The Social Work Role in Reducing 30-Day Readmissions: The Effectiveness of the Bridge Model of Transitional Care

The hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. Novel approaches to addressing the complexities of transitional care are emerging as possible solutions. The Bridge Model is a person-centered, social work-led, interdisciplinary transitional care intervention that helps older adults safely transition from the hospital back to their homes and communities. The Bridge Model combines 3 key components—care coordination, case management, and patient engagement—which provide a seamless transition during this stressful time and improve the overall quality of transitional care for older adults, including reducing hospital readmissions. The post Affordable Care Act (ACA) and managed care environment’s emphasis on value and quality support further development and expansion of transitional care strategies, such as the Bridge Model, which offer promising avenues to fulfil the triple aim by improving the quality of individual patient care while also impacting population health and controlling per capita costs.     

New Directions for the Study of Incarcerated Older Adults: Using Social Capital Theory

As the population of older adults continues to rise, so, too, does the population of older adults in prison. The body of literature on older adults in corrections is scant, particularly with regard to health and social functioning. Past studies of aging inmates primarily focus on health care and related costs. The purpose of this article is twofold: (a) outline and synthesize the research on older adults living in prison; and (b) propose a framework for future research and intervention development based on social capital theory. Recommendations for social work practice, programs, and research are discussed.     

Disaster Preparedness among Older Adults: Social Support,Community Participation,and Demographic Characteristics

This study examined factors associated with disaster preparedness among older adults, with special attention paid to demographic characteristics, social support, and community participation. From a larger study about disaster preparedness of persons with disabilities, a total of 719 adults aged 55 years and older were used for this study. The results of the logistic regressions indicate that individuals who have higher levels of social support and more connections to community organizations are more likely to be prepared for disaster-related emergency situations. In another model, using resource preparedness as the dependent variable, an interaction effect between social support and income was found. Overall, higher income and higher informal support are related to a higher level of resources for disaster preparedness. However, the relationship between income and disaster preparedness is much stronger for those sub-groups receiving more informal support. The findings of this study expand knowledge regarding issues of disaster preparedness among older adults and demonstrates the importance of social resources and networks. This study suggests an intervention model for decision-makers and community leaders in terms of providing information and advice to members of their communities about how to adequately prepare for natural disasters.     

Individual- and Contextual-Level Factors Affecting the Use of Social Support Services among Older Adults

ABSTRACT

By 2060, the number of Americans aged 65 and older is expected to more than double, while the number of Americans aged 85 and older is expected to nearly triple. As the nation's aging population grows, older adults will need to rely on social support services, such as transportation and housing services, in order to remain active and lead independent lives. In this study we use data collected from the elderly supplement of the Southeastern Pennsylvania Household Health Survey (SPHHS) (n = 3,042) to explore the relationship between the availability of elderly specific social service providers and utilization of social support services among older adults. We find that while the number of elderly specific social service providers can increase use of social support services among older adults, its impact is relatively minimal. We find that individual factors, instead, are stronger predictors of service use. This is a finding that should be particularly encouraging for elder care providers who may not have the resources needed to undertake large structural changes (like building new facilities). Still, future research should explore how the availability of a broader range of elderly specific social services (than explored in this study) impacts use.     

Awareness of LGBT Aging Issues Among Aging Services Network Providers

Very little research exists examining the interactions between community-based aging service providers and lesbian, gay, bisexual, and transgender (LGBT) older adults. It is unclear whether mainstream aging services acknowledge the needs of this community. We asked direct care providers and administrators in the Michigan aging services network to describe their work with LGBT older adults. We found there are very few services specific to the needs of older LGBT adults and very little outreach to this community. At the agency level, resistance to providing services was found.     

Pathways to age-friendly communities in diverse urban neighborhoods: Do social capital and social cohesion matter?

ABSTRACT

Using a social capital and social cohesion lens, we reposition the concept of civic engagement among older adults to examine pathways for building age-friendly communities. We analyzed data drawn from a Community-Based Participatory Research study in the Southern U.S. that explored lived experiences of older adults, age 55 and above, who participated in individual interviews (n = 15) and six focus group discussions (n = 45) to examine their perceptions of social identity, social connectedness, and civic engagement geared toward an age-friendly city. Findings indicated that several older adults had access to social networks and socially invested resources, thereby having opportunities for civic engagement and building age-friendly neighborhoods. However, social, cultural, linguistic, and structural barriers were more evident among certain diverse ethnic populations. Marginalized low-income minorities and immigrants, such as Hispanic participants, felt the lack of social cohesion among the larger society limited their ability to give back, thus decreasing their civic engagement activities. In contrast, Caucasian and African-American older adults were able to contribute to the political process through more civic participation activities. We provide implications for examining the role of social capital and social engagement to bolster civic engagement among older adults in building age-friendly communities.     

