SOCW-6111-Discussion Wk 6

Discussion 1:Self-Determination

In the Christ & Diwan (2008) article, the authors list seven domains that social workers should address in order to fully assess an older client’s needs. Each domain is considered equally important. This comprehensive evaluation fits well with the social work perspective that it is important to not only address the internal concerns of clients but also their environment. Making decisions for older adults without their input occurs often. In society people sometimes treat their elders like children—making decisions for them based on what they think is best rather than from the client’s perspective. While at times this may be well intentioned, the potential for infantilism and, in turn, compromised self-determination, occurs.

For this Discussion, review the program case study for the Petrakis family. You will focus not on Helen, but on her mother-in-law, Magda. What decisions were made about Magda’s treatment without a formal assessment and/or her input? Consider how Christ & Diwan’s (2008) seven domains relate to Magda’s case. Complete an assessment for Magda and identify the choices that were made without her feedback.

· Post a summary of your assessment of Magda’s situation that addresses the seven domains.

· Fill in the gaps in content as necessary.

· Describe ways you would have included Magda in the original assessment and treatment plan.

· Include questions you would have asked Magda and her professional support system (doctors, nurses, etc.) to gain further insight into the situation.

References (use 2 or more)

Christ, G., & Diwan, S. (2008). Chronic illness and aging: The role of social work in managing chronic illness care. Council on social work education. Retrieved from http://www.cswe.org/getattachment/Centers-Initiatives/CSWE-Gero-Ed-Center/Teaching-Tools/Gero-Competencies/Practice-Guides/Assignments-Measurments/CI-Sec2-Role-SW .aspx

Paveza, G. J. (2013). Assessment of the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 177–195). Hoboken, NJ: Wiley.

Plummer, S.-B., Makris, S., & Brocksen, S. M. (Eds.). (2014a). Sessions: case histories. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader].

The Petrakis Family (pp. 20–22)

Discussion 2: Elder Abuse

Each year on or around June 15, communities and municipalities around the world plan activities and programs to recognize World Elder Abuse Awareness Day, a day set aside to spread awareness of the abuse of the elderly (Center of Excellence on Elder Abuse & Neglect, 2013). The abuse of older adults is a growing concern and statistics suggest that the number of elders experiencing abuse is an alarmingly high number. Research suggests that close to half the people diagnosed with dementia experience some form of abuse (Cooper, C., Selwood, A., Blanchard, M., Walker, Z., Blizard, R., & Livingston, G., 2009; Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W., 2010, as cited on http://www.ncea.aoa.gov/Library/Data/index.aspx). Elder abuse takes on many forms and can include physical, emotional, psychological, and economic abuse. The legendary American actor, Mickey Rooney, spoke to the United States Senate, describing his own experiences of pain and neglect at the hands of his stepson, asking legislators to take seriously the abuse of the elderly.

For this Discussion, find a scholarly article that presents some of the most salient psychosocial issues related to elder abuse.

· Post a summary of the article you found.

· How does the article reinforce the importance of assessing potential abuse and neglect when working with the elderly?

· Describe prevention and/or intervention strategies on the micro, mezzo, and macro levels that can be used to address the issue of abuse and neglect of the elderly.

References (use 2 or more)
Paveza, G. J. (2013). Assessment of the elderly. In M. J. Holosko, C. N. Dulmus, & K. M. Sowers (Eds.), Social work practice with individuals and families: Evidence-informed assessments and interventions (pp. 177–195). Hoboken, NJ: Wiley.

Petrakis Family Episode 3

Petrakis Family Episode 3
Program Transcript

FEMALE SPEAKER: And you’re sure Alec is stealing from her? Pills. From his
own grandmother.

FEMALE SPEAKER: I can’t call the police. He’s still on probation! Possession.

FEMALE SPEAKER: Have you spoken to him about it?

FEMALE SPEAKER: He denied it. But I found them. He got her oxy prescription
refilled so he could take them himself. How old are you?

FEMALE SPEAKER: Excuse me?

FEMALE SPEAKER: I said, how old are you?

FEMALE SPEAKER: I don’t see what that has to do with anything.

FEMALE SPEAKER: You’re too damn young to be doing this job. That’s it. You
don’t know what you’re doing! None of this would have happened! It was your
bright idea! You’re the one who told me to have him move in with her and take
care of her!

