Social Work Roles in Health and Long-Term Care

Gerontological social workers provide clinical services to older adults and their families, develop programs to serve older adults and reshape current programs where consumers are aging, administer health and long-term care organizations, and help develop health and social policies. Gerontological social workers provide these services in health and long-term care settings, including health care clinics, hospitals, extended care and rehabilitation units, assisted-living facilities, and nursing homes. They also serve older adults in private homes through home health, hospice, and other community-based care agencies (both public and private). Social workers work with other allied health professionals in these settings, often as part of interdisciplinary teams. They are distinguished from other professionals by their knowledge of community resources and the range of options available to meet the biopsychosocial needs of clients, their psychosocial perspective and multidimensional assessment skills, and their skills in engaging elderly persons, their families, and the community in aspects of problem solving.

Social work interventions in health and long-term care often begin with a referral from another provider, such as a doctor or an administrator, or from routine screening or outreach protocols. Referrals are generally made in response to complicated psychosocial situations, the need to transition between settings, or the need for service arrangements. The social worker often completes a multidimensional assessment covering physical functioning, mental status, emotional health, social resources, living arrangements, physical environment, informal and formal service use, and financial resources. Social work values also call for assessing values and preferences of older adults and their families to enhance care planning.

Social workers implement a variety of interventions in health and long-term care settings. Clinical case management is often needed in these settings. Case management is an intervention aimed at organizing an effective and efficient package of services to meet client needs. Primary tasks include assessing service needs, planning with older clients and their families, care arrangement and coordination, follow-up, and monitoring. The termclinical case management is used because counseling is important in this process; it is more than just information and referral. Family dynamics are complex, clients refuse services, clients and personal care workers clash, and service needs change for clients who have degenerative conditions. Family care and assistance from formal sources must be balanced. Also, the development of service arrangements depends on client resources and entitlements, which the social worker must understand accurately. This can be challenging because even though numerous federal, state, and local programs provide health and social services and income to older adults, financing care packages is usually difficult. Social workers must know the programs that affect their clients, assist clients in obtaining coverage, and maximize the use of these financial supports while helping clients and their families to budget costs that must be borne privately.

Social workers provide discharge-planning services to patients in nursing homes, day treatment [Page 531]programs, and hospitals. They are also called on to help with other transitions such as home to day care center and home to nursing home. Social workers strive to ensure continuity of care, to ease adjustment, and to maximize client self-determination and choice. Within health care facilities, and in conjunction with community-based organizations, they organize and lead therapeutic groups that address various challenges such as widowhood, caregiving, and recovering from or adjusting to stroke or Parkinson's disease. Critical to the counseling function offered by social workers is psychoeducation to clients and families about disease and disease management (e.g., depression, Alzheimer's, diabetes, sensory impairment). Social workers are also members of hospice teams that provide planning for end of life care as well as counseling for dying patients and their families.

...