits of lifelong learning is a growing service sector (Villar & Celdran, 2012). The Adult Education and Family Literacy Act of 1998 provides minimal federal funding earmarked for older adult education. Area Agencies on Aging are required to provide information on local tuition-free educational resources. Alternatively, universities, community colleges, specific Learning in Retirement Programs, the national Elderhostel network, the Older Adult Service and Information System (OASIS), and at-home learning services are a growing service sector.
While the majority of older Americans live in single-family homes (82%), about 4% live in noninstitutional supportive housing (Gonyea, 2006). Supportive housing programs are residential settings designed to provide varying degrees of assistance and oversight. Examples include cohousing such as Elder Cottage Housing Opportunities (ECHO), senior congregate housing facilities, continuing care retirement communities, board and care homes, and adult foster care. Most of these public, nonprofit, and for-profit settings offer private rooms or apartments connected to shared areas and services for dining, socialization, recreations, and housekeeping in a secure environment. On-site providers typically include building managers or social activity coordinators, not medical or social service personnel. Innovative models offer "housing with services" and may include integrated health, mental health, and other social services to promote aging in place.
With the increase in alternatives, the proportion of older adults residing in nursing homes has recently declined to about 3 million people (Vourlekis & Simons, 2006). Nursing homes provide short-term skilled nursing and therapeutic care for older adults expecting to return to the community as well as longer-term care for older adults who are not likely to regain the functional ability to be discharged. Nursing homes are the least preferred setting by older adults and their families; and quality of care problems abound (Institute of Medicine, 1986; Kane, 2001; Lehning & Austin, 2010). Of the 16,100 nursing facilities certified by Medicare and/or Medicaid, most are classified as for profit and free standing (Centers for Disease Control and Prevention, 2012). Medicaid is the predominant payer (52%), followed by out-of-pocket (41%), Medicare, private long-term care insurance, or other funds (Federal Interagency Forum on Aging, 2012).
With roots in the Americans with Disability Act of 1990 and the Olmstead decision of 1999, consumer direction of aging services is a growing initiative. Consumer direction transfers authority for care arrangements from agency professionals to older clients or a designated representative. In a national demonstration of consumer-directed care, called the Cash and Counseling Demonstration and Evaluation (Mahoney & Simone, 2006), consumers receive a monthly allowance and guidance to make decision about care and manage the assistance they need. Consumers can pay family members or friends for their personal assistance services. A stringent evaluation found that program participants have fewer unmet needs and higher levels of satisfaction than those in the comparison group (Foster, Brown, Phillips, Schore, & Carlson, 2003; San Antonio et al., 2010). In light of this success, the program is expanding to other states with support from the Robert Wood Johnson Foundation, U.S. Department of Health and Human Services, and other state mechanisms. These movements are blurring the line between informal and formal caregivers.
The Program for All Inclusive Care for the Elderly (PACE) is a capitated managed care service, offering primary, acute, and long-term care services to adults over the age of 55 who are eligible for nursing home care according to state regulation and living in a PACE catchment area. PACE providers receive monthly payments from Medicare and Medicaid for low-income older adults enrolled in the program. Older adults with more income can choose to enroll, and Medicare and private resources are used to cover the rate. While enrolled, the PACE program becomes the sole source of Medicare or Medicaid covered services. The per-capita rate covers all health and social services needed by the participants throughout their time of enrollment, including nursing home and hospice care. The heart of the program is an interdisciplinary team that works to ensure comprehensive care to each participant. Most programs utilize an adult day health center, where clients come at least once a week, usually more. Staff physicians, nurses, social workers, dieticians, physical/occupational/recreational therapists, drivers, and aides provide as many services as possible in the home or the day center, including step-down services after hospital discharge.
Evidence suggests that PACE achieved the following statistically significant outcomes: fewer hospitalizations, fewer nursing home placements, better quality of life, and more satisfaction with care (Grabowski, 2006). Success of the model resulted in the Balanced Budget Act of 2007 establishing the PACE model as a permanent Medicare program and allows states to service Medicaid clients through this option. There are currently over 80 PACE or pre-PACE program across the country (National PACE Association, 2012). Currently, CMS is supporting the development of the model in rural areas. The model is not expanding as quickly as expected (Hansen & Hewitt, 2012; Hirth, Baskins & Dever-Bumba 2009). Medicare-only clients are not opting to buy into the model; clients are reluctant to give up their own physicians; and states are hesitant to commit in the face of growing Medicaid budgets and enrollees.
