The Future of Nursing Home Social Work
Social Work Today
By David Surface
Vol. 4 No. 4 p. 19

Imagine a world in which medical students knew that more than two-thirds of their future practice would be comprised of cancer patients but less than 5% of their training was devoted to cancer care. No medical school would allow this to happen. Yet, it is exactly the situation that new social workers find themselves in when it comes to working with older adult clients.

It’s common knowledge that the population of older adults in America is expected to hit record numbers as baby boomers reach retirement age. While other industries are preparing themselves for this eventuality, most experts agree that social work is lagging.

In a 1998 report from the Center for Work Health Forces Studies in Albany, NY, 62% of social worker respondents said gerontological knowledge was required for their degree, but less than 3% said they were enrolled in specifically labeled aging programs.

“We know from experience that most social workers are going to have older clients directly or via their clients’ families,” says Jim O’Sullivan, program officer at the John A. Hartford Foundation, an organization dedicated to helping meet the health needs of older Americans. “Schools of social work are not preparing all of their students for that reality, however, and graduates find—to their surprise—that they have a lot of older clients to work with.”

Perhaps one of the most unfortunate results of the lack of attention to older adults in the social work educational establishment is its effect on nursing homes. “Most of the people I’ve talked to in the nursing home industry say there used to be more master’s-trained social workers,” says Scott Miyake Geron, PhD, director of the Institute for Geriatric Social Work (IGSW) at the Boston University School of Social Work. “In recent years, social workers’ presence in nursing homes has been minimized.”

The Problem of Regulation
According to Geron, it’s the regulatory environment that makes culture change in nursing homes especially difficult. “Nursing homes are among the most regulated industries in the nation,” says Geron. “Usually, these regulations end up stifling innovation because they force the providers to spend too much time on compliance-related issues that have mostly to do with safety, which is important, but it doesn’t leave much consideration to more important issues such as client empowerment. There must be changes on the regulatory side that allow and create greater autonomy for residents and great innovation at facilities.”

In addition to the current regulatory structure stifling creativity and innovation, current reimbursement options have also had a negative impact on the role of social workers in nursing homes. “Medicare and Medicaid reimbursement barely covers the cost of providing custodial and skilled nursing care now,” Geron says, “so facilities cut back on their services, and one of those areas is social services in general and social work in particular.”

According to Geron, many of the social workers who are still employed by nursing homes are restricted to duties that make little if any use of their professional skills. “Social workers do too much paperwork and do not get to spend as much time working with the residents and their families around the important issues that these folks are dealing with—loss of functioning, fear, concerns about death and dying, grief. That’s where we’d like social workers to use their skills and training.”

For social workers forced to work under these restricted conditions, Geron believes the situation is particularly stressful. “Think of a well-trained social worker who can see the needs of their clients, and they can’t do anything about it,” says Geron. “We have to change what nursing homes are and make them a better place for social workers to practice.”

Changing the Setting
According to Geron, there are at least two movements underway to change the nursing home setting and make it more attractive to social workers. The first is the Pioneer Network, a nonprofit organization that seeks to empower nursing home residents to have more control over their lives, organizes staff in cooperative teams that care for the same residents, and redesigns the space to provide more privacy. The second, the Eden Alternative (“A Journey in Honoring Our Elders: The Eden Alternative”; Social Work Today, January 27, 2003), also attempts to effect culture change in nursing homes and is known by its efforts to bring animals, children, and plants into the facilities.

Geron points out that both movements were started by providers. “Providers know that no one wants to go into nursing homes,” says Geron. “Nursing home providers know they need a different model if they’re going to survive.”

The Attitude Factor
Granted that regulatory and reimbursement restrictions make nursing homes an unattractive career choice for many new social workers—if those factors improved, would new social workers still be reluctant to enter nursing homes? Geron believes so.

“In the past, the population social work students want to work with are kids and families, not older adults,” says Geron. “Most social workers starting their careers still do not see older adults as an attractive group to work with. That is beginning to change, but it has not been easy.”

O’Sullivan agrees that social attitudes play a role in new social workers’ reluctance to take jobs at nursing homes and believes those attitudes can be changed. “We’ve seen convincingly at schools of social work that when students get meaningful exposure to a wide range of older adults, those attitudes can change,” he says. “The social work educational establishment is starting to look for ways to give students a realistic picture of older clients. The stereotypical older client is a person who is minimally functioning and a difficult professional challenge. That’s only one part of the work, but until recently it’s been the only part students know about.”

Infusing the Curriculum with Aging-Related Material
“The Hartford Foundation’s main program goal is to increase our nation’s capacity to deal with the health needs of older Americans,” explains O’Sullivan. “Eighty percent of our funding goes toward training the nurses, doctors, and social workers of tomorrow how to work with older patients. There’s relatively little capacity for medical schools, nursing, and social work schools to do this, even though much of their graduates’ future client base will be older adults.”

Between 1998 and 2003, the Hartford Foundation awarded $26.3 million in grants for gerontological social work eduction. The foundation’s curriculum projects are focused on providing training and aging-related curriculum resources to professors who self-identify as being interested in gerontology. “Hundreds and hundreds of people have attended these workshops,” says O’Sullivan. “The program works through regional trainings and, in addition, we have two programs to identify and cultivate social work faculty who might be interested in gerontology.”

