Future trends in health and health care: implications for social work practice in an aging society.

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Future Trends in Health and Health Care: Implications for Social Work Practice in an Aging Society a

William J. Spitzer PhD DCSW & Kay W. Davidson DSW a

b

Glen Allen , Virginia , USA

b

School of Social Work , University of Connecticut , West Hartford , Connecticut , USA Published online: 20 Nov 2013.

To cite this article: William J. Spitzer PhD DCSW & Kay W. Davidson DSW (2013) Future Trends in Health and Health Care: Implications for Social Work Practice in an Aging Society, Social Work in Health Care, 52:10, 959-986, DOI: 10.1080/00981389.2013.834028 To link to this article: http://dx.doi.org/10.1080/00981389.2013.834028

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Social Work in Health Care, 52:959–986, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2013.834028

Future Trends in Health and Health Care: Implications for Social Work Practice in an Aging Society WILLIAM J. SPITZER, PhD, DCSW Downloaded by [Selcuk Universitesi] at 22:04 01 February 2015

Glen Allen, Virginia, USA

KAY W. DAVIDSON, DSW School of Social Work, University of Connecticut, West Hartford, Connecticut, USA

Major economic, political, demographic, social, and operational system factors are prompting evolutionary changes in health care delivery. Of particular significance, the “graying of America” promises new challenges and opportunities for health care social work. At the same time, the Patient Protection and Affordable Care Act of 2010, evolution of Accountable Care Organizations, and an emphasis on integrated, transdisciplinary, person-centered care represent fundamental shifts in service delivery with implications for social work practice and education. This article identifies the aging shift in American demography, its impact on health policy legislation, factors influencing fundamentally new service delivery paradigms, and opportunities of the profession to address the health disparities and care needs of an aging population. It underscores the importance of social work inclusion in integrated health care delivery and offers recommendations for practice education. KEYWORDS future U.S. health care directions, health care social work practice, education for health care social work practice

Received April 30, 2013; accepted August 8, 2013. Address correspondence to William J. Spitzer, 12208 Chadsworth Court, Glen Allen, VA 23059. E-mail: [email protected] 959

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W. J. Spitzer and K. W. Davidson

Downloaded by [Selcuk Universitesi] at 22:04 01 February 2015

THE CHALLENGE OF THE FUTURE: RE-ENVISIONING HEALTH CARE SOCIAL WORK Health and health care are predominant issues in the United States and a major challenge is presented by the increasing health needs of the aging population, along with decreases in physician and caregiver availability, ethical care dilemmas prompted by evolving technologies, and increased consumer expectations for affordable quality and participation in decision making. With new legislation and integrated service models changing the face of health care delivery, the professional challenge to social work is to not just respond to the present, but anticipate and prepare for the future. Social work has a distinguished history of positively impacting health care services. Since the inception of medical social work in 1905 when Dr. Richard Cabot hired the first social worker to provide services in the outpatient clinics at Massachusetts General Hospital (MGH), the profession has steadily made contributions at the interface of social issues with physical and mental health conditions. The profession’s evolution of terms and practices has progressed from friendly visiting to counseling, discharge planning, interdisciplinary care, case- and care management and on to integrated, transdisciplinary care. The basic components of our current practice are in many regards unchanged since Ida Cannon organized the nation’s first hospital-based social work program and sought to positively affect the health of patients presenting at Massachusetts General Hospital (MGH) in 1906. Those elements included: addressing tuberculosis; assisting “unmarried girls, pregnant, morally exposed or feeble-minded”; caring for “delicate children”; making “provisions for patients dumped at the hospital”; and “assistance to patients needing treatment after discharge” (see: http://www.mghpcs.org/ socialservice/Documents/HistoryTimeline.pdf). Over one hundred years later the focus of health care social work practice continues to reflect many of the same priorities. Among lasting concerns are chronic health issues, patient/family education, mother and child care, and most certainly, helping patients unable to return home or without solid post-discharge plans. Despite a century of “progress,” however, our society and our profession continue to contend with unresolved health and health care delivery issues that have defied remedy, even when solutions seem apparent. What IS different after one hundred plus years? ●

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Dramatic changes in American demographics, particularly the “graying of America”; and increasing health disparities within the aging population; Remarkable advances in sophisticated health care technologies; Evolving perspectives on whether good health and health care access are fundamental “rights”;

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Increased consumerism and a focus on healthy lifestyles; Shifts in health care priorities and methodologies for efficiently delivering effective health services; and Social work efforts to redefine practice in the face of the above factors.

Our challenge is to: (1) recognize what drives the evolving health care environment; (2) capitalize on the benefits of innovation; and (3) demonstrate professional creativity and energy in refining practice. In promoting “best practices” that reflect sensitivity, compassion, ethics, and rationality, social work must also actively seek new techniques and contexts in which to provide cost-effective patient/family intervention. Social work must develop a business-oriented acumen, developing and participating in planned change (Jansson & Dodd, 2002), while sustaining its historic commitment to a strengths perspective, social justice, and enhancement of quality of life. To do so we must also re-examine how we educate for practice, particularly the nature of how information and values are conveyed to students in schools and by practitioners. To envision future social work practice in health care, one must identify: (1) populations likely to be in greatest need of health services by virtue of sheer numbers, life impacts, and/or projected health care costs; (2) initiatives triggered by innovation, patient need, and/or problems in the health care delivery system; (3) evolving trends such as consumerism, increased focus on healthy lifestyles, and the corporatization of health care services; and (4) the historic strengths and potentials of the profession.