FEMALE SPEAKER: I did tell you to do anything! I only suggested it. And we
talked about it together.

FEMALE SPEAKER: No, no. That’s not true. I followed your advice. You’re going
to have to fix this. You have to do something. I don’t know what else to do. I can’t
call the police. He can’t go back to jail. Awful things will happen to him. I can’t let
that happen. I won’t!

Petrakis Family Episode 3
Additional Content Attribution

MUSIC:
Music by Clean Cuts

Original Art and Photography Provided By:
Brian Kline and Nico Danks

1
*Grace Christ, DSW—Columbia University, School of Social Work
Sadhna Diwan, PhD—San Jose State University, School of Social Work

CHRONIC ILLNESS AND AGING

SECTION 2: THE ROLE OF SOCIAL WORK
IN MANAGING CHRONIC ILLNESS CARE

Grace Christ and Sadhna Diwan*

Synopsis

Managing chronic illness presents a profound challenge to the social work

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

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

Characteristics of Chronic Illness
as They Impact the Social Work Role

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

1. The trajectory for many serious illnesses has changed from an acute terminal
course to a much longer chronic period, with episodes of exacerbations and
remissions interspersed with extended periods of good functioning.

2. The trajectory of advanced chronic and terminal illnesses has changed from a
relatively brief period to a longer period in which both curative and
palliative treatments are combined. Research suggests that a long, advanced
chronic illness can be highly stressful for both patients and their families.

Christ & Diwan Chronic Illness—Role of Social Work

3. The increase in the total number of older people with advanced chronic and
terminal illnesses will require more curative and palliative care being
provided in the home, with greater reliance on provision by family members.

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

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

Psychosocial Assessment of Older Adults with Chronic Conditions

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

Comprehensive Assessments

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

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

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

Christ & Diwan Chronic Illness—Role of Social Work

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

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

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

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

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

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

http://www.americangeriatrics.org/

Christ & Diwan Chronic Illness—Role of Social Work

for psychosocial help are still the most important part of service delivery and mark the
beginning of the intervention process (Berkman et al., 2002).

Process of Conducting Geriatric Assessments

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

Establishing rapport with the respondent

Explaining the purpose of assessment

Using observation and clinical judgment

Assessing the client’s preferences (Kane & Degenholtz, 1997)

Knowing human behavior and caregiver dynamics

Demonstrating cultural competency in addressing and understanding
diverse groups of older persons

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

Biopsychosocial Framework for Seven Domains of Assessment

The conceptual framework that supports comprehensive geriatric assessment,
evaluation, and management is a biopsychosocial approach to understanding
chronic illness care.

To develop a substantive understanding of an older adult’s needs and resources
there are seven typical domains of assessment that are important for social
workers.

1) Physical well‐being and health
2) Psychological well‐being and mental health
3) Cognitive capacity
4) Ability to perform basic ADLs and instrumental activities of daily living

(IADLs)
5) Social Functioning
6) Physical environment
7) Assessment of family caregivers

Christ & Diwan Chronic Illness—Role of Social Work

These domains of assessment along with the rationale or evidence supporting
specific areas of assessment are adapted from Diwan & Balaswamy, (2006) and
presented in Table 1.

Christ & Diwan Chronic Illness—Role of Social Work

Table 1. Biopsychosocial Assessment Domains and Specific Areas of Assessment Related to Chronic Illness Care

Major
Domains of
Assessment

Current Evidence or Rationale Supporting

Specific Areas of Assessment Within Each Domain

Physical well-
being and
health

The prevalence of chronic diseases increases significantly with age, with the most common health problems being arthritis,
cardiovascular disease, cancer, and diabetes (Administration on Aging, 2007).

Important areas of assessment are overall health status; the presence of pain; nutritional status; risk for falling; incontinence;
sleep; alcohol and drug use; dental or oral health; sensory perception, especially vision and hearing (McInnis-Dittrich, 2004);
and use and misuse of medications (Kane & Kane, 2000).

These health conditions may significantly influence other domains: for example, by lowering psychological well-being, limiting
functional ability, and diminishing quality of life.