Anticipated Engagement in a Village Organization for Aging in Place

Although older adults prefer maintaining residence independently in the community as they grow older it is not always possible due to impairments, isolation, and changing health needs. Villages, an emerging consumer-directed care model providing social engagement and services, support aging in place. To be viable organizations villages must attract and enroll sufficient numbers of members. This study examined factors associated with older adults anticipated engagement as a village member. Using a cross-sectional survey design community residing older adults (N?=?193) identified predisposing, enabling, and need factors associated with anticipated engagement. Participants rated anticipated engagement between “Slightly Unlikely” and “Likely” (Mean?=?2.71, SD?=?1.31). A model including predisposing and enabling factors produced the best overall fit [?2 Log likelihood?=?246.514, χ2(8)?=?20.414, p.?=?.008] correctly classifying 61.1% of cases and explaining 13.4% of the variance according to the Nagelkerke R² statistic. Older adults who engage in preventative health behaviors may be predisposed to joining a village as well as those who are already engaging in supportive acts of neighboring. Villages might consider these factors in designing outreach and service programing. Future research should identify how factors such as income and personal health practices contribute to interest in village membership.     

Assessment of multiple constructs of social integration for older adults living in nursing homes

ABSTRACT

A variety of terms and measures have been used in the literature to denote being socially integrated, and many studies of older adults focus on only social networks or social support and often only include those living in the community. The purpose of this study was to assess multiple constructs of social integration (i.e., social networks, social capital, social support, and social engagement) for older adults in nursing homes. Data were collected from 140 older adults at 30 nursing homes in Kansas. We interviewed older adults’ in-person using a survey questionnaire, and used multilevel confirmatory factor analysis to analyze the data. The final model that included the four constructs had acceptable fit (χ² = 174.71; df = 112; p < .01; CFI = .93; RMSEA = .06; SRMR-W = .06; SRMR-B = .12). The results showed that the proposed model was supported at the individual level. At the between-level, social networks and social support were supported. Study results have methodological and practice/policy implications for the study of older adults in long term care settings. In particular, this study contributes to understanding how to operationally define and differentiate social integration variables in studies of older adults, particularly when study data are hierarchical.     

For the Sake of their Health: Older Service Users' Requirements for Social Care to Facilitate Access to Social Networks Following Hospital Discharge

Facilitating older service users’ requirements for accessto or re-engagement in social networks following hospital dischargeis recognized in social care analysis and policy as criticallyimportant. This is because of the associated benefits for restoringphysical health and psychological well-being. However, it tendsto be a neglected dimension of current social care/intermediatecare. Our paper draws on a qualitative study of voluntary sectorhospital aftercare social rehabilitation projects in five UKlocalities, which focused on addressing this issue. Throughexamining older service users’ feedback and experience,our study confirms the health benefits of social care facilitatingaccess to social networks at this crucial juncture. By providingsensitive interpersonal interaction, advocacy and ‘educational’assistance, social care workers supported older service users’re-engagement in a variety of networks. These included friendship,recreational and family groups, health care treatment programmesand locality based contacts and organizations. As a result,material, interpersonal and health care resources were accessed,which contributed to restoring and sustaining physical healthand psychological well-being. The process of such social carealso emerged as critical. This included ensuring that objectivesreflected service users’ priorities; integrating ‘low-level’home care; offering befriending; and challenging the pre-settime frame of intermediate care.     

Risk Management Paradigms in Health and Social Services for Professional Decision Making on the Long-Term Care of Older People

Risk management systems and structures are developing rapidlywithin UK health and personal social services. However, therisk management strategies of organizations need to take intoaccount the conceptual frameworks used by professionals. Thisgrounded theory study used data from nineteen focus groups andnine semi-structured interviews (ninety-nine staff in total)to explore perspectives on risk and decision-making regardingthe long-term care of older people. Focus group participantsand interviewees comprised social workers, care managers, consultantgeriatricians, general medical practitioners, community nurses,occupational therapists, home care managers and hospital dischargesupport staff. Social work and health care professionals conceptualizedrisk and its management according to six paradigms that appearedto be in a state of reciprocal tension: (i) Identifying andMeeting Needs; (ii) Minimizing Situational Hazards; (iii) Protectingthis Individual and Others; (iv) Balancing Benefits and Harms;(v) Accounting for Resources and Priorities; and (vi) Warinessof Lurking Conflicts. The effective translation into practiceof risk management strategies needs to address the complex andoften contradictory issues facing health and social servicesprofessionals.     

