Improving the Health Care of Older Adults Through Social Work

Improving the Health Care of America’s Older Adults Through Social Work The John A. Hartford Foundation Corinne H. Rieder Executive Director and Treasurer National Association of Deans and Directors of Social Work Spring 2009 Conference Scottsdale, Arizona March 16, 2009

Overview
What are key problems in meeting the health care needs of our rapidly aging population?
The Hartford Foundation: What is it? Why Aging? Why is this important to Social Work?
What was the state of geriatric social work in 1999 when Hartford began its grantmaking & what has been accomplished?
Observations & opportunities for promoting aging in social work.

I. Key Problems in Meeting the Health Care Needs of our Rapidly Aging Population
Work Force Shortages
There are too few geriatrics specialists, including academics, in social work, nursing & medicine
Deficiencies in Health Care Delivery & Quality
Quality of care is often unacceptable
Systems of care may be inefficient & not well coordinated.
Patients & families not active partners in care provision

A. Work Force Shortages
Social Work
NIA estimated the need for 70,000 geriatric social workers by 2020.
Currently only 4% of students specialize in geriatrics despite the fact that 73% work with older adults & between 8% & 10% of social workers are employed in long-term care.

Social Work (Continued)
The number of programs is also decreasing. In the 1980s, 50% of MSW programs offered an aging specialization; by the early 1990s this had dropped to 33%, & as of 2003, only 29% offered an aging specialization.
Of the 2000 doctorates awarded nationally since 1995, only 289 (14%) focused on aging topics.

Medicine & Psychiatry
In medicine, certified geriatricians have declined from 8,000 in 1998 to 7,000 in 2004, or 1 geriatrician for every 2,500 older Americans.
Assuming current growth rates, by 2030 there will be only 7,750 geriatricians or 1 for every 4,250 older people despite a projected need for 30,000 geriatricians.

A. Workforce Shortages
Medicine & Psychiatry (Continued)
Currently there are less than 1,600 certified geriatric psychiatrists. At the present graduation rate, there will be only 1,700 geriatric psychiatrists in 2030, or 1 per 5,700 older Americans with a psychiatric disorder.

Nurses
The most recent projections of the nursing shortage range from 340,000 to 1 million nurses.
Of the 240,000 advanced practice nurses only 3,500 are geriatric nurse practitioners.

B. Deficiencies in Health Care Delivery to Older Adults
The quality of care is often unacceptable
The health care workforce receives very little geriatric training.
The health care needs of older adults are frequently neither comprehensively addressed nor patient-centered.
Too little attention is paid to providing preventive services & coordinating the treatment of chronic & acute care conditions.

B. Deficiencies in Health Care Delivery to Older Adults (Continued)
Services are often not provided efficiently.
Providers need to be trained to work in interdisciplinary teams & financing & delivery systems need to support these teams.
Care coordination is essential & patient transitions need to be facilitated across various delivery sites. All providers need access to patient information.
A number of new cost-effective models have been developed & tested which improve patient outcomes, which should be widely adopted & adapted.

B. Deficiencies in Health Care Delivery to Older Adults (Continued)
Patients & their families are too often not active partners in patient care or supported.
These partnerships need to include the adoption of healthy lifestyles, self-management of chronic conditions & increased participation of patients & their families in decision making.
The 33 million caregivers providing help to adults over 50 need support and training.

But it Doesn’t Have to be this Way! I Can Envision a Time When:
Older adults receive quality health care from sufficient numbers of well-trained health professionals.
Care for older adults is comprehensive, patient-centered & coordinated.
Health professionals are trained to & work in interdisciplinary teams, & our country’s financing & delivery systems support them.
Our health care system takes account of the increasing social, demographic & geographic diversity of older adults.
Health care is seamless across various delivery sites & all clinicians have immediate access to patients’ health information & communicate with one another.
Older people & their families are active partners in their care & where there is greater attention to & financing of disease prevention, the adoption of healthy life styles & the preservation of function.