Psychological
well-being and
mental health

Depression, anxiety, and dementia are frequently under-diagnosed in elders, in part because symptoms can be misattributed to
health problems, and in part because of stereotypical beliefs that aging is associated with increased negative affect.

Substance use, misuse, or abuse (particularly of alcohol, prescription drugs, and over-the-counter medications) is also under-
diagnosed, often because decreased activity among the elderly is attributed to other age-related factors. Consequently,
substance abuse is not seen as the cause of a disruption from work or social activities (Widlitz & Marin, 2002).

As an indicator of mental health problems, the rate of completed suicide in the U.S. is highest among people over 65 years of
age (DHHS, 1999)

Cognitive
capacity

Two distinct types of cognitive changes occur as people age: The first is the gradual decline in memory, selective attention,
information processing, and problem-solving ability that occurs with normal aging; the second is a progressive, irreversible,
global deterioration in capacity that occurs as a result of illnesses or diseases such as Alzheimer’s, Huntington’s, Parkinson’s,
and AIDS; or vascular dementia, often caused by strokes or tumors.

As the dementia progresses, significant changes occur in memory, language, object recognition, and executive functioning: the
ability to plan, organize, sequence, and abstract. Behavioral symptoms, such as agitation, hallucinations, and wandering also
are common. Individuals exhibiting these behaviors require increased supervision by family members and others, which often
causes considerable strain and burden on caregivers, both formal and informal.

Ability to
perform various
ADLs

Functional ability is measured through performance in the ADLs, which include dressing, bathing, eating, grooming, toileting,
transferring from bed or chair, mobility, and continence; and performance in the IADLs, which include cooking, cleaning,
shopping, money management, use of transportation, telephone, and administration of medications.

Increasing disability in performing these activities predicts a person’s movement along the continuum of care, ranging from
independent living to assisted living to nursing home care.

A variety of physical, psychological, cognitive, and environmental factors influence a person’s ability to perform ADLs and
IADLs. Therefore, an evaluation of all factors that may contribute to a person’s disability is recommended.

Christ & Diwan Chronic Illness—Role of Social Work

Table 1 continued…

Major
Domains of
Assessment
Specific Areas of Assessment Within Each Domain

Social
functioning

Social integration (having social ties, roles, and activities) is associated with better health outcomes, such as lower risk of
mortality, cardiovascular disease, cancer mortality, and functional decline (Unger, McAvay, Bruce, Berkman, & Seeman,
1999).

Health also affects social functioning because people who are confined to bed or have severely impaired mobility are likely
to disengage from social activities.

Satisfaction with one’s social support is more strongly related to psychological well-being than are objective indicators of
social functioning, such as frequency of social contact (Krause, 1995).

Physical
environment

The risk of falling increases exponentially with age and, among older adults, falls are the leading cause of deaths caused by
injury and are the most common cause of injuries and hospital admissions for trauma. For people ages 65 and older, two-
thirds to one-half of falls occur in or around the home (CDC, 2006).

Thus, assessing the fit between the older person’s capabilities and his or her home environment is an important assessment
domain, and the prevention of falls is a critical area of intervention. Typical home assessments will examine the condition,
adequacy, and accessibility of lighting, flooring, and carpeting, including obstacles or potential hazards for falling; bathing
and toileting, including the need for assistive devices; kitchen; heating and cooling; access to the home from outside; access
to rooms within the home; and personal safety issues, such as neighborhood conditions.

Older adults may prefer to live in an environment regarded as inadequate by a professional, but one that permits them more
freedom and social connection. Kane & Kane, (2000) suggest integrating the concept of “negotiated risk,” into the
assessment process whereby older persons have a voice in determining their level of risk-taking,

Assessment of
family
caregivers

Approximately 66% of community-dwelling people who need long-term care rely solely on family and friends for help, and
28% receive a combination of informal and formal care (Liu, Manton, & Aragon, 2000).

With declining functional ability associated with chronic illness and dementia, increasing numbers of older people are in
need of care. The need for increased vigilance puts considerable strain on caregivers, which in turn not only puts the elderly
person at greater risk for entering a nursing home but also increases the likelihood of abuse or neglect.

Thus, assessing both objective and subjective components of caregivers’ strain is important for gaining a better
understanding of their needs.

