Physician and nurse practitioner perceptions of social worker and community health worker roles in primary care practices caring for frail elders: Insights for social work

Social workers (SW) and community health workers (CHW) have emerged as key workforce personnel in efforts to care for elders in the U.S. However, little is known about the presence and roles of SW and CHW in primary care practices. This paper presents findings from a nationally representative survey of geriatrics and primary care practices. Physician and nurse practitioner clinicians were randomly selected within practices, stratifying by practice staffing and presence/absence of geriatric clinicians; our final sample for this analysis included 341 practices. Key findings include: reported challenges in meeting the social service needs of elders, underutilization of SW, and fuller utilization of social work competencies in practices in which both SW and CHW were present. These findings offer a unique perspective of SW on interprofessional teams and have implications for the future of the profession.

CLINICIAN PERCEPTIONS OF SOCIAL WORKERS AND COMMUNITY HEALTH WORKERS IN PRACTICES CARING FOR FRAIL ELDERS

Social workers (SW) and community health workers (CHW) have emerged as key workforce personnel in efforts to care for elders in the U.S. However, little is known about the presence and roles of these professionals in outpatient practices. This paper presents findings from a nationally representative survey of geriatrics and primary care practices. Key findings include: reported challenges in meeting the social service needs of elders, underutilization of SW, and fuller utilization of social work competencies in practices in which both SW and CHW were present. These findings offer a unique perspective of SW on interprofessional teams and have implications for the future of the profession.

Social Work Gerontological Practice: The Need for Faculty Development in the New Millennium

There is a pressing need to upgrade the gerontological knowledge and skills of practicing social workers. Geriatrics and gerontology, as specialized fields of knowledge, have not been sufficiently integrated into formal academic training programs. There are major trends in the health care environment which impact on social work education, including technological advances, a shift from inpatient to outpatient and community care settings, increasing diversity of the older population, and client and family participation in decisionmaking. These trends necessitate social work education to emphasize new content areas in gerontology and the development of new skills in clinical, case management, care coordination, and teamwork. A significant obstacle to the preparation of future social workers to deliver the complex services needed by older adults and their families is a serious shortage of social work faculty in gerontology. Sustained and broad initiatives, such as the John A. Hartford Foundation funded Geriatric Social Work Faculty Scholars Program, are needed to develop academic and practice-based faculty in gerontology. This is crucial if social work is to maintain an important service role in the new millennium.

Linking the NIH strategic plan to the research agenda for social workers in health and aging

Although social work has a long and distinctive tradition of practice-relevant research aimed at enhancing the health and well-being of older adults, the profession has been underrepresented among the ranks of academic researchers and the National Institutes of Health's (NIH) scientific endeavors. In this article, the inherent capacities of social workers to generate and disseminate empirical health-related knowledge are discussed and recent developments in social work's geriatric research infrastructure are described. Emerging domains for advancing the profession's contribution to practice-relevant geriatric research on the federal level are identified and the next steps toward advancing the field's research agenda are posed.

Social work and aging in the emerging health care world

Social work practice with older adults and their families is increasingly recognized by the profession as a major field of practice in a wide range of health care and community-based settings. This article reviews emerging trends and issues in the fields of aging and health care, drawing on gerontological health care research which bridges these areas. Given the growing number and diversity of older adults in our society, and dramatic changes in the organization and delivery of health care, the authors suggest skills and competencies essential to enhancing the well-being of older adults and their families in the 21st Century.

Assessment and the ubiquity of culture: threats to validity in measures of health-related quality of life

Social workers in health care settings are increasingly using patient-based assessments (PBAs) of health-related quality of life such as the SF-36. However, the validity of many PBAs for use with cultural minority groups is limited. To ensure that cultural minority groups are not misrepresented by standardized measures, social workers--as effective patient advocates--must be familiar with the underlying conceptual assumptions of measurement theory to articulate the strengths and limitations of measures used to investigate populations with which they have not been tested and advocate for cultural minority groups using language and terminology that measurement practitioners can understand and embrace.