THE CATALYST: CHANGING DEMOGRAPHICS, HEALTH DISPARITIES, AND POTENTIAL USE OF CARE The most profound demographic change affecting health care delivery in the United States is the aging of our population. The next generation of older adults will be the most educated and diverse group in the nation’s history, characterized by having fewer children, higher divorce rates, and a lower likelihood of living in poverty (He et al., 2005; U.S. Census Bureau, 2008). The projected increase in numbers of elderly and their health conditions and needs have profound implications for care financing and service delivery, especially in light of widely recognized health disparities and inequalities. Decreasing fertility and gains in life expectancy have led to a rapid aging of the American population. Life expectancy reached an all-time American high in 2009 of 78.5 years, up from 47.3 years at the turn of the century (National Center for Health Statistics, 2012). This gain is largely attributable since mid-century to improvements in the prevention and control of chronic diseases of adulthood (Shrestha, 2006). Not only is the U.S. population expected to expand from 310 million to 439 million between 2010 and 2050,

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30% 25% 20% 15% 10% 5% 0%

% 60+

% 65+

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050


FIGURE 1 Older population by age: 1900–2050—Percent 60+, Percent 65+, and 85+ (color figure available online). Sources: Projections for 2010 through 2050 are from: Table 12. Projections of the Population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12), Population Division, U.S. Census Bureau; Release Date: August 14, 2008. The source of data for 1900 to 2000 is Table 5. Population by Age and Sex for the United States: 1900 to 2000, Part A. Number, Hobbs, Frank and Nicole Stoops, U.S. Census Bureau, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century, 2002. This table was compiled by the U.S. Administration on Aging using Census data noted.

but the percentage of Americans age 65 plus has more than tripled from 4.1% in 1900 to 13.1% in 2010 (Figure 1), and the number has increased almost thirteen times from 3.1 million to 40.4 million. That number is projected to increase to 55 million in 2020 (a 36% increase for the decade) and by 2030, nearly one in five U.S. residents will be aged 65 years or older. By 2050, there will be about 88.5 million older persons, over twice their number in 2010 (Vincent & Velkoff, 2010), with those 65 years and older constituting 20% of the U.S. population. By comparison, that age group comprised 4% of the total population at the turn of the nineteenth century (U.S. Census Bureau, 1995). The U.S. Census Bureau projects that the population aged 85 and over could grow from 5.5 million in 2010 to 19 million by 2050 (Vincent & Velkoff, 2010). Not only does concern exist about the burgeoning numbers of elderly; persistent health disparities exist among older racial and ethnic groups. Life expectancy may be increasing, but gaps continue; life expectancy at birth in 2000 averaged 77.4 years for Caucasians and 71.7 for African Americans. While disability rates are declining, older African Americans have higher rates of disability in activities of daily living with 75% saying they have no disability compared with 80% of older Caucasians (Manton, 2001). Robert and House (1996) also found linkages between wealth, age, and health status with financial assets associated with health throughout adulthood and old age, at least until ages 85+. Analysis of non-Hispanic black, Hispanic, and non-Hispanic white populations by Pollack et al. (2013) disclosed that, except among the younger Hispanic population, net worth (wealth) was significantly associated with self-reported poor/fair health status. Net worth attenuated the association between education and poor/fair health (in all


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racial/ethnic groups) and between income and poor/fair health (except among older Hispanics). Chronic disease is of particular concern among the elderly. Effective new medical interventions coupled with increased longevity have had the impact of converting what would have been once-fatal diseases to lifelong conditions. Waidmann and Liu (2000) estimate the number of older people with impairments or limitations could increase from 22 million in 2005 to 38 million by 2030. Chronic diseases (e.g., Alzheimer’s, diabetes, heart disease) affect 80% of older adults (Anderson, 2003) and are the leading causes of death in that cohort (Kramarow et al., 2007). Reflecting the relationship between mental and physical health (New Freedom Commission on Mental Health, 2003), chronic disease brings risk of major depression, which is associated with substantial disability (Moussavi et al., 2007). Approximately 31% of persons with disabilities and 45% of severely disabled persons manifest depressive symptoms; 15% of older adults with disabilities and 25% of severely disabled older adults are cognitively impaired (Johnson & Wiener, 2006). An estimated five million people aged 65 or older had Alzheimer’s disease in 2013, a number expected to increase by 40% or 7.1 million in 2025. Between 2013 and 2050 those 65 or older with Alzheimer’s may nearly triple to a projected 13.8 million or 15.5% of the 65+ population (Alzheimer’s Association, 2013). Johnson, Toohey, and Wiener (2007) emphasize that with the rapid growth of the older population, the number of disabled older Americans will soar in coming decades, creating significant need for additional care providers. The dominant providers of long-term care services are families and friends (Johnson & Wiener, 2006; Spitzer, Neuman, & Holden, 2004), with the percentage of adult children providing personal care and/or financial assistance to a parent more than tripling over the past 15 years. However, it is projected that by 2040 there will be only about nine adults ages 25 to 64 to support each disabled older adult, down from about fifteen younger adults in 2000 (Johnson, Toohey, & Wiener, 2007). The increasing numbers of older adults coupled with projected decreases in available caregivers has prompted some estimates of triple the number of elderly requiring nursing home care between 1990 and 2030 (Zedlewski & McBride, 1992). Whether they will have access to that level of care will be a function of affordability and the number of available beds and trained professional staff.

THE HEALTH CARE WORKFORCE: A NATIONAL CONCERN While the U.S. population is aging, the physician workforce is also aging, average hours worked are falling, and many physicians are nearing retirement. According to the Association of American Medical Colleges’ Center for Workforce Studies (AAMC, 2010), there will be a shortage of 45,000 primary