Objective components of burden refer to the disruption in finances, family life, and social relations, whereas subjective
components refer to caregivers’ appraisal of their situation as stressful (Gaugler, Kane, & Langlois, 2000).

ADLs: activities of daily living; IADLs: instrumental activities of daily living

Adapted from Diwan & Balaswamy (2006).

Christ & Diwan Chronic Illness—Role of Social Work

Biopsychosocial Needs and Services for Chronic Illness Care

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

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

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

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

Christ & Diwan Chronic Illness—Role of Social Work

Table 2. Biopsychosocial Health Needs of Chronically Ill
Older Adults and Evidence-Informed Services

Biopsychosocial Health
Needs

Evidence Informed Services for Addressing
Needs

Information and education about
illness, treatments, costs, health
maintenance, and services
available for patients.

Continuous access to information and education about
illness, treatments, and their effects, costs, health
maintenance, and psychosocial and financial services.

Decision-making support for patients and family who are
considering options for treatment and care
arrangements.

Useful information and support through services such as
health education classes, disease management seminars,
and health coaches.

Help in managing illness
throughout its different phases:
e.g., prevention, diagnosis,
treatment, remissions and
exacerbations, and advanced
illness.

Care coordination interventions to facilitate more
appropriate delivery of services and assist with
transitions in care.

Comprehensive disease management/self-care
programs.

Interventions vary by characteristics of the disease (e.g.,
life threatening) degree of functional and role
impairment, amount of pain and discomfort, and
available supports.

Help in coping with emotions
accompanying illness and
treatment.

Community and peer support programs.
Coaching/supportive counseling for patient and family.
Pharmacological treatment for depression/anxiety

coupled with psychotherapy.
Pain and coping skills training for pain and discomfort.

Assistance in changing behaviors
to minimize impact of disease and
treatment and manage their
effects.

Health promotion interventions such as:
Assessment/monitoring of key health behaviors such as

diet, smoking, exercise.
Medication counseling/brief physician counseling.

Material and logistical resources
such as transportation, home
care.

Community and financial resources.
Access to home care and environmental alterations.
Information to informal caregivers.

Help in managing disruptions in
work, activities, family life, and
social network.
Prepare for care transitions due
to disease progression.

Family/caregiver education, counseling.
Assistance with activities of daily living (ADLs), and

instrumental activities/chores (IADLS).
Information on legal protections and services.
Ongoing social network development.

Financial advice and/or
assistance. Managing and

Assist with financial planning/counseling including
management of activities such as bill paying.

Christ & Diwan Chronic Illness—Role of Social Work
Biopsychosocial Health
Needs
Evidence Informed Services for Addressing
Needs

maintaining health insurance over
time.

Insurance counseling/advocacy.
Eligibility assessment for supplemental income benefits

and assistance with major out of pocket expenses.

Adapted from a report by the Institute of Medicine titled Cancer Care for the Whole Patient: Meeting
Psychosocial Health Needs, 2007. Available at: http://www.nap.edu/catalog/11993.html.

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

What Is Care Coordination?

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

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

The Need for Care Coordination

The structure of the health care delivery system in the U.S. is marked by
fragmentation, complexity, pervasive deficiencies, and remarkable variation in
patient safety and healthcare quality (McDonald et al, 2007).

Additionally, older patients are more vulnerable to the negative consequences
of this fragmentation as they often have complex management regimens for
their chronic conditions, strained or reduced family support, and lower health
literacy (McDonald et al, 2007).

The range of psychosocial services described earlier that are useful in
improving the health and quality of life of elders are located in various delivery
systems in the community, making it difficult for elders and families to access
these services.

http://www.nap.edu/catalog/11993.html

Christ & Diwan Chronic Illness—Role of Social Work

The following summary statement characterizes the view of many health
professionals about current challenges to the health care system.