Educating social workers to meet the challenge of an aging urban population: a promising model

As Americans live longer, they will require more health and social services to address the onset of acute and chronic conditions. The persistent changes in health care delivery and the increasingly diverse older adult population in urban settings, coupled with the high expectation for families to be responsible for home care needs, challenge social workers, who work alongside physicians, nurses, and other health care professionals, to provide services effectively. Because social workers are becoming more essential, social work education must increase the numbers of social workers with the knowledge and skills necessary for practice in the current U.S. health, mental health, and social service systems, particularly in caring for the aging populations in urban settings. A New York Academy of Medicine study identified the need for increased synergy between the two components of graduate social work education: the field experience and classroom instruction. One educational model, the Practicum Partnership Program, which is designed to better integrate field and classroom, is being tested at six sites. Early results from over 300 graduates are encouraging, with evidence that students' knowledge and skills regarding aging adults have increased, their satisfaction with the experience was very high, and those who were trained reflect the diversity of the population of older adults. The early success of this program suggests that innovative educational models that expose graduate social work students to diverse populations across the continuum of care are possible. Such models will be essential for the nation to be successful in producing a social work labor force qualified to meet the challenge of an aging urban population.

Mentoring new social work faculty:a gerontological perspective

The John A. Hartford Foundation, in collaboration with the Gerontological Society of America, has developed new models to create geriatric faculty capacity within social work. The Faculty Scholars Program is building faculty leadership in academic geriatric social work through a strategic approach that includes long-distance national and institution- based mentoring. While mentoring models have proven to be effective means of career development, this is relatively new in academic social work and little is known about the impact of long-distance mentoring in association with sponsorship from a mentor at the scholar's home institution. This paper describes the mentoring model and its conceptual underpinnings. Evaluation data from an ongoing evaluation is presented in discussion of the strengths and limitations of the mentoring model.

Social work education for health care: addressing practice competencies

The study discussed in this article examines how social work graduates are prepared to help clients and families who need health and mental health services. The study identifies recent shifts in social work practice in health care settings, calls for greater integration of practicum and classroom education, and proposes curriculum enhancement to ensure competence in three key areas: self-directed practice, population-based practice and a refocus on basic skills. Findings are based on a New York Academy of Medicine study conducted from 1997-1999 which included a survey of course offerings at 128 CSWE-accredited schools; literature review of current practice models, focus groups, and review by an expert advisory council.

Use of standardized measures in agency based research and practice

This article reviews criteria for social workers' selection and use of standardized outcome measures for practice and research. Issues related to reliability and validity are discussed. The utility of standardized Health Related Quality of Life (HRQL) measures, either generic or disease specific, is presented utilizing one measure, the SF-36+ Social Work, as an exemplar. The article concludes that such measures are viable and necessary for social work to demonstrate its value-added qualities in the emerging healthcare environment.

Standardized screening of elderly patients' needs for social work assessment in primary care: use of the SF-36

Fewer hospitalizations and decreased lengths of stay in the hospital have resulted in an increased need for extensive support services and continuing care planning for elderly people in primary care. Early identification of elderly patients needing community and hospital nonmedical services is necessary so that timely appropriate services can be delivered. This study addresses the issue of whether a standardized health-related quality of life questionnaire, the SF-36, can be used independently as a screen predicting primary care elderly patients' needs for social work assessment. In addition, the question of what scales on the SF-36 a social worker would use to screen patients in need of assessment is explored.

Spirituality and quality of life in gynecologic oncology patients

PURPOSE

The inclusion of spiritual well-being in healthcare assessments can provide insight into patients' needs and coping resources. This study explored the relationship between spiritual well-being and quality of life (QOL) in gynecologic oncology patients in an attempt to clarify the significance of spiritual well-being in the assessment process.

DESCRIPTION OF STUDY

Eighteen women with gynecologic cancer completed a self-administered questionnaire that obtained sociodemographic, medical, spiritual, and functional information. The Spiritual Well-being Scale was used to assess spiritual well-being, and the Functional Living Index: Cancer (FLIC) measured QOL. Data were analyzed using descriptive statistics, comparison of means, and analysis of variance.

RESULTS

Patients with gynecologic cancers other than ovarian reported a better QOL and a higher degree of spiritual, existential, and religious well-being. Older patients consistently reported higher degrees of spiritual well-being and QOL than did younger patients. Married patients consistently reported higher degrees of spiritual well-being than patients who were not married (never married or separated). Catholic patients scored higher in degrees of religious and spiritual well-being as well as in FLIC scores than other patients.

