Rehr/Fizdale Professor Columbia University School of Social Work National Director Hartford Faculty Scholars Program

Recent years have witnessed a significant upgrade in the quality of research that is published, particularly in health and aging. Theory has become richer; datasets are larger and more reliable; new methodologies have become available; and computing power and techniques have advanced. As social workers, we are making significant strides in our efforts to understand and study issues related to our practice in health and mental health care with older adults and their families.

Five societal trends pose significant challenges to society and to social work practice: living with chronic illness, community-based practice, patient diversity, family caregiving, and palliative and end-of-life care (National Institutes of Health, 2003). This paper looks at these trends, tying them to research priorities which a panel of social work researchers in the United States identified as most significant (Raveis, Gardner, Berkman and Harootyan, 2010).

Chronic illness

Today there are significant changes in outcomes of patient care stimulated by technological advances in biomedicine and pharmacology. People are living longer with complex chronic physical and mental health issues, which can be long term or permanent, often requiring monitoring and management for extended periods of years (Administration on Aging, 2008). The leading causes of morbidity and mortality are almost all related to chronic diseases, resulting in acute episodes of illness over a lifetime of chronic processes (Paulson, 1994). These elderly people often have significant functional impairments and quality-of-life issues (Gonyea, Hudson and Curley, 2004; Burnette and Kang, 2003).

The view that illness is a chronic process raises the question of whether an acute episode can be prevented, placing importance on consumers in determining their health care needs and outcomes (Berkman, 1996). The focus of care becomes primary care, with an emphasis on disease prevention and health promotion (Paulson, 1994). Our research priority becomes changing lifestyle and other social environmental influences which can impact outcomes of health in aging.

Thus, self care in health promotion is an important area of research in which social workers have been significantly involved. An excellent example is Susan Hughes’s application of the “Fit and Strong” intervention, a video-based physical activity program for people with chronic arthritis, focused on social workers helping to boost adherence to a prescribed physical activity (Hughes, et al., 2004). Another good example is the work of Sudershan Pasupuleti, who is doing groundbreaking research in brain fitness in older adults using simulation software paired with physical activity to help increase cognitive function (Pasupuleti, in press). The state of the knowledge in the area of changing lifestyle behavior is still very basic, and we need more interventions that focus on prevention and health promotion.

Community-based practice

The majority of chronically ill older patients are living in the community with interacting physical and mental conditions that diminish one’s capacity to function independently. This results in significant health and financial burdens for the affected individuals, and also impacts their families. This challenges us as social workers to expand our intervention skills to enable patients and families to access and utilize social and health care services effectively so as to improve their quality of life (Berkman, Gardner, Zodikoff and Harootyan, 2005). The emphasis on community-based services is increasingly essential.

Research on home- and community-based long-term care has focused primarily on physical health, an important outcome. However, an equally important research priority in long-term care is to maintain health and functioning and preserve quality of life in the face of chronic care and functional needs (Robert, 2003). Innovative models of service delivery are now being developed to impact the environmental and psychosocial factors which can have detrimental effects on quality of life, morbidity and mortality (Raveis, Gardner, Berkman and Harootyan, 2010). For example, Amy Horowitz has studied the course of depression over time as it affects, and is affected by, impairment severity, functional ability and rehabilitation service utilization (Horowitz, 2003; Horowitz, Reinhardt, Boerner and Travis, 2003; Horowitz, Reinhardt and Kennedy, 2005). Researchers are also actively involved in developing and testing interventions to alleviate geriatric depression, which often goes unreported, undiagnosed and untreated (Gellis, et al., 2004; Pickard and Guo, 2008). As an example, Gellis and colleagues conducted a randomized clinical trial to compare Brief Problem-Solving Therapy in home care to usual care for a sample of older medically-ill home care patients with severe depression (Gellis, McGinty, Horowitz, Bruce and Misener, 2007).