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

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

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

Models of Care Coordination Programs

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

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

Christ & Diwan Chronic Illness—Role of Social Work

Table 3. Models of Care Coordination and Selected Evidence

1. INTERDISCIPLINARY TEAM CARE
Providers from different disciplines collaboratively manage the care of a patient.
Example: Program for All-Inclusive Care for the Elderly (PACE).
Specific Aim: Within a managed-care program (for those eligible for Medicaid and Medicare),
address the spectrum of needs for adults aged 55 and older whose disability level qualifies them for
nursing-home care.
Intervention: PACE services are provided by an interdisciplinary team composed of at least the
following members: a primary care physician, a registered nurse, a social worker, a physical
therapist, a pharmacist, an occupational therapist, a recreational therapist, a dietician, a PACE
center-manager, a home-care coordinator, personal care attendants, and drivers. PACE has an
innovative team approach as it includes both professionals and direct-care workers as part of the
care team. Each member of the team performs an initial assessment of each patient, and then the
group works together to create a single care plan that takes the different assessments into account.
The services, which are provided primarily at an adult day-care center, are also highly coordinated.
Outcomes: PACE enrollees showed higher patient satisfaction, improved health status and physical
functioning, an increased number of days in the community, improved quality of life, and lower
mortality. The benefits of PACE were even greater for the frailest older adults, who had lower rates
of service utilization in hospitals and nursing homes and higher rates of ambulatory care services.
Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
Workforce. http://www.iom.edu/?ID=53452

2. CARE MANAGEMENT
In most forms, a nurse or social worker provides patients (and sometimes families) a combination of
health assessment, planning, education, behavioral counseling, and coordination. Their
communication with primary care providers varies depending on the care-management program.
Example: Improving Mood: Promoting Access to Collaborative Treatment for Late Life Depression
(IMPACT)
Specific Aim: To treat depression in primary care settings because depression is common among
individuals with chronic illness.
Intervention: Patients participating in IMPACT receive educational materials about late-life
depression and visit a depression-care manager at a primary care clinic. The care managers
(typically nurses, psychologists, and social workers) are trained as depression clinical specialists
and work with the patient’s regular primary care provider to establish a treatment plan. Care
managers are supervised by a team psychiatrist and a primary care physician. Results indicate that
evidence-based care for major depression can be successfully delivered by specially trained nurses,
psychologists, and social workers in primary care settings.
Outcomes: IMPACT participants had higher rates of depression treatment, greater reductions in
depressive symptoms, more satisfaction with their care, less functional impairment, greater quality of
life, and more depression-free days. Positive results were maintained over 1 year.
Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
Workforce. http://www.iom.edu/?ID=53452

http://www.iom.edu/?ID=53452

Christ & Diwan Chronic Illness—Role of Social Work

3. CHRONIC DISEASE SELF-MANAGEMENT PROGRAMS
Self-management programs are structured, time-limited interventions designed to provide health
information and to empower patients to assume an active role in managing their chronic conditions.
Some are led by health professionals and focus on the management of specific conditions, such as
stroke, while others are led by trained laypersons and address chronic conditions more generally.
Example: Chronic Disease Self-Management Program (CDSMP)
Specific Aim: To teach self-management skills useful for managing a variety of chronic diseases such
as arthritis, diabetes, lung and heart disease.
Intervention: CDSMP workshops are held in community settings and meet 2 1/2 hours per week for
6 weeks. Workshops are facilitated by two trained leaders, one or both of whom are non-health
professionals living with a chronic disease. This program covers topic such as techniques to deal
with problems associated with chronic disease; appropriate exercise; appropriate use of
medications’ communicating effectively with family, friends, and health professionals; nutrition; and
how to evaluate new treatments.
Outcomes: Participants in the CDSMP have shown significant improvements in exercise,
communication with physicians, self-reported general health, health distress, fatigue, disability, and
social/role activities limitations.
Source: CDC. http://www.cdc.gov/arthritis/intervention/index.htm