II. The Hartford Foundation
80 year old, $434 million foundation
30 year history in improving the health of older people
Narrow & consistent focus is unique for a foundation our size; peers multiple foci & shorter term commitments; less than 2% philanthropic dollars go to aging
Places importance on partnering: 2 major partners spending down (Atlantic and Reynolds)
National in scope; put a premium on projects that can be sustained & have a multiplier effect, while avoiding duplicating the efforts of others
Strategic in grantmaking; rarely fund proposals that come over the transom
Committed $400 million to 200 organizations over the past 30 years

The Impact of the Current Recession on the Hartford Foundation
Independent foundations like Hartford rarely have new money coming. Depend solely on the growth of investments.
Nor, obviously, do they have a stream of tuition or research monies or grateful alums.
In October 2007, Hartford was a 78 year old Foundation with an endowment of $750 million instead of $434 million.
With a $320 million decrease in its endowment, the Foundation has been forced to cut not only many future grants, but also current grantees. Something that has been very painful for us to do.
Despite the recession Hartford will maintain our commitment to improving the health care of older people & will increase its efforts when the stock market recovers & the endowment again grows.

Hartford’s Strategies
The Foundation pursues 3 strategies:
Education & training
Improved service delivery
And, drawing excellent scholars into aging R&D to advance knowledge and improve practice.

The bequest from John A. Hartford, which established the Foundation, directed future Hartford trustees
“ to do the greatest good for the greatest number.”
And…”to carve from the whole vast spectrum of human needs one small band that the heart and mind together tell you is the area in which you can make your best contribution.”

The Foundation’s Choice & Its Importance to Social Work & to You
Given Mr. Hartford’s wishes, what led the Foundation to choose improving the health care of older adults as its goal?
1. Respect for Mr. Hartford’s desire to focus on a limited area to achieve maximum impact & to stay within health, his major area of interest.
2. The demographics.
3. No other foundation had that area as a major focus.

Why are the Demographics Important?
The growth of older Americans is dramatic.
It is widespread across the country.
The increase in the number of people over 85 & 100 years of age is especially large.
Chronic diseases increase with age as do the use of health care services & their costs.

Growth in the Number of Older Adults
Those over 65 years of age will double between 2000 & 2030, growing from 35 million to over 70 million.
Much of the growth is attributed to the “baby boom” generation born between 1946 & 1964.
85+ the most rapidly growing group, going from 1.5% in 2000 to 5% of population in 2050.
100+ projected to grow from 50,000 to 800,000 over the same time period.

US Population Pyramids

Increases in the Oldest Old U.S. Population Aged 85+ (in millions) Sources of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005; U.S. Census Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004.

The Prevalence of Chronic Diseases Increases with Age: Data from 2003-2005 4% 13% 27% 37% 7% 31% 49% 55% 2% 8% 19% 24% 0% 10% 20% 30% 40% 50% 60% 18-44 45-64 65-74 75+ Age in Years Heart Disease Hypertension Cancers

The Use of Health Services Also Increases with Age
Older adults represent 13% of the population, yet account for:
46% of patients in critical care
50% of hospital days
50% of specialty ambulatory care visits
70% of home health services
90% of residents in nursing facilities

What Other Challenges does our Nation Face in Providing Quality Health Care & Social Services to Older Adults?
Health Care Discrimination & Ageism
The Growing Cost of Health Care & the Political, Financial & Ethical Issues Associated with that Growth & the need for, & difficulty in, achieving fundamental reforms to health care delivery

Why are these important to you & the Social Workers that you educate?
1. Discrimination & ageism negatively impact:
a. Quality of care that older people receive.
b. Recruitment of students into geriatric health professions.
c. Educational & training environment, i.e., poor care becomes standard care.
d. And, students need to be prepared to identify & treat older adults that have been abused &/or suffer from self-neglect.

Why are these Important to You? (Continued)
The growing cost of health care & the difficulty in achieving fundamental reforms to health care delivery
Annual Medicare costs are over $400 billion.
Growing concern about the mismatch between projected Medicare entitlements & the ability of the economy to pay for them.
Complex & divisive ideological & ethical issues are also at stake.

There are also Remarkable Opportunities to Make a Difference in Geriatric Social Work
Geriatric Social Work:
Is the key discipline for coordinating health care & long term care services for older adults & their families.
Has primary responsibility for supporting families & informal caregivers.
Takes the lead in promoting healthy life styles, reducing the incidence of chronic diseases & eliminating health disparities among different segments of the population.
Actively helps older adults maintain their psychological & cognitive health, including the promotion of social interaction.
Is increasingly attractive to philanthropy, business & governmental leaders.

III. How is Hartford’s Grantmaking in Social Work Meeting these Challenges? Are they succeeding?
What was the state of geriatric social work in 1999 when Hartford began its grantmaking in social work?
What has been accomplished through these efforts?