Increased Patient Diversity

The older adult population is increasingly diverse in terms of age, race, ethnicity, gender, and socioeconomic status. There are vast differences in factors affecting their health care in terms of emotional reactions, health beliefs, health care utilization, health risks, and patterns of relationships with family members (Johnson, 2005; Maramaldi and Guevara, 2003). A priority for social work researchers is focusing on designing interventions that aim at reducing health disparities by effectively addressing the physical and mental health problems confronting elders and family members from different cultural backgrounds. A recent example of intervention research in this area is Letha Chadiha’s design and testing of an innovative empowerment intervention for African American women caregivers, which may have a significant effect on positive caregiving outcomes (Chadiha, Adams, Phorano, Ong and Byers, 2003; Chadiha, Adams, Biegel, Auslander and Gutierrez, 2004). And we can appreciate research developing culturally and linguistically appropriate communication materials aimed at decreasing barriers to cancer screening for racial and ethnic minority groups (Maramaldi and Guevara, 2003).

Increased Family Caregiving

Another emerging societal trend that challenges social work practice is the increasing expectation that families will assume responsibility for home care needs of their loved ones, despite the fact there is a reduction in the numbers of family members available to provide care (Gardner and Zodikoff, 2003). Thus, the burden of care is falling on fewer family members, who may have less physical, psychological, social, financial and environmental resources to provide such care.

In family caregiving research, social work has taken a leadership position, recognizing that family caregivers, who help patients maintain functioning, have their own health problems, being very prone to depression and physical problems. The research priority focuses on improving their quality of life. Marsha Seltzer, Jan Greenberg, and Lydia Li are just a few of the many social work researchers examining the experiences of caregivers, and are testing interventions to help alleviate stress. Innovative responses to the needs of caregivers are required if persons with disabilities are to remain in the community with quality of life (McCallion, Toseland, Gerber and Banks, 2004).

One risk associated with the increased burden of family caregiving is elder mistreatment. Although most social workers are aware of the individual and societal costs of elder mistreatment, there is little known about the incidence, the precipitating factors, the consequences and effective treatment of this form of family violence (Paveza and Vande Weerd, 2003). There remains a serious need for empirical research to address this multifaceted public health concern. Social workers leading new efforts in this specific area are Greg Paveza, Tazuko Shibusawa and Pat Brownell.

Palliative and End-of-Life Care

Palliative and end-of-life care are growing areas of significance to social work practice. Social workers offer a uniquely valuable perspective to intervention and research efforts in these arenas. These perspectives value families, communication, and a focus on the person-in-environment. The evidence base in this arena remains limited, but there is now growing interest in building knowledge of the dying experience in both acute care and long-term care settings where most deaths occur. Psychosocial challenges associated with death and dying include managing pain, anxiety and depression, caregiving needs, and the need for social support and communication among family members and providers (Morrison and Meier, 2003).

While psychosocial outcomes of treatment at the end of life or as a result of palliative care may be difficult to quantify, or to measure, social scientists are leading the way forward in this growing field of research and practice. Research may focus on any number of relevant outcomes, such as satisfaction with palliative or end of life care, quality of life, social adjustment, and compliance with patient and family preferences for place of death (Ringdal, Jordhoy and Kaasa, 2002; Corner, et al., 2003; Tudiver, Hilditch, Permaul and McKendree, 1992; Ratner, Norlander and McSteen, 2001). Researchers such as Aloen Townsend, Mercedes Bern-Klug, Betty Kramer, Deborah Waldrop and Dan Gardner are beginning to make distinct research contributions in these areas. The values and perspectives of the social work profession, such as person-in-environment and the strengths-perspective, can place social work in the mainstream of this research agenda.

Summary

The societal trends of increased chronic illness, community-based practice, patient diversity, and family caregiving, and increased attention to palliative and end-of-life care are expected to continue well into the future. The expansion and diversification of the older adult population will most likely generate increasing demand for health care services such as home health and long-term care, and research will be challenged by many new trends. As society grows older and a greater proportion of adults experience chronic conditions our expectations of later life will change dramatically with respect to employment, housing, social relationships, independent functioning and quality of life.

Conducting research with older people will continue to be challenged by the complex multidimensionality of the problems they face. With multiple conditions, multiple providers, and multiple interacting treatments, the study of older adults is never simple. They may simultaneously confront significant physiological, psychological, and social impairments, and measuring outcomes of treatment activities may require an array of measures across multiple domains during both the assessment process and after the intervention. However, the future of social work practice in geriatric health care relies on our ability to generate meaningful research on health-related psychosocial problems. With increasing research, social work educators will be able to integrate evidence-based knowledge into their curricula and teach our future professionals to use empirically derived intervention approaches in their practice with older adults and their families.

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