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care physicians and 46,000 surgeons and medical specialists in the next decade. Also, nearly one-third of current physicians are expected to retire in the next decade (AAMC, 2010). Women, an increasing proportion of physicians, typically work fewer hours per year than their male colleagues, so that total hours of physician services are increasing less rapidly than the number of licensed physicians (13% versus 16% between 2005 and 2020) (Martz & Smith, 2012; U.S. Department of Health and Human Services, 2008). At the same time, the growth and aging of the population will contribute to a 22% increase in demand for physician services between 2005 and 2020, with demand highest among specialties that predominantly serve the elderly (e.g., cardiology, internal medicine, and most surgical specialties) (U.S. Department of Health and Human Services, 2008). Concern about the adequacy of the health care workforce to meet future service needs is not limited to physicians. By 2030 the Bureau of Labor Statistics predicts the United States will need an additional 3.5 million formal health care providers—a 35% increase from current levels—just to maintain the current ratio of providers to the total population (Institute of Medicine, 2008). It also predicted that the need for personal- and home-care aides and home health aides will develop rapidly between 2006 and 2016, exacerbating current shortages (Institute of Medicine, 2008). While older adults account for about one-third of visits to physician assistants (PAs), less than 1% of PAs specialize in geriatrics. Remarkably, less than 1% of both registered nurses and pharmacists are certified in geriatrics. Anticipated shortages of health care professionals are particularly acute in mental health services. The recent plan of HHS Substance Abuse and Mental Health Services Administration (SAMHSA) outlining strategic initiatives to reduce the impact of substance abuse and mental illness in communities reports that by 2020 behavioral health disorders will surpass all physical diseases as a major cause of disability worldwide (Bloch, 2011). Resources are insufficient to meet existing mental health care needs, much less projected levels of mental illness. Butcher (2012) notes that more than half of all U.S. counties have no practicing psychiatrists, psychologists, or social workers. Nearly 80 million Americans currently live in a mental health professional shortage area, according to the U.S. Health and Human Services, Health Resources and Services Administration (Novotney, 2011). With the aging American population comes the necessity to “ramp up” services to meet physical and psychosocial care needs, including expanded options such as assisted living, continuing care retirement communities and other long-term care settings. Just over two-thirds of all older adults will need some form of long-term care at some point in their lives (AAHSA, 2007; Kemper et al., 2005). With the number of persons aged 85 and over projected to increase five-fold by 2050, those requiring long-term care could increase from approximately 8 million to 19 million by 2050. Given such trends, demand will intensify for social workers’ expertise in providing services


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such as care coordination, case management, mental health services, and related support. Whitaker, Weismiller, and Clark (2006) view recruitment and retention of social workers, especially those interested in working with older adults, as the primary challenge facing the profession. In 1987 fewer than 30,000 U.S. social workers were working either full-time or part-time with the elderly (Council on Social Work Education, 2001). The number of professional social workers employed in long-term care settings was projected by BLS in the Occupational Employment Matrix to increase from approximately 36,000 in 2002 to 55,000 in 2012. The number of social workers needed in long-term care is anticipated to increase to 109,000 by the year 2050 (U.S. Department of Health and Human Services, 2006).

TECHNOLOGY-DRIVEN HEALTH CARE Health care delivery is being profoundly affected by technological innovations in the areas of preventive health care, wellness and interventions to address chronic conditions particularly among the elderly. These innovations influence how, when and where care is delivered and affect future social work services. Genetic engineering and nanotechnology are advancing the practice of personalized medicine, in which particular therapies are developed for people with specific gene sequences and then incorporate medicines and interventions that best meet individual genetic, lifestyle, and environmental differences. A shift in focus to preventive versus disease management strategies is evident in growing use of molecular sensors and biochip implants that enable testing and the identification of patients’ susceptibility to disease. Interventions can be more accurately planned and initiated earlier, minimizing both patient risk and overall care cost. Dramatic advances in bioinformatics are evident in the monitoring of patient health conditions including heart rates, blood pressure, blood glucose, and weight through use of nearly 15,000 mobile telephone applications currently available. These devices not only collect crucial patient health status information, but transmit it to physicians’ smartphones or tablets, allowing an understanding of the patients’ conditions and preparing hospital staff to treat patients as soon as they reach the hospital. With treatment of chronically ill patients constituting nearly four-fifths of U.S. health care spending and almost 95% of all health care expenditures among older Americans, a compelling case is made for cost-effective interventions like tele-health to enhance coordinated care (Baker, Johnson, Macaulay, & Birnbaum, 2011). One example of this technology, Bosch’s Health Buddy System’s health management program, addresses a broad range of chronic disease conditions in both post-acute and chronic care coordination settings. It utilizes standard practice guidelines in monitoring signs


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and symptoms, promoting self-care, facilitating education, and providing patient guidance. Outcome measurement data is collected, including health care resource utilization, patient satisfaction, quality of life, health management compliance, and patient population reporting. Through a combination of symptom review, vital sign gathering, and education/health coaching aimed at the support of positive behavior change, health care providers are able to engage patients and intervene before deterioration occurs (Bosch Healthcare, nd). Such focused intervention is invaluable for elderly patients where unstable health and/or unsupervised living arrangements make expedited care essential. Heightened computer literacy and the popularity of mobile telephones and electronic applications across all age ranges are transforming the dissemination of health information. Aging “baby boomers” are electronically savvy and have heightened expectations of health services. With awareness that “patients want more than a fifteen minute office visit and callback at the end of the day” (Tanner, 2012) there is growing evidence that embedded in physicians’ work between checkups are instances in which blogs, Facebook, and Twitter pages along with e-mail and text messaging offer patient education and answer patients’ questions. The evolution of these communication modalities is moving consumer trends toward greater involvement in selfcare, focusing on enhanced health, physical fitness, and sports. Wireless broadband has already been a game-changer, with wireless health portals allowing use of personalized bio-data templates to conveniently obtain real-time feedback and self-evaluation of select health status variables. The relevance of these devices becomes even greater when advanced age, physical condition, geographic distances, absence of care providers/family and/or transportation make outpatient visits difficult or impossible. Changes in national policy have increasingly prompted adoption of electronic medical records (EMRs) and electronic health records (EHRs). Historically, providers did not share a common medical record—the absence of which proved problematic particularly when urgent care was needed and practitioners were unfamiliar with the patient. Multiple files contributed to unnecessarily incurred file maintenance costs, jeopardized record accuracy, and contributed to misdirected and/or delayed patient care potentially endangering patients. EMRs allow physicians to electronically maintain files of lab results, visit notes, diagnostic test results, insurance information, demographics, health histories, and other medication information within their offices while EHRs facilitate the electronic exchange of EMRs between providers, thereby allowing the medical record to “follow” patients among providers (AMA, nd). These systems aid physicians and other health care providers with managing scheduling, patient registration and insurance status, health histories, insurance status and medication lists. Professionals can electronically preview patients’ medical histories, prescribe medication, order tests and labs, initiate billing, submit claims and facilitate coding as well as electronically communicate with their consulting providers, payers, labs and