Where was Gerontological Social Work in 1999 when we began our efforts?
No national aging curriculum models .
No focused national recruiting into geriatric social work.
No articulation of competencies in aging to guide curriculum training.
No national training projects to prepare faculty to teach geriatrics.
Minimal resources to train staff or improve the overall care of older people.
No nationwide social work initiatives to improve care to older clients.

Where Were We By the Numbers?
Overall, less than 3% of social work graduates enrolled in geriatric courses.
2. ~95% of students took less than 2 courses on aging in their social work programs.
3. 73% of social work students report working with older adults.

Hartford’s Social Work Objectives
1. Prepare a geriatrically competent workforce.
2. Incorporate geriatrics in the education & training programs of all social work schools in the country.
3. Ensure that there are sufficient geriatric social work faculty members.
Develop, test and disseminate innovative, cost-effective models of training & care that improve social work services to older adults.
Draw national attention to the importance of social work’s role in improving the health care of older people.
6. Communicate the idea that older adults are “a core business” of health care & of social work.

Hartford Financial Commitments to Social Work to Achieve these Objectives
1999-2008
$70 Million authorized
($64.5 million in education & $5.5 million for
research and new models)
$47 Million paid out
34 Major grants approved

Hartford’s Leveraging: 2001-2007
Total Funding Brought to Geriatric
Social Work: $163 million
$

Partnerships
The Archstone Foundation
The Atlantic Philanthropies
The Hearst Foundations
The Jacob and Valeria Langeloth Foundation
The Helen Bader Foundation
Veterans Administration
National Institutes of Health
National Association of Social Workers
AARP Andrus Foundation
The Louis and Samuel Silberman Fund
The Administration on Aging
The Centers for Disease Control
Werner and Elaine Dannheisser Trust
Plus approximately 50 local funders

Hartford’s Social Work Initiative
Broadly speaking, Hartford’s Social Work is
organized around 3 themes:
Academic leadership development
Faculty Scholars Program
Doctoral Fellows Program
Pre-dissertation Awards
The Leadership Academy in Aging
Curriculum for aging
GeroEd Center (previously GeroRich, SAGE S/W)
Providing real-world training for social work students.
Hartford Partnership Program for Aging Education (HPPAE, formerly PPP)

What’s Been Accomplished and Where are We Today?
81 scholars in 8 cohorts. Of the 81 scholars, all who have applied for tenure received tenure. These scholars serve on the faculty of 37 schools in 28 states; they have written 260 book chapters, 21 textbooks, & the 1 st 6 cohorts have published 612 articles in top tier journals; overall these scholars have made 1,605 research presentations & were awarded 206 grants.

What’s been Accomplished and Where are We Today? (Continued)
2. 69 doctoral fellows have been selected who show promise to become faculty leaders in geriatric social work. Of these, 35 former doctoral fellows hold full-time faculty status or post-doctoral appointments; almost half (32) are still engaged in dissertation research.
3. 80 Pre-Dissertation Awardees have been selected; 16 have gone on to become doctoral fellows; 8 applied for the August selection cycle, and 26 more plan to apply this year.

Curriculum grants resulted in new aging curricula being disseminated & adapted by over 180 schools .
Gero-Ed is a model for the development of additional competencies (CSWE EPAS).
6. Aging-content is being increased in social work text books.
7. Geriatric questions have been written for social work licensing exams.
HPPAE has been adopted in 72 schools in 32 states.

9. In January 2006, The Handbook of Social Work in Health and Aging was published, a 1,000-page reference text edited by Dr. Barbara Berkman & authored by 33 scholars and 31 program mentors.
A national leadership development program for deans & directors has been established to strengthen skills & promote gerontological social work.
11. At this meeting, Dr. Nancy Hooyman, is unveiling her new book, Transforming Social Work: The First Decade of the Hartford Geriatric Social Work Initiative.

IV. Observations & Opportunities for Promoting Aging in Social Work
Observations
Recommendations for promoting aging in social work

8 Observations About Social Work
The general public & some health professionals are not fully aware of social work’s real & potential contributions to improving the health care of older people. Nor, do they understand the expertise that social workers bring to the table. Within the field, there has been inadequate attention given to program evaluation & measuring the cost-effectiveness of social work services. These factors contribute to social workers being underutilized & sometimes feeling that their skills are undervalued.