Connecting and engaging with health and social care: Exploring the core components of a telephone and web-mediated family navigation prevention service

Early engagement with health care, mental health care, and social services can promote the well-being of children and families. How practitioners can best support family engagement with these services however remains largely unknown. To address this gap in knowledge, data from a voluntary 12-week telephone and web-mediated family navigation preventive intervention called Navigate Your Way were subject to mixed-methods analysis. Twenty-nine caregivers and five family navigators contributed data to the study. Thematic analysis of weekly navigator check-ins, participant closing interviews, navigator discharge notes, and lab meeting notes was conducted and followed by quantitative analysis of navigator effort across project activities. Results were then mixed to illuminate the essential conditions for supporting family connection to health care, mental health care, and social services. Qualitative analysis identified themes related to empathic engagement and person-centred navigation as central to connecting families to needed services. Quantitative analysis of navigator effort identified participant outreach, weekly check-ins, service identification, and ongoing supervision as essential navigation activities. Together, providing an environment that is supportive, consistent, flexible, person-centred and tailored to families' specific needs are important for connecting to health and social care.     

The Role of Mastery and Social Support in the Association Between Life Stressors and Psychological Distress in Older Canadians

Gerontological social workers and other health professionals are often dealing with older adults in psychological distress. Greater clarity on the relationship between stress and psychological distress will enhance the efficacy of outreach and treatment initiatives for older adults. This study explored the underlying causal structure of the relationships of common life stressors and psychosocial resources for Canadians 65 years and older (542 men and 835 women). Using structural equation modeling of data collected in the National Population Health Survey in 2004–2005 and 2002–2003, the roles played by socioeconomic conditions, physical health, chronic stress, sense of mastery, and perceived social support in the stress–psychological distress relationship were estimated and compared. Findings revealed that chronic stress was the strongest determinant of the level of psychological distress for both genders; however its effect was higher for men compared to women. Poor physical health played a more important role in determining women's psychological distress compared to men. Higher levels of mastery and perceived social support were associated with lower levels of psychological distress for both men and women. These associations were somewhat stronger for men compared with women. Socio-economic conditions played a minor role in the stress–mental health relationship for both genders.     

The role of the voluntary,community and social enterprise sector in Early Help: Critical reflections from embedded social care research

The independent review of children's social care (2022) has proposed a radical reset of England's children's services, shifting a remote, assessment heavy system towards one that works alongside communities to help prevent statutory interventions. However, notions around the harnessing of community resources to deliver Early Help are often underpinned by assumptions regarding the voluntary, community and social enterprise (VCSE) sector and the ease with which such organizations can be integrated into preventative strategies. This paper reports findings from embedded research within a unitary authority in Southwest England during remodelling of its Early Help service to work more collaboratively with local VCSE organizations. The study generated data from ethnographic observations, semi-structured interviews and focus groups with 95 participants, including local parents, service providers, VCSE organizations and Council leaders. The findings illustrate that families value the compassionate, responsive and flexible support available within many VCSE settings. However, differences in practice cultures, regulatory pressures on statutory providers, the need to (re)build trust in communities and sensitivities around power-sharing and resourcing meant negotiating VCSE sector integration was fraught with complexities. Few studies have gained such privileged access to a Local Authority's remodelling of Early Help services, and this paper has significant insights for the debates surrounding the independent review of children's social care (2022) and its recommendation to bring services ‘closer to communities’.     

Chapter 16. Future Training and Education Recommendations for Rural Gerontological Social Workers

SUMMARY

With the increasing number of older adults, social work students need to be prepared to work with this population in a variety of settings. Rural areas may have high concentrations of older adults including those who age-in-place, and those who relocate to retirement areas in small towns and rural communities. Within the curriculum, content on health care, economics, and leadership/decision making need to be included to prepare students for practice in these areas. In addition, programs need to actively seek students who have an interest in working within more rural practice settings.     

Comparing Supports for LGBT Aging in Rural Versus Urban Areas

Studies of rural populations typically underrepresent lesbian, gay, bisexual, and transgender (LGBT) older adults. This secondary analysis examined data from a nationwide sample of LGBT baby boomers (n?=?1201). Geographic differences with respect to self-reported outness, acceptance of sexual identity, social and familial support, and household income were assessed with one-way analyses of variance. Guardedness about one's sexual identity and household asset levels were assessed with chi-square analyses. Rural individuals reported lower levels of outness, guardedness with people including siblings and close friends, and lower levels of household income. Providers should consider strategies for connecting older rural LGBT adults for potential care and support.     

