Fluent Essays

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. By Day 3 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. Support your posts with specific references to the Learning Resources. Be sure to provide full APA citations for your references. 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.  2 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  3 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   4 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.   5 Christ & Diwan Chronic Illness—Role of Social Work 6 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 7 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.  8 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. 9 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. …