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pharmacies. In some cases, patients may view their results through a patient portal (AMA, nd). Adoption of electronic medical/health records was initially deterred by concern over implementation costs. In 2008, only 17% of physicians were using advanced electronic health records and just 9% of hospitals had adopted electronic health records (Lambrew, 2013). In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of the Recovery Act, created the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs to promote the adoption of EHRs in support of improving the quality of patient care and reducing health costs (Centers for Medicare and Medicaid Services, 2013a). Professionals who meet specific federal requirements for EMR may receive up to $44,000 through the HITECH Act, while those providing service in geographic areas known as Health Professional Shortage Areas (HPSA) are potentially eligible for additional incentives. The incentives for institutional health care providers are even greater, with base payments for eligible providers beginning at $2 million. By April 2013, more than half of eligible providers—doctors, dentists, and others—qualified for and received incentive payments for adoption of certified electronic health records, exceeding the Department of Health and Human Service’s target for the end of 2013 (Department of Health and Human Services, 2013a). Moreover, nearly 80% of eligible hospitals have qualified to receive incentive payments (Lambrew, 2013). With predictably deteriorating health conditions and more frequent use of health services, aging patients are prime benefactors of information systems that facilitate rapid, universal access of medical records and provider consultation. EMR and EHR use is promoted by the Patient Protection and Affordable Care Act of 2010 (PPACA) as essential to efficient health care delivery systems.

HEALTH CARE ECONOMICS: A DRIVER FOR LEGISLATIVE AND SERVICE DELIVERY REFORM While health care spending is a key component of any industrialized country’s economy, the United States spends more on health per capita than any other country. Concerns over continuously escalating overall health care costs, growing disparities in expenditures for care of the elderly and steady increase in the percentage of public health care financing have served as principal drivers of legislative reform. U.S. health care spending in the 1950s amounted to approximately 4% of the Gross National Product (GNP). By 2011 spending reached a record level of $2.7 trillion and accounted for $8,680 per person or nearly 18% of GNP (Centers for Medicare and Medicaid Services [CMS], 2012). That figure is expected to rise to 30% of GNP by the year 2030 (Friedman & Mandelhaum, 2011).


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Older Americans experience particularly significant increases in health care costs. In 2011 older consumers averaged out-of-pocket health care expenditures of $4,769, an increase of 46% since 2000. In contrast, the total population spent considerably less, averaging $3,313 in out-of-pocket costs. The elderly spent 12.2% of their total expenditures on health, almost twice the proportion spent by all consumers (6.7%) (U.S. Department of Health and Human Services, 2013b). More than two-thirds of all health care expenditures are associated with treatment of chronic illnesses (CDC & The Merck Company Foundation, 2007), with care for elderly Medicare beneficiaries accounting for 93% of all fee-for-service expenditures (U.S. Department of Health and Human Services, 2012). The federal government financed 28% of total health spending in 2011, a substantial increase from its share of 23% in 2007. By comparison, the shares of the total health care bill financed by households (28%), businesses (21%), state and local governments (17%), and other private revenues (7%) all declined (CMS, 2012). At the same time, over 16% of the U.S. population (49.9 million) had no health insurance—a number amounting to almost one in six U.S. residents and equal to the combined populations of 25 U.S. states. Private insurers in the current managed care environment are not willing to informally subsidize health care providers for uncompensated care to uninsured and can no longer pass along these costs through increased premium hikes to individuals and businesses (Silverman, 2012). Of particular concern, the federal and state governments spent more than $250 billion in 2009 on health care benefits for the 9 million lowincome elderly or disabled people jointly enrolled in Medicare and Medicaid (Congressional Budget Office, 2013). “Dual eligible” beneficiaries account for a disproportionate share of spending in the Medicare and Medicaid programs. In 1995, an estimated 6 million dual-eligible beneficiaries accounted for about 30% of Medicare spending and 35% of Medicaid spending, although they represented only 16% of the Medicare population and 17% of the Medicaid population (Agency for Healthcare Research and Quality, 2013). That number is now estimated to have grown to seven million receiving full benefits from both programs. In the case of Medicare, this is mainly due to poorer health status, which requires greater use of medical services compared to other program beneficiaries. In the case of Medicaid, dual eligible beneficiaries’ relatively high spending is generally attributable to their greater need for long-term services and supports (Kaiser Foundation, 2013). Sixty percent of all dual eligible beneficiaries are elderly, while 25% of all dual eligibles are diagnosed with mental illness. Nearly 30% of people with Alzheimer’s and other dementias, for example, are on both Medicare and Medicaid, compared to 11% of individuals without these conditions. The average per-person Medicare costs for those with Alzheimer’s and other dementias are three times higher than for those without these conditions. Total payments for health care, long-term care, and hospice for people with



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Alzheimer’s and other dementias are projected to increase from $203 billion in 2013 to $1.2 trillion in 2050 (in current dollars) and contributing to a 500% increase in combined Medicare and Medicaid spending (Alzheimer’s Association, 2013). In addition to the growing numbers of elderly beneficiaries and the extensiveness of health care needs stemming from multiple disabilities and illnesses (nearly one-fifth have three or more chronic conditions), escalating health care costs are associated with both the inefficient manner in which payments are made concurrently to both programs using different procedures and uncoordinated, unnecessarily expensive approaches used in health care delivery. Unfettered costs and inefficient, questionable quality of care have become the targets of intense scrutiny, prompting reformulation of national policy and contributing to passage of the landmark Patient Protection and Affordable Care Act in 2010. Health care expenditures are primarily affected by the unit cost of medical goods and services and the amount of care delivered. Even though the number of in-hospital days was nearly the same from 2009 to 2010, the cost of those days went up more than 10% (Regence, 2013). Much of the cost is thought to be unwarranted. The Institute of Medicine calculated that in 2009 alone the United States wasted more than one-third of the $2.5 trillion spent on health care through unnecessary use of high cost services, defensive medicine, the duplicative costs of administering different health plans, inefficiently delivered services, uncoordinated care and medical errors, unreasonably high prices, Medicare/Medicaid fraud, and poor delivery of clinical prevention services (Regence, 2013). These factors prompted service delivery reforms including the reorganization of providers through acquisitions, mergers, and program restructurings or elimination. Managed care, or what Munson (2002) refers to as “managed cost,” arose in an effort to create a more financially efficient service methodology, but it has not effectively integrated patient care across settings nor produced optimal patient outcomes. Despite spending a greater percentage of its gross domestic product on health care than any other country, the Centers for Disease Control (2009) note that the average U.S. life expectancy of about 78 years fell from 11th to 48th in the world, while the U.S. infant mortality rate placed it at 28th in the world among developed countries. While paying more for care, our health outcomes are less.