CLINICAL IMPLICATIONS

Health professionals do not generally assess spiritual well-being in their evaluations of patients' needs. The findings from this study support the inclusion of spirituality as part of routine patient assessment and intervention. Clinical intervention that would increase a patient's level of spiritual awareness and his or her level of comfort associated with a personal perspective on death could help decrease the patient's level of psychosocial distress. Despite the medical establishment's bias to the contrary, religion and spirituality are positively associated with both physical and mental health and may be particularly significant to terminally ill patients. The curricula of medical, nursing, and other health schools should be redesigned appropriately.

The emerging health care world: implications for social work practice and education

Dramatic changes in patient care delivery have been stimulated by advances in technology and new approaches to the financing of health care. Traditionally, the American health care system has been based on a paradigm of unpredictable acute simple disease, a model that has become inappropriate as increasing numbers of patients are presenting with multiple, chronic health problems. Because chronic illnesses are determined by many factors, such as an individual's social, psychological, and physical environment; genetic makeup; and health care accessibility factors, the hospital, once the dominant organization in health care, must become part of a primary care network of community-oriented delivery systems focused on chronic disease management. In this model, the social worker treats the patient throughout the continuum of care. Therefore, dynamic training that addresses the changing health care environment will be needed. In addition, social workers will need to work as members of a team in addressing the needs of patients for preventive, curative, and rehabilitative services.

Social work in the academic medical center: advanced training--a necessity

Although the total number of social workers within the academic medical center will probably decrease because of decreasing hospital bed usage, the role for those who remain will be that of a clinical specialist, a sophisticated and adaptable practitioner who can work flexibly under minimal supervision. The valued social work practitioner will be an independent player on the health care team who assumes a significant role which no other member of that team is equipped to take. Advanced training is more important today than ever before in the evolution of social work practice in academic health care. However, this training is not now available within the parameters of the two year master's program.

Ambulatory elderly patients of primary care physicians: functional, psychosocial and environmental predictors of need for social work care management

With increasing numbers of elderly people, and the escalating costs of health care, screening becomes increasingly important for identifying those older people with social health care needs who appear in their primary care physicians' offices. Many people are not aware of available social services. Families with serious social problems are not finding the help they need. The aim of this study was to develop and refine a questionnaire as a screening tool to identify elderly outpatients in primary care settings who are at high risk for psychological, social or environmental needs. This study identified those ten factors at each site which were most indicative that further intervention was needed. There were consistencies among the coordinators across sites in terms of what factors triggered intervention. Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) were more likely to be predictive of the coordinator's intervention than were other factors.

Myths and biases related to cancer in the elderly

Advances in medical science have led to effective treatments for cancer; however, there are myriad myths and biases related to older people and cancer that pervade both patients' and professionals' ideas on causation, course of illness, treatment, and recovery, and act as hindrances to early detection, treatment, and rehabilitation. The geriatric population is comprised of a heterogeneous group of persons who are not categorized easily according to chronologic age. Health care professionals are particularly susceptible to ageist stereotyping and negative attitudes toward the elderly because they lack training in caring for older people. In the future, the elderly will be better educated, expect greater participation in decision-making, and be less likely to postpone entry into the medical care system. There is a need to educate both health care professionals and the elderly population about the myths and realities of cancer detection and treatment.

Postpolio survivors: needs for and access to social and health care services

A needs assessment survey of 268 polio survivors residing in Maine explored the incidence of postpolio syndrome as well as perceived need for and access to social and health care services. A large proportion reported experiencing postpolio syndrome. Although knowledgeable of their condition, a majority perceived that they had no access to knowledgeable physicians or social and health care services and most were having difficulty coping. Findings indicate that polio survivors' self-appraisal of their illness status is related to their perceived need for and access to social and health care services. The need for community-based services, including medical, rehabilitative, educational, and social work services, is indicated.

Advocacy. Necessary to achieve cancer control goals

As resources become increasingly scarce, oncology professionals and consumers of oncology services are increasingly engaging in advocacy efforts to achieve goals in cancer control. Effective advocacy includes both legislative and direct educational efforts.

Social work in health care: directions in practice

As technological advances within biomedicine uncover more complex and confusing situations, social workers are forced to deal with the patient and family with greater uncertainty. To competently address today's biomedical environment with an anticipation of tomorrow's advances is an incredible challenge. The focus of the theoretical framework necessary as the foundation for health care practice has shifted from an emphasis on psychopathology to a focus on what people do well, on their adaptive capacities with the goal of preventing maladaptive behavior. Therefore, the focus of practice must be on factors that affect normal or typical growth and development in the course of living and must include an understanding of the interaction between the biological, psychological, cognitive, social, cultural, and environmental dimensions of social functioning.