For residential care, the emerging trend is assisted living. Assisted living has no agreed upon definition nor federal regulation. In general, the term is used to denote a residential setting that combines housing and supportive care in a home-like, social-model environment (Kane, 2006; Zimmerman, Munn, & Koenig, 2006). Tenants have private spaces (that is, single-occupied apartments with locked doors) and public shared spaces. The philosophy focuses on quality of life, autonomy, independence, and control over one's care, setting, and negotiated risks. The goal is to meet the scheduled and unscheduled needs of tenants while accommodating functional changes and preferences. Services include 24-hr supervision, routine provision of meals, personal care, nurse monitoring, and optional services (that is, housekeeping and transportation). A national survey of state licensing agencies, conducted by AARP. The Commonwealth Fund, and the SCAN Foundation (2010 found that market forces and preferences have led to increased privacy in assisted living facilities. Only about 3% of units were occupied by two unrelated individuals in 2009 (AARP, 2010; American Association of Homes and Services for the Aging et al., 2009). Researchers question the ability to “age in place” in assisted living since one-third of tenants will transfer to a nursing home, one-third will move elsewhere, and one-third will remain until time of death (National Center for Assisted Living, 2007). While some states offer Medicaid coverage, 75% of assisted living residents are paying out-of-pocket (Zimmerman et al., 2006), making assisted living inaccessible to those without adequate income.
The Pioneer Network is a coalition of professional, providers, families, and consumers, striving for radical culture change of nursing homes, where quality of life for residents and staff is paramount. Although no one specific model is advocated, the idea is perhaps best represented by the Green House model in Tupelo, Mississippi (Rabig, Thomas, Kane, Cutler, & McAlilly, 2006). The residential units are self-contained houses offering private bedrooms and bathrooms along with common cooking, eating, and living space to a maximum of 10 adults. “Universal workers” support the elders in all aspects of daily life. There are no nurses’ stations, no fixed daily schedules, no medication carts, and the call system is wireless. Green House residents, family, and staff have significantly better outcomes in quality of life and satisfaction while quality indicators were either equivalent or better than usual care (Kane, Gutler, Lum, & Yu, 2005; Rabig et al., 2006).
Another current issue in long-term care is the “balance” between Medicaid covered services in the nursing home versus the community. Medicaid has an inherent bias toward nursing home care. By federal law, states must provide nursing home care to meet long-term care needs of Medicaid recipients; but the provision of long-term care services in the community are optional; further, states can place limits on the size of community-based programs. Thus, home- and community-based services account for about 36% of total Medicaid spending on long-term care (Shirk, 2006). The Centers for Medicare and Medicaid Services has commissioned a study of this “rebalancing” (Kane, Priester, Kane, & Mollica, 2006). Results will help identify state policies, such as "Money Follows the Person" and practices that contribute to more effective community long-term care, and can shape the service system of the future.
Gerontological Social Work Services
A specialized body of social work knowledge and skills in gerontology has emerged, and the demand for gerontological social workers will continue to increase in response to our aging society and the ever-expanding array of aging services (Wilson, 2006). Social workers serve in all of the settings reviewed above by developing and administering programs across the continuum of care, by providing clinical services, case management, and discharge planning to elders and their families, and by participating in the development of social policies. In addition to aging-specific services, gerontological social workers are found in hospitals, primary health care clinics, hospices, psychiatric units of acute care hospitals, and mental health clinics.
Social workers are standard members and even leaders of interdisciplinary teams, and they are distinguished because of their knowledge of community resources; their psychosocial perspective and multidimensional assessment skills; and their skills in engaging the elderly person, family, and community in aspects of problem solving. They often have the broadest knowledge of the client and family and the most frequent contact with the client's family or friends.
For clinical interventions, social workers organize and lead therapeutic groups that address all types of challenges, such as widowhood, caregiving, or recovering from/adjusting to specific medical conditions. Social workers provide individual counseling for depression or adjustment to multiple late-life losses. Families often need assistance in dealing with an aging relative's increasing dependence and in making decisions about care arrangements and finances. Along with Medicare and Medicaid coverage for the specific services previously described, many agencies and private clinicians have sliding scale fee schedules. Social workers at the macro level can advocate for seamless services along a continuum of care.
Many of the ethical issues that arise in gerontological social work are familiar in practice with clients of any age, but some issues are more common when working with older clients. Given the parentalism in this society toward frail older people, issues of self-determination versus best interest and safety abound. Older clients often make choices that seem unwise to others. For examples, an older adult may deny supportive services in the face of great need or choose to live in situation that appears unhealthy or dangerous to others. This situation becomes even more challenging when exploitation or impaired cognition comes into play. Yet older adults who have not been legally assessed as incompetent have the right to make their own decisions, despite any vulnerability.
Social workers often are needed to support client choice and mitigate risks while working with opposing preferences from families, other providers, or the service agency. This leads to many questions. Who is the client when working with older adults and their families? Whose best interest is primary? What information should be shared? What is confidential? In fact, empowering older adults and engaging them and their families in active, open problem-solving are in line with social work values, even if it requires time and patience, especially with sensory or cognitive impairments slowing the process. In sum, social workers strive to promote quality of life, self-determination, and choice in all the situations experienced by older adults and their families.
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