THE NEED FOR ACCOUNTABLE, INTEGRATED CARE: THE CASE FOR ACOs Although older adults make up only about 12% of the U.S. population, they account for approximately 26% of all physician office visits, 47% of all hospital outpatient visits with nurse practitioners, 35% of all hospital stays, 34% of


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all prescriptions, 38% of all emergency medical service responses, and 90% of all nursing-home use (Institute of Medicine, 2008). Despite such statistics and the United States Bipartisan Commission on Comprehensive Health Care (the ‘‘Pepper Commission’’) ‘‘Call for Action’’ blueprint for health reform in September 1990, care provided to the elderly and disabled has not improved. In 2007, 69% of Medicaid long-term care spending for elderly individuals and adults with physical disabilities paid for institutional services. Only six states spent 50% or more of their Medicaid long-term care dollars on home and community-based services for elderly individuals and adults with physical disabilities while one-half of the States spent less than 25%. This disparity continues to be a concern as it is estimated that Medicaid dollars can support nearly three elderly individuals and adults with physical disabilities in home and community-based services for every one individual in a nursing home. Although all of the states provide certain services under home and community-based waivers, these services are unevenly available and reach only a small percentage of eligible individuals (PPACA, 2010, p. 188). Fragmented health care delivery to the elderly is both inefficient and potentially harmful. Older patients often receive services from multiple physicians and without coordination, may receive duplicated care while not receiving needed services and/or being exposed to increased risk of medical errors. Anderson (2003) determined that Medicare beneficiaries with more than one chronic condition visit an average of eight physicians in a year. One in seven Medicare patients admitted to a hospital has been subjected to a harmful medical mistake in the course of their care, while nearly one in five Medicare patients is readmitted within 30 days—readmissions regarded as avoidable had care outside of the hospital been aggressive and better coordinated (U.S. Department of Health and Human Services, 2012). Enacted in 2010 and upheld in 2012 by the U.S. Supreme Court, the PPACA places a fundamental focus on integrated care, quality improvement and cost containment, achieved primarily through development of Accountable Care Organizations (ACOs). A total of 428 public and private sector ACOs were operating in 49 states, Washington, DC, and Puerto Rico by the end of January 2013. The most typical ACO sponsors are hospital systems, physician groups, insurers, and community-based organizations, with physician groups identified as the most common sponsoring entity (Muhlestein, 2013). ACOs provide incentives for health care providers to collaborate in treating patients across care settings—including physicians’ offices, hospitals, and long-term care facilities (U.S. Department of Health and Human Services, 2012). Partnerships between patients and physicians in making health care decisions are enhanced, giving patients more control over their health care and providing physicians with information about their patients’ medical history.



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ACOs demonstrating cost-effectiveness while delivering “benchmark” quality care benefit in “shared savings” through Medicare program reimbursement based on their enhanced performance in patient/caregiver experience of care, care coordination, patient safety, preventive health, and services to the frail elderly and at risk populations (U.S. Department of Health and Human Services, 2012; PPCA [Sec. 3022, Medicare Shared Savings Program], 2010). On January 10, 2013 the Centers for Medicare & Medicaid Services (CMS) announced that 106 ACOs were joining the Medicare Shared Savings Program (MSSP), bringing the total number of MSSP ACOs to more than 250 with coverage of up to 4 million Medicare beneficiaries (Muhlestein, 2013). Efficiencies already achieved by the ACOs are reflected in the fact that health care costs to their beneficiaries grew by only 0.3% in 2012 compared to nearly 1% for non-ACO beneficiaries. Thirteen of the first 32 “Pioneer ACOs” produced shared savings with CMS, generating a gross savings of $87.6 million in 2012 and saving nearly $33 million for Medicare Trust Funds. Pioneer ACOs earned over $76 million by providing coordinated, quality care. By comparison, only two Pioneer ACOs had shared losses totaling approximately $4.0 million. Program savings were driven, in part, by reductions that Pioneer ACOs generated in hospital admissions and readmissions (Centers for Medicare and Medicaid Services, 2013b). Along with the evolving ACOs, the targeted use of existing Federally Qualified Health Centers (FQHCs) reflects the fundamental premise of the PPCA to re-conceptualize service delivery by integrating proprietary and community primary care and supportive services to medically needy individuals to allow them to manage their own health while reducing costly hospital visits. Designated by the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services, FQHCs are nonprofit public or private clinics located in medically underserved areas or providing care to a medically underserved population (Takach and Buxbaum, 2011). Entities may qualify for FQHC status if they received funding under Medicare Part B, a Public Health Service grant or through either the Indian Self-Determination Act or Title V (Centers for Medicare and Medicaid Services, 2013c). Patient care integration is promoted by physically co-locating services when feasible, utilizing electronic medical records commonly shared across service settings and disciplines, and establishing transdisciplinary teams that respond to both health and mental health care needs of patients. Unlike interdisciplinary teams characterized by groups of professionals working interdependently, but with clearly defined disciplinary bounds and utilizing their own tools, the transdisciplinary team approach is based on the premise that one person can perform several professional roles by providing services to the patient under the supervision of individuals from the other disciplines involved. With their person-centered focus, evolving integrated care models establish partnerships among practitioners, patients, and their families to ensure