Failure to thrive: paradigm for the frail elder

A retrospective study of 82 elderly "failure to thrive" (FTT) inpatients suggests that FTT is diagnosed when the elderly patient's functional ability to live with multisystem diseases, cope with the ensuing problems, and manage his/her own care are remarkably diminished and no longer responsive to health care interventions. In an attempt to clarify the clinical picture of FTT, we used standardized questionnaires to abstract data from medical charts.

Estimation of fertility and fitness in Huntington disease in New England

The advent of presymptomatic and prenatal testing in Huntington disease (HD) may change the reproductive behavior of persons at risk for HD. In order to assess future change, an analysis of fertility and reproductive fitness was carried out on 999 affected and 2,253 unaffected offspring from 235 New England families. Ascertainment biases observed for persons born before 1910 and after 1929 reduced the sample to 250 HD cases and 201 unaffected sib controls born between 1910 and 1929. No increase in reproductive rate was found in HD-affected men compared to male control sibs. A small increase in fertility averaging 0.5 child was seen in HD-affected females compared to unaffected females, but this difference was not significant. The increase in mean number of children for HD females is accounted for in part by a small number of affected women who had very large families. No evidence was found to suggest that any increase in reproductive rate for affected persons was related to offspring being born after HD onset. The fitness of both HD-affected and unaffected females was not significantly different from that of the general population of Massachusetts.

Attitudes toward presymptomatic testing in Huntington disease

One hundred thirty-one individuals at 50% risk of inheriting Huntington disease (HD) responded to a survey to study their attitudes toward taking a genetic test based on the identification of a genetically linked DNA polymorphism. Ninety-six percent of the respondents believe that presymptomatic testing should be available, and 66% say they will use it themselves. Fewer married individuals, in comparison to those single, separated, and divorced, intend to take the test. Many respondents (40%) said their primary reason for wanting to be tested is to end the uncertainty in their lives. Results suggest that there will be self-selection in test use, with many individuals who believe they will be depressed or possibly suicidal with a positive test result deciding not to be tested or unsure about testing. However, 15% of those who want to be tested acknowledge that they may be at risk for suicide if they are probable gene carriers. Only 12% of all respondents say they will be likely to use prenatal testing, suggesting that initial demand may be low in New England. Implementation of presymptomatic testing challenges health care providers to develop strategies to care for otherwise healthy persons who will be given a diagnosis years before the onset of illness.

Factors related to hospital readmission of elderly cardiac patients

Elderly patients with cardiac disease are at high risk for physical deterioration during posthospital recovery and suffer frequent early readmission. This study found that mental status and posthospital stress were significantly related to early readmission.

Increased rate of suicide among patients with Huntington's disease

The proportion of deaths attributed to suicide was examined among 506 deceased individuals with diagnosed or suspected Huntington's Disease from New England USA. Comparison of this proportion with that of the general population indicated that the odds of a death being due to suicide in the Huntington's disease group is 8.2 times that of the Massachusetts population for persons aged 50 to 69 yr, but no difference appears in the 10 to 49 yr age group. Among the 157 Huntington's disease patients for whom cause of death was known, the corresponding odds estimates are 23.0 for the 50 to 69 yr age group and 2.7 for the 10 to 49 yr age group. More than half of the suicides occurred in individuals who showed early signs of the illness but who had not been diagnosed, suggesting that suicide may occur more frequently in the early stages of the illness.

Potential impact of a predictive test on the gene frequency of Huntington disease

Fifty-five individuals at 50% risk of inheriting Huntington disease (HD) were given in-depth structured interviews to survey attitudes toward use of a predictive test and to assess the possible impact of such a test on the number of gene carriers born. Three-quarters of the sample said they would take predictive test. Given a positive predictive or prenatal test, the number of individuals choosing to have children is reduced from 80% of the total sample to 42%, or by almost one-half. The large proportion of at risk individuals who say they would use a predictive test underscores the importance of developing guidelines for its administration prior to implementation.