Does Volunteering Experience Influence Advance Care Planning in Old Age?

Advance care planning (ACP) increases the likelihood patients will receive end-of-life care that is congruent with their preferences and lowers stress among both patients and caregivers. Previous efforts to increase ACP have mainly focused on information provision in the very late stage of life. This study examines whether a relationship exists between volunteering and ACP, and whether this relationship is associated with social support. The sample comprises 877 individuals who were aged 55+ in 2008, and were deceased before 2010. The sample is derived from seven waves (1998–2010) of data from the Health and Retirement Study. Logistic regression results showed that overall ACP and durable power of attorney for health care (DPAHC) were both higher (OR = 1.61 and 1.71, respectively) for older adults with volunteering experience in the past 10 years than those without such experience. Available social support (relatives and friends living nearby) was not associated with the relationship between volunteering and ACP. Other factors related to ACP included poorer health, death being expected, death due to cancer, older age, and being a racial minority. Involving older people in volunteer work may help to increase ACP. Future research is encouraged to identify reasons for the association between volunteering and ACP.     

An evaluation study of a dementia screening program in taiwan: an application of the theory of planned behaviors

A challenge facing dementia service providers is how to detect dementia early to facilitate timely intervention. This article reports findings of an evaluation study of a dementia-screening program in Taiwan utilizing the Theory of Planned Behaviors. We present the Short Portable Mental Status Questionnaire (SPMSQ) program rationale and examine the effects of this important health and social service intervention. Follow-up telephone interviews were completed by 108 respondents. Findings indicate that the SPMSQ program was successful in identifying suspected dementia. Results also show that the dementia-screening program contributed to an increase in medical service utilization and in unpaid informal care.     

Current Developments in Social Care Services for Older Adults in the Czech Republic: Trends Towards Deinstitutionalization and Marketization

ABSTRACT

Deinstitutionalization and marketization of eldercare has been delayed by 20 years in the Czech Republic compared to Western Europe, and it takes place in a completely different context, characterized by the legacy of communism, a growing older population, and less generous public subsidies. This study is the first in the Czech Republic to examine how deinstitutionalization and marketization effect implementation of these principles on the availability and quality of eldercare services at regional and municipal levels. A mixed-method approach was used, combining several data sources (policy documents, administrative data, statistics, expert panel, and secondary use of qualitative data). The findings suggest that the support for and availability of home-based care has declined, despite the ever-increasing number of older adults and policy preference for deinstitutionalization. Furthermore, home-based services have failed to adjust to growing care needs of older adults (e.g., inflexible schedules, limited provision of time-demanding care, inadequate staff composition). This situation occasioned an unintended outcome: the emergence of nonregistered, semilegal, for-profit nursing homes offering low-quality care and poor working conditions, and subject to no quality control. The health and even lives of older adults are at risk if they choose such services. Research is needed to study older adult decision making and offer them tools to identify and avoid questionable services.     

A Client Satisfaction Measure of Homecare Services for Older Adults

Client satisfaction can be used as an indicator for service quality. Without concrete feedback from clients, however, the usefulness of client satisfaction data for service improvement can be limited. This study described the development of a client satisfaction measure that can be used to provide concrete feedback for service providers. Based on a conceptual framework proposed in the literature, the Client Satisfaction: Home Care (CSAT-HC) uses a client-centered perspective to measure client satisfaction for homecare services for older adults. A survey of 200 older adults receiving homecare services provided by a social service agency in a large U.S. Midwest city was conducted to assess the psychometric properties of CSAT-HC. Results based on the 156 completed surveys show that CSAT-HC has good validity (correlation r = .62 with a popular client satisfaction measure) and test-retest reliability (r = .75). These results indicate that CSAT-HC is a valid and reliable client satisfaction measure; and therefore, providers of homecare services for older adults can use CSAT-HC to obtain client feedback for quality assurance or program evaluation purpose. Future research may use CSAT-HC to explore the potential influences of quality of homecare services on the well-being of older adult clients.     

Social Work Knowledge of Community-Based Services for Older Adults: An Educational Model for Social Work Students

Social workers are often the key link between older adults, their families and community-based services. Thus, knowledge about older adults and community-based care is imperative for social work practice. Evaluation data are provided on a national multisite effort (N = 353) from 35 schools to assure graduate social work student's competency related to community services for older adults. Results suggest that the educational model as described in this article sets forth positive outcomes in the education of aging savvy social workers. Ongoing social work education is needed to meet the burgeoning needs of the geriatric population.