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that decisions respect patients’ wants, needs, and preferences and patients have the education and support they need to make decisions and participate in their own care (Institute of Medicine, 2001). Preventive care and wellness are emphasized with services rendered primarily in physician offices, outpatient clinics, and home settings. Less intrusive surgical procedures, ease of access, consumer preference, and reduced costs all encourage use of these settings. Promoted through the PPCA, the fastest growing models of primary care redesign are the patient-centered medical homes (PCMHs). Care management is central to the recent shift from episodic acute care to a focus on health management of defined populations, especially those living with chronic health conditions (Collins, 2011; SAMHSA, nd). Regardless of ACO or FQHC context, PCMH models utilize a health care team providing comprehensive and continuous medical care to patients that includes preventive services, treatment of acute and chronic illness, and assistance with end-oflife issues. As defined by the PPCA (p. 204), the term “team of health care professionals” means a team of health professionals that may include physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State. The transdisciplinary team model engages all needed disciplines, affords them an equal voice in formulating shared treatment plans and in so doing, shapes the future of modern service delivery (Little, 2011). Coordinated by a personal physician, the team works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety (American College of Physicians, nd). With the integration of primary and behavioral health care, emphasis is directed to building care manager/behavioral health care consultant and consulting psychiatrist functions. Consideration of both primary and behavioral health needs in treating the whole person is prompting consideration of renaming PCMHs to “PersonCentered Healthcare Homes” and promoting use of integrated care models such as IMPACT (SAMHSA, nd; IMPACT-UW, 2013). Along with a higher incidence of physical illness, individuals with depressive symptoms often have higher rates health care utilization and an increased need for long-term care (Federal Interagency Forum on Aging Related Statistics, 2006). As major depression is prevalent in 5% to 10% of older adults seen in primary care settings, and is often chronic or recurrent, with few older adults receiving adequate treatment, a study was initiated to explore the effects of project IMPACT, a collaborative intervention with in-person visits, telephone contact, depression primary care specialists, consultations and medication (Unutzer et al., 2002). The University of Washington’s IMPACT model utilizes a primary care physician working with a care manager to develop and implement a


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treatment plan with psychiatric consultation. The goal is a 50% reduction in symptoms within 10–12 weeks of a evidence-based algorithm (IMPACTUW, 2013). Although the model did not include social work, its positive results with participants more likely to use treatment and report greater satisfaction with their depression care (Unutzer et al., 2002) suggest the value of integrative medical and psychiatric care for the aging, with a potential role for social workers as part of the integrated team (Little, 2011).


IMPLICATIONS FOR SOCIAL WORK PRACTICE IN HEALTH CARE Aging and the more complex health care needs of the elderly, technological advances, re-conceived health care delivery systems emphasizing integrated transdisciplinary care, evolving consumerism, projected physician shortages, heightening demands on health care payers and redefined health care legislation and regulation all combine to affect the future of health care social work. The U.S. Department of Health and Human Services (2006, emphasis added) unambiguously states “increased demand for social work services will no doubt provide a strong impetus for continued job growth in the future.” To prepare an appropriately qualified work force, changes in education and practice would include: ● ●

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Emphasis on integrated care and transdisciplinary collaboration Increased recognition of demographic trends, particularly the aging population Knowledge of evidence-based practice Expansion of health care practice environments employing social work services Increased focus on preventive health care, wellness, and chronic care Skills in complex discharge planning arising from greater need/available resources Attention to service cost reduction and outcomes accountability Increased discussion of bioinformatics, particularly telemental health modalities Greater focus on “benchmark practice”/Continuous Quality Improvement (CQI)

With the PPACA representing the most significant health policy initiative in modern times and already reformulating service delivery priorities and integrated practices, social work can anticipate new and expanded in- and outpatient roles. The impact of integrated care for social work is its shift toward more preventative care, continuity of care and care management for


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mental health concerns (Leone, 2011; Mutschler, 1990). As the ACOs promote primary care settings as gateways for individuals with both behavioral health and primary care needs, providers are integrating behavioral health care services into their settings . . . a trend furthered in part by $174 M in grants by SAMHSA to 93 community behavioral health organizations (Khazan, 2013). The emerging approaches use care managers, behavioral health consultants, behavioralists, or consultation models (SAMHSA-HRSA Center for Integrated Health Solutions, nd). Schimpff (2011) anticipates such circumstances will enhance opportunities for professions like social work. Provisions in Medicare Part B financing of FQHCs delivering preventative, primary health care services already include reimbursement for medical social work services (Centers for Medicare and Medicaid Services, 2013c). “The development of integrated care has and will continue to be the most important factor transforming the delivery of social work services in health care in years” (Little, 2011, p. 1). Little (2011) forecasts that “social workers practicing in either medical or mental health settings will soon all be practicing in some version of an integrated model of care” (p. 1, emphasis added). Social workers as “natural members” of patient centered medical home teams will play critical roles that include patient education, case management, advocacy, and community outreach (Collins, 2011; Peterson, 2012). Little (2011) and Ehrlich, Kendall, and Muenchberger (2012) advise, however, that the greater transdisciplinary coordination necessary with integrated care will require an increased collegial understanding of what each discipline represents as a service provider. Participation of social work in practice boundary discussions is crucial to avoid social work being “shut out” of evolving professional relationships and NASW has advocated for the inclusion of social workers in Medicare ACOs (Collins, 2011, 2013). Improving the quality of life for older adults is further supported by national health policies encouraging “robust discharge planning programs that ensure patients requiring post-acute care are appropriately placed in, or have ready access to, post-acute care settings” (HR3590-205, Section 2704, (a)(5); see http://www.govtrack.us/congress/bills/111/hr3590/ text). An implication of this amplified discharge planning focus is that the health education and information and referral components of social work discharge planning roles are likely to increase (Reisch, 2012). However, while Judd and Sheffield (2010) note that social workers reported spending a great percentage of their time in discharge planning activities, Reisch (2012) predicts that longer hospital stays in the future will not necessarily mean more social work duties with individual patients, but instead social workers will move on to new cases while a patient awaits transfer out of the hospital. Patient-centered care models with their presumed active engagement of the patient and family in decision making offer the potential for social workers to be key respondents to care needs. Heightened focus on non-medical