4. PREVENTIVE HOME VISITS
Home visits are provided to older persons by nurses or other visitors to monitor health and
functional status and to encourage self-care and appropriate use of health care services. These
visitors usually see their clients quarterly and communicate regularly with their clients’ primary care
providers.
Example: Geriatric Resources for Assessment and Care of Elders (GRACE)
Specific Aim: Providing health care for low-income older adults as they face several challenges,
including high incidence of chronic illness, limited access to care, low health literacy, and
socioeconomic stressors that lead to unmet need and greater burden of illness.
Intervention: A team consisting of a nurse practitioner and a social worker visits patients at their
homes for an initial assessment and then follows up with the patients at least once a month, either
by phone or face-to-face. Home visits are also conducted after any emergency-department or
hospital visit. This two-person team is supported by an interdisciplinary team led by a geriatrician
that includes a pharmacist, physical therapist, mental health social worker, and community-based
services liaison. This group, using input from the patient’s primary care physician, establishes a care
plan for the patient that incorporates protocols for the treatment of 12 targeted geriatric conditions.
Outcome: A controlled clinical trial of the GRACE program indicates improved quality of care and
reduced acute-care utilization. However, improvements in health-related quality of life were mixed,
and physical functional outcomes did not differ from the control group.
Source: Institute of Medicine, 2008. Retooling for an Aging America: Building the Health Care
Workforce. http://www.iom.edu/?ID=53452

http://www.cdc.gov/arthritis/intervention/index.htm

http://www.iom.edu/?ID=53452

Christ & Diwan Chronic Illness—Role of Social Work

5. CAREGIVER EDUCATION AND SUPPORT
These community-based programs are designed to help the informal caregivers of older persons
with chronic conditions such as dementia and stroke. Led by psychologists, social workers, or
rehabilitation therapists, these programs provide varying combinations of health information,
training, access to professional and community resources, emotional support, counseling, and
coping strategies.
Example: Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II)
Specific Aim: Support caregivers of persons with dementia.
Intervention: Provide educational information, skills to manage care recipient behaviors, social
support, cognitive strategies for reframing negative emotional responses, and strategies for
enhancing healthy behaviors and managing stress. Methods used in the intervention include
didactic instruction, role-playing, problem-solving tasks, skills training, stress management
techniques, and telephone support groups.
Outcome: Caregivers in the REACH II intervention group experienced greater improvement in
quality of life and fewer cases of clinical depression.
Source: National Registry of Evidence-Based Programs and Practices, SAMHSA.
http://www.nrepp.samhsa.gov/

6. TRANSITIONAL CARE
Typically a nurse or an advance-practice nurse prepares and coaches the patient and informal
caregiver for the transition from hospital discharge to home care.
Example: The Care Transitions Program
Specific Aim: To help patients with complex care needs learn self-management skills to ensure their
needs are met during the transition from hospital to home.
Intervention: For 4 weeks after discharge the nurse visits the patient at home to ensure that all
needed medication, equipment, and supplies are available, and that the patient and caregiver
know how to use them, how to self-monitor, and whom to call if problems arise. The nurse continues
to monitor the situation for several weeks until the patient has returned to pre-admission status,
contacting the primary care physician as needed.
Outcome: Intervention patients had fewer hospital readmissions, reported high levels of confidence
in obtaining essential information for managing their condition, communicating with members of the
health-care team, and understanding their medication regimen (Coleman et al., 2004).
Source: The Care Transitions Program. www.CareTransitions.org

Features of Innovative Care Coordination Models

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

http://www.nrepp.samhsa.gov/

The Care Transitions Program

Christ & Diwan Chronic Illness—Role of Social Work

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

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

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

Common components of care coordination programs include the following:
1) Essential care tasks (e.g., assess client and develop a care plan)
2) Associated coordination activities (e.g., service arranging, psycho‐

education)
3) Common features of interventions to support coordination activities (e.g.,

standardized protocols and manuals, multidisciplinary teams).
Key aspects of these care coordination interventions are thoroughly integrated in

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

education).

Evidence for the Relative Efficacy of Various Care Coordination Programs

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

Christ & Diwan Chronic Illness—Role of Social Work

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

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

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

Care coordination strategies for older adults have resulted in reduced
numbers of hospital admissions.

Interventions by multidisciplinary teams have improved continuity of
service for severely mentally ill patients, reduced mortality and hospital
admissions for heart failure patients, reduced symptoms for terminally ill
patients, and reduced mortality and dependency for stroke patients.

Disease management programs have reduced severity of depression and
improved adherence to treatment in patients with mental illness, reduced
mortality and hospital admissions in patients with heart failure, and
improved glycemic control in patients with diabetes.

Case management programs have shown reduced rates of rehospitalization
among patients with mental health problems, and improved glycemic
control among patients with diabetes.

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

Christ & Diwan Chronic Illness—Role of Social Work

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Curriculum Resources