Attitudes toward marriage and childbearing of individuals at risk for Huntington's disease

Huntington's Disease (HD), a mid-life onset inherited neurological disorder, can have a profound social and psychological impact on affected individuals and relatives. This paper discusses the attitudes of 45 individuals at risk for inheriting HD toward marriage and childbearing. Social and demographic variables influencing these attitudes were also examined. Subjects who had graduated from college were found to be more likely to be deterred from having children than those with less education. Current childbearing status was also found to influence attitudes toward hypothetical situations dealing with having children. Knowledge of the factors influencing attitudes in these areas can aid health professionals involved in genetic counseling for Huntington's Disease and other inherited mid-life onset disorders.

The use of theoretical constructs and research data to establish a base for clinical social work in health settings

This article suggests a means for organizing a base for clinical social work practice in health settings. Membership, as a theoretical construct, is used to explore the essentials of social work, to explicate its key practice concepts, and to review characteristics of the health field. Selected findings from a secondary analysis of data from the New England Regional Survey of Social Work Practice are considered with reference to theory and essential concepts of health social work practice. Questions are raised and implications drawn for the practice of clinical social work in health settings and for education for that practice.

An interdisciplinary geriatric consultation service: a controlled trial

The structure and function of a newly created interdisciplinary Geriatric Consultation Team (GCT) are described. The GCT was introduced on a single medical unit, where consultations were given to 46 consecutive patients aged 75 years and over. The GCT patients had, on the average, 5.5 illnesses and were receiving 3.7 medications. Anemia (50 per cent), were hypoalbuminemia (65 per cent), and elevated blood urea nitrogen (BUN) (58 per cent) were frequent. Functional assessment showed frequent dependence on others for assistance with ambulation (59 per cent), transfers (54 per cent), and dressing (52 per cent); cognitive impairment was found in 52 per cent and clinical depression in 11 per cent of the patients. In comparison with control units, the GCT increased use of physical therapy by 357 per cent, occupational therapy by 390 per cent, and speech therapy by 300 per cent without increasing length of stay. In comparison with control subjects, GCT patients had no decrease in hospital readmission rates (43 per cent) over 10.5 months of follow up. It was concluded that a GCT in an acute-care hospital promotes geriatrics, teaches interdisciplinary teamwork, improves awareness of functional problems of patients, and increases use of rehabilitative services, but does not decrease the high rate of readmission of hospitalized geriatric patients.

Health agencies and a school of social work: practice and research in partnership

Growing out of their joint recognition of the need for evaluation, accountability, and definition of social work's interdisciplinary contributions, a school of social work and Boston-area health agencies formed a research partnership. Fifty-five studies involving graduate students' research resulted in reportings, publications, and utilizations of findings.

Screening for high social risk: principles and problems

Sound use of hospital social work services is not achieved when workers rely on other health personnel for referrals. The authors propose a screening mechanism to identify patients at what they term high levels of social risk and to restore the initiative to social work staff. Relevant principles and problems are also discussed.

Psychosocial problems and outcome: an external validity study

Six acute-care teaching hospitals participated in a study to determine the validity of a problem-outcome classification system. Three hundred and forty-three randomly selected clients of 152 social workers served as external sources to determine the validity of the instrument. In 77 percent of the problems, social workers and clients agreed on the nature of the problem dealt with during intervention. However, workers tended to give more negative values to their assessments of outcome of intervention than did their clients.

Survey offers guidelines for social work

Collection of hospital social work data is a step toward making the product of social work practice both measurable and quality controlled and can serve as a guide for all hospitals.

Regional profile data as basis for social work audit

Profile data obtained in a regional survey of social work practice have been used by one social work department of a general hospital to identify three problem areas of practice with patients whose discharges are delayed beyond medical necessity. The authors describe the department's analysis of the data, its identification of a topic of concern, and the subsequent steps taken in a departmental audit.

A social work department develops and tests a screening mechanism to identify high social risk situations

This paper describes a model for developing and testing a screening mechanism to identify high psychosocial risk patient situations in need of early intervention by social workers. Although the criteria developed need further refinement, it was found that multiple criteria are significantly more predictive of high risk than single factors and that three variables, (1) severity of illness: life threatening, (2) severity of illness: physically dysfunctional; and (3) chronic illness were good predictors of need for social work services. It is suggested that similar screening mechanisms be developed and utilized in hospitals throughout the country.