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barriers to health care and the need to negotiate increasingly complex service delivery systems will, however, demand greater brokerage and collaboration skills (Reisch, 2012; Zabora, 2011). Despite projections and persistent calls in the literature for expanded professional availability to meet senior long-term care needs (Feinberg, 2002; Franks, 2002; Spitzer, Neuman, & Holden, 2004; Stahlman & Kisor, 2000; Williams, 2002), it has yet to occur in sufficient scale. Gibelman and Schervish (1997) and Teare and Sheafor (1995) determined that only 16% of baccalaureate social workers and about 4% of of MSWs specifically worked in services to the aged. CSWE reported the number of students specializing in aging in 2009–2010 as only 2.8% BSW graduates and 6.7% MSW graduates, averaging 5% of all graduating social workers (CSWE, 2011). The majority of both BSW and MSW educational programs have been seen as offering students little direct or infused gerontology content (Scharlach et al., 2000). NASW’s Center for Workforce Studies found that only 9% (or 30,000) of respondents reported their primary practice area as aging (NASW, 2008). Although nearly 75% of licensed social workers engage in some capacity with older adults, many lack specific training (Whitaker, Weismiller, & Clark, 2006). The perceived lack of financial incentives in the form of stipends, loan forgiveness, and wages is viewed as the most pronounced barrier to the recruitment and retention of professional social workers into long-term care careers (U.S. Department of Health and Human Services, 2006). While these forms of support remain greatly needed, CSWE has joined forces with the John A. Hartford Foundation to develop programs supporting education in gerontology. Projects have been developed as components of the Geriatric Social Work Initiative, including the Hartford Faculty Scholars Program, Hartford Doctoral Fellows Program, the Hartford Partnership Program for Aging Education and the National Center for Gerontologocial Social Work Education (the Gero-Ed Center) (Getz, 2010). The PPACA (Section 5305, p. 504-5) addresses this issue with financial grants to social work educators and students committed to gerontology.

EDUCATING FOR FUTURE PRACTICE Forty years ago Kahn (1972) observed that “social work practitioners enter the health care field without adequate preparation or understanding of the health care system within which they practice or other health care systems within which it may integrate.” More recently, CSWE observed a “lack of sustained national leadership focused on changing the culture of social work in order to strengthen the profession’s response to a growing aging population” (2001, p. 3), further noting “a lack of leadership in academia to strategically address competing curricular and organizational demands that impinge on strengthening gerontological social work” (2001, p. 3).

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The continuing challenge for social work education is to evaluate and continuously update the professional knowledge base and curriculum, and develop methods to teach practice skills addressing contemporary needs (Spitzer & Davidson, 2012). CSWE has noted “the majority of social work faculty, students and employers are not aware of the range of roles, settings and practice opportunities in gerontology” (2001, p. 4). Their recommendations focus on collaboration between social work professional organizations and individual employers and provider associations toward identifying client and provider needs and benefits of social work involvement. In light of heightened service needs of an aging population and evolving integrated health care delivery environment, social work education will need to focus on:

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Awareness and appreciation for the factors shaping health care delivery Active collaboration with health care professionals designed to promote social work’s role in enhancing patient/family and provider service outcomes Reassessment of the required competencies for contemporary practice Use of evidence-based practices in patient care services Integration of new learning technologies in classroom and practicum sites Expansion of the array of field sites to reflect evolving practice, particularly in ACO and FQHC primary care–related settings using PCMH models, community services, ambulatory clinic care, home-based, and prevention/wellness programs Adjustment of practicum formats to facilitate greater exposure to diverse practices

Historically, tensions have existed between academia and practitioners regarding whether students learn pertinent knowledge, skills, and abilities for contemporary practice (Caroff, 1977; Carlton, 1989a, 1989b; Silverman, 2012; Spitzer & Nash, 1996). Volland (1996) once observed “social work in health care has increasingly been defined by events and boundaries set by the health care delivery system in which practice occurs” (p. 37). It is important that students understand and appreciate factors shaping these environments and the skills relevant for effective institutional change (Jansson & Dodd, 2002). Further, Reisch (2012) observes that the focus on accountability and prospect of functioning in complex delivery systems will require social workers “to possess a high level of self-esteem and self-awareness, a tolerance for ambiguity, openness to change and the ability to self-mentor” (p. 888). For students to develop such a perspective requires that current practice theories and the organizational context for service delivery be discussed



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not only in the classroom, but also with practicing health care social workers, health care administrators and professionals from other health fields. Exposure to such dialogue benefits all involved, including field instructors who may be relying on teaching models from their own earlier experiences. Both practitioners and faculty members may need to change their teaching methods to include evolving service delivery theories (Davidson, 1998). Practitioners familiar with evolving models may need to interpret changes to faculty members less directly involved in rapidly changing health care environments (Gilbert et al., 2011). The educational goals are to insure that: (1) students are versed in the CSWE (2008) practice competencies; (2) achieving those competencies relate to the needs of contemporary patients and families and reflects practice setting expectations, priorities and constraints; and (3) field work experiences afford opportunities to practice those competencies (Spitzer & Davidson, 2012). In the current health care environment, Leone (2011) notes that integrated care has changed the training needs of social workers, particularly the need for training in use of evidence-based practices (EBPs). Gilbert et al. (2011) emphasize that with integrated care requiring short-term, EBP models, shorter hospital stays and limited clinic visits, social workers need familiarity with Rapid Assessment Tools (RAT) and brief, problem-solving therapies. Social workers need to have a more thorough understanding of other health professionals’ roles, be capable of multi-tasking collaboration, and have familiarity with health information technologies including electronic medical records (Gilbert et al., 2011; Leone, 2011). Being cognizant of the physical, environmental, and psychological factors influencing both patients’ conditions and their response to treatment becomes more crucial for effective functioning on transdisciplinary teams that address the health and mental health needs of the “whole patient” while emphasizing prevention and wellness (Gilbert et al., 2011). Social workers need to be oriented not just to provision of individual patient care, but to population management, including the review and tracking of outcomes for both individuals and groups of patients (Little, 2011). It is not enough that social workers have clinical practice competence. They must be cognizant of the factors driving practice, including the priorities, missions, capabilities, and limitations of the organizations (Gilbert et al., 2011; Spitzer & Nash, 1996). Silverman (2012) argues strongly for maintaining professional competency that significantly features “organizational awareness.” Insufficient environmental awareness may have cost social work going into the DRG environment of the 1980s and beyond. Rosenberg (1983), referencing an earlier observation by Bracht (1974), noted that our profession short-changed itself in having a role in managing, coordinating, and planning the functions of the emerging health care system by maintaining a focus only on what we perceived to be the manner of conducting one-on-one clinical work.