Observations (Continued)
2. Who speaks for social work education nationally? The field of social work is fragmented by its multiple national associations. This situation reduces its impact in a variety of ways & dilutes the potentially pivotal role played by deans & directors.

3. Social work is a complex & challenging profession with a commitment to meet the multiple needs of our country’s diverse population. While this is a positive, the field can also become so fragmented that it overlooks common human needs that cut across specific population groups, e.g. aging, income inequality.

Is there too much separation between policy & practice within social work programs? Do social work’s diverse roots in clinical practice & community organization prevent policy from being fully integrated into the field’s curriculum, clinical practice & research efforts?

5. Improving the health care of older people is an interdisciplinary effort in practice, policy & R&D. How well connected are you and your school’s faculty with counterparts in medicine, nursing & other health professions? Are there silos or turf battles that need to be addressed in your institution? How much have you exploited the resources of other professions to advance social work?

6. Social work needs more research focused on: a) better understanding & improving service delivery, b) the assessment & teaching of required competencies that need to be exercised in specific care environments, and c) evaluation & cost-benefit studies of different interventions. Private funders ask: Where in social work is the health services research that we see in medicine and nursing?

7. Some colleges and universities seem unwilling to assume a responsibility for meeting national work force needs. While this tendency may be less in social work, it still takes its toll on school & departmental resource allocation decisions & pressure to bring in research funding in research intensive universities. How is this viewed in your institution? Does it impact your school?

OBSERVATIONS (Continued)
8. Some in leadership positions argue that social work is not sufficiently proactive, future oriented & strategic. They attribute this to it being a “helping” profession & the field’s clinical orientation, thus focusing on & reacting to specific “here & now” health & social problems. Are deans & directors, in your view, honing their strategic skills to think & plan for the future?

One Recommendation
Incorporate Geriatrics into your
School’s Program

11 Ways to Incorporate Geriatrics into your School’s Program
Infuse geriatrics across the curriculum in existing non-geriatric courses & increase stand-alone courses. Exercise your leadership to include geriatric competencies & content in state licensing exams. To assist you, access the extensive teaching & curricular resources through WWW.Gero-EdCenter.org.
Exert your influence to ensure that the new EPAS emphasis on context, e.g. demographics, is applied in reaffirmation/accreditation processes. The Gero-Ed and HPPAE programs have the best developed geriatric social work competencies now available.

Incorporating Geriatrics (Continued)
Increase the number, quality & variety of clinical experiences that students experience with older people & the institutions that serve them. Also, educate social workers to measurably improve the health outcomes of family caregivers. Again, HPPAE is an excellent model to adopt.
4. Increase the number of social workers focused on geriatrics at all levels of social work including health, substance use & mental health specializations (Gero-Ed Center Masters Advanced Curriculum Project—MAC).

Hire more faculty members with expertise in gerontology. Help faculty re-train in geriatrics when possible.
Increase efforts to obtain government, corporate & philanthropic support to expand aging social work programs, especially important are monies for financial assistance to master’s & doctoral level students. Given social work salaries relative to those of other health professionals, it is critical that deans & directors advocate for & speak up on state & federal legislation providing student financial assistance, including proposals for loan forgiveness.

Deans & directors are eager that faculty members apply for & receive Hartford & other funding, but they also need to support faculty with sufficient in-kind resources & additional funding beyond that which foundations provide.
8. Support the adoption & adaptation of existing evidence-based social worker models, such as the Hartford Partnership Program in Aging Education (HPPAE), that improve the education of trainees and the delivery of health care services to older patients.

9. Initiate interdisciplinary teaching programs so graduates are better able to work in interdisciplinary teams, especially serving frail older adults.
10. Have your school take a leadership role in critical geriatric areas where there is insufficient attention, strategies, models & creativity. Among those that stand out are: 1) prevention & public health, & 2) mental health, both diseases and social isolation.

11. Increase educational, research & practice relationships with non-social work schools in your institution to better prepare social workers to assume managerial, policy & leadership roles within & outside social work programs & academic health centers. Social work leaders also need to strengthen their partnerships with community leaders to provide better services to older adults.

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Improving the Health Care of Older Adults Through Social Work

by National Association of Deans and Directors of Schools of Social Work on Sep 17, 2009

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Improving the Health Care of Older Adults Through Social Work — Presentation Transcript