“Schools must do more to infuse aging-related content into their courses, like the Hartford Foundation is doing,” agrees Geron. “Those kind of efforts have made a huge difference, but I still believe it’s a drop in the bucket. Typically, schools don’t like change and it takes a real commitment from the top down to implement these changes. We’ve got a long way to go before schools do this as a matter of course.”

Reaching Social Workers in the Field
Even if schools of social work do start providing more aging-related courses, what about practicing social workers in the field who are currently working with older adults?

“Specialized training in aging for practitioners who have already received their social work education at the BSW or MSW level offers the greatest potential and most cost-effective approach to improve care for older adults,” says Geron. “No matter what we do on the education side, we must address the needs of practicing social workers who are out there and need more training and education to work effectively with older adults.”

“The Institute for Geriatric Social Work was funded by The Atlantic Philanthropies to do just that—provide practicing BSW and MSW social workers, the large majority of whom have received little or no geriatric training, with the knowledge, skills, and tools they require to work with older adults and their families,” says Geron. “IGSW is particularly focused on serving social workers who already work with older adults, but we believe that all social workers, no matter what their practice setting, can benefit from training in aging.”

Funding — Why is Gerontology a Hard Sell?
Funding for social work gerontology has historically been problematic. “There has not been money for gerontological research in the past,” says O’Sullivan. “In the ’60s, there was some funding available, but that dried up in the ’70s. Doctors can get some training money through Medicaid and Medicare funding, but there is no similar mechanism for social workers.”

The Hartford Foundation is doing its part to change the funding situation for gerontological studies. “Our doctoral fellows do gerontological dissertations to prepare for academic careers and to publish and get grants,” says O’Sullivan. “The Hartford Faculty Scholars Program supports people who are already associate or assistant professors and have some interest in gerontology, but because of the way the money has gone have not been able to do the kind of research in aging they might have done otherwise.” O’Sullivan reports that the Hartford Foundation Trustees recently authorized an additional $2 million for social work dissertations and faculty programs.

O’Sullivan believes the popularity of social service studies and programs aimed at other populations such as children creates a funding pattern that’s hard for gerontology to break into.
“People apply for, say, child welfare money, and they get a grant,” says O’Sullivan. “That naturally leads to more people applying for child welfare money and more funding being allocated to meet that demand. You go where the money is. Unfortunately, there has not been the development of that kind of investigator-initiated funding stream for gerontology. If you want to work on older people, you have to find your own path. Now, we’re going to be able to help a lot of those people.”

O’Sullivan recognizes that gerontology faces an uphill battle when it comes to competing with children’s programs for funding. “It’s hard to make geriatrics as warm and compelling as kids,” says O’Sullivan. “That’s not to knock kids and that important work, but it’s much easier to make a case that ‘we’re doing something for the next generation.’ That starts a spiral, which gets new research started, and those grants and programs attract yet more money. We’re trying to do that now for gerontology in social work. It’ll take some time before it’s self-sustaining.”

Proving the Effectiveness of Gerontological Social Work
In today’s highly competitive funding environment, funding applicants are under pressure to document the effectiveness of their programs—an area where geriatric social work falls short. “The lack of an evidence base for the efficacy of geriatric social work is causing us to run into a brick wall at the policy level,” says O’Sullivan. “It’s not fair because other disciplines have not been subjected to the same pressure to prove effectiveness, but that’s the way it is. Until geriatric social work can prove it’s working, it’s going to continue to be a stepchild in getting research dollars and federal funding.”

The need for a stronger research base to influence policy is also recognized by IGSW. According to Geron, the lack of regular reimbursement stream for geriatric social work is one of the principal obstacles to promoting aging practice in social work. “To make the case to policy makers to reimburse geriatric social work, we need better research that shows the real contributions that social workers can make to improve the lives of older adults and their families.”

Geron reports that IGSW is committed to conducting the type of large-scale clinical studies that meet both the high standards of research and also address potentially reimbursable areas of practice. “We are beginning a large randomized controlled trial this year to test the effectiveness of a social work intervention in primary care with frail older adults,” says Geron. “I think this will be the most important social work research project in the country—and the kind of study that is needed to influence policy makers.”

Reason to Hope
Despite the many challenges that social workers face in preparing themselves to work with the aging of America, O’Sullivan and Geron both believe the change is inevitable.

“Given the demographics of this country, it’s clear that aging is going to have a powerful effect in our country and society,” says Geron. “Eventually, the negative images are going to change. Models of intergenerational care are going to filter down into social work. Before long, it’ll be commonplace to think of all problems in intergenerational terms because there’ll be older adults involved even when the client is a child. That change will promote aging as a specialty practice for social workers.”

“Social work education has recognized the need,” says O’Sullivan. “Five years ago, gerontology was difficult for people to focus on—at conferences now, the rooms that have gerontological topics have standing room only. Broadly speaking, the social work educational community understands that their students need to know gerontology and know it well. That’s the field stepping up to the plate.”

— David Surface is a freelance writer based in Brooklyn, NY.