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As today’s practice environment makes it essential that social workers be familiar with integrated service delivery models, particularly person-centered health care homes, the National Association of Deans and Directors of Schools of Social Work (NADD), in conjunction with CSWE, is working to produce a research-informed curriculum on competencies and roles of social workers in integrated behavioral health and primary care settings. With funding from the SAMHSA- and HRSA-funded Center for Integrated Health Solutions, the intent is to create master’s-level curriculum materials for courses in advanced clinical practice, policy, and services. The signature pedagogy of social work, field instruction, provides an experience in which theory is integrated with practice, allowing students to demonstrate achievement of program competencies (CSWE, 2008; Gilbert et al., 2011; Wayne, Bogo, & Raskin, 2010). The critical importance of field education has long been recognized as the classroom focuses on student mastery of the theoretical foundations for clinical and policy practice (Fortune, McCarthy, & Abramson, 2001; Gilbert et al., 2011; Spitzer et al., 2001). Because field work has a major effect on shaping student competence and enthusiasm for practice, it is vital that sufficient numbers of quality placement sites be available. Such is not the case, however, as Dawson and Santos (2000) perceive lack of trainee funding for first-year MSW placements as the primary reason for the limited supply of gerontologically trained social workers. The absence of funding combined with time constraints and conflicting organizational priorities combine to make many health care agencies reluctant to provide staff time for field instruction activities. Addressing such issues, Section 5305 of the PPACA makes provision for comprehensive geriatric education and training, with specific consideration to both social work educators and aspiring geriatric social workers. Up to 24 geriatric education centers are created under the Act to offer “fellowship programs” with “short-term intensive courses that focus on geriatrics, chronic care management and long-term care” for faculty members of medical schools and other health professionals including social work (PPACA, 2010, p. 504-5). To foster greater interest in such practice, health professionals including “clinical social workers” pursing a doctorate in geriatrics or related fields and who are full-time junior (non-tenured) faculty are eligible to receive “geriatric career incentive awards” in the form of financial grants or contracts presuming the individual will “teach or practice in interdisciplinary education in geriatrics, long-term care or chronic care management for a minimum of five years under guidelines set by the Secretary of Health and Human Services” (PPCA, 2010, p. 506–507). In addition to provisions for preparing social work educators in geriatric services, the PPACA encourages the recruitment of students for direct practice by offering “mental and behavioral health education and training grants” to baccalaureate, master’s, and doctoral degree candidates in Council on Social Work Education (CSWE)– approved schools. The expectation is that the CSWE schools will “recruit



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social workers from and place social workers in areas with a high need and high demand population” (PPACA, p. 508–509). Growing recognition of our shifting demography and health care emphasis should be a catalyst to expand fieldwork sites, including assisted living communities, skilled nursing homes and home care (Feinberg, 2002; Franks, 2002; Harrington, 1999; Spitzer, Neuman, & Holden, 2004), as well as the continuum of in-/outpatient integrated, transdisciplinary care settings addressing chronic health issues. Rotational internship formats with multiple field instructors are widely viewed as maximizing students’ exposure to diverse contemporary practice, helping students to formulate their own “synthesized” practice and broader perspective on health care service delivery (Farrar & Hardesty, 2012; Gilbert, Nelson-Becker, & Spira, 2012; Spitzer et al., 2001; Spitzer & Nash, 1996). The steadily evolving use of virtual learning technology in social work classrooms will benefit health care students by preparing them for practice in technologically sophisticated health care environments characterized by use of bioinformatics and telemedicine. Online seminars allow students to reflect on their field work experiences, comment on other students’ experiences and vicariously benefit from expanded exposure to diversified placement dynamics (Birkenmaier et al., 2005). An example exists in which MSW students are issued pre-programmed “avatars” to explore community-based agencies and use cause-related simulations developed by non-profit organizations (Vernon, Lewis, & Lynch, 2009). Such interactive mediums can afford students safe opportunities in which to experience conducting assessment, discharge planning and related social work interventions with patients and families or to “participate” in the “give and take” of transdisciplinary patient care conferences evaluating strategies and resources. Familiarizing students with a broadened range of realistic scenarios will better enable new graduates to “hit the ground running” in today’s and tomorrow’s advanced health care practice settings.

SUMMARY The legacy of health care social work is exciting, complex, and challenging. An aging population and current and anticipated changes in practice techniques, health care technologies, integrated provider system models, collegial relationships and service opportunities will affect social work practice. As Baby Boomers reach their sixth decade and beyond, there will be increases in vulnerable sub-groups that will require more intensive services, specifically the oldest old, older women, elderly racial minorities, and those living in or near poverty. The needs of these sub-groups, coupled with demands for effective practice and evolving integrated service models, offer expanded opportunity for social work. Similar to Ida Cannon’s experience, the challenge is before us.

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The price of success: health care in an aging society.

Health innovation for aging society.

Contemporary health-related decision aids: tools for social work practice.

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Insights in Public Health: From Hale to Kauhale: Public Health, Social Work, and Aging.

Health care strategy for ensuring work ability in an aging Korea.

The future funding of health and social care in England.

Integrative health care: implications for nursing practice and education.

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Integrating funds for health and social care: an evidence review.

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Social equity in health care.

Social work in an intensive care unit.

Negotiating access to a diagnosis of dementia: Implications for policies in health and social care.