Marrying social work with senior long-term and hospital care will require studying the organization and function of medical programs, health care and economic consequences and outpatient follow-up, four aging healthcare experts at a conference on aging.

Four panelists at their presentation titled “Current and Emerging Sustainability Avenues for Social Work in Health Care” during the Aging in America conference by the American Society on Aging said that it is necessary to connect social work to senior care in general and that this will involve much examination and planning before execution.

“[There is a] business case [to be made about connecting social work with senior long-term care and health care at] Rush [Presbyterian St. Luke’s] Hospital [Medical Center in Chicago’s lower West Side],” said Robert Mapes, director of program and community support at AgeOptions in the city, and a panelist.

“[This means] identifying clinical and economic outcomes, comparing quality and cost outcomes for reduced hospital readmissions and Emergency Department (ED) visits [as well as] for appropriate outpatient follow‐up and isolating essential program elements [to] create efficiencies.

“[This means also] making [the business] case for improving quality and reducing cost to position as ‘compelling solution for the payer community’: private purchasers, insurers, public payers and providers; get consumer to ask for [the] program, and; need to know they should expect transitional care.”

Mapes explained that separating the costs of providing health care to seniors from the medical contributions or value of such care results in a solid business case to be made to investors. He said it is crucial to measure or weigh the costs of hiring and firing staff, overhead and multiple stakeholder perspectives.

This calls for data collection, analysis and interpretation. Contributions to measure include 30-day re-admissions for aging patients, emergency room utilizations, nursing home placement, patient satisfaction, health disparities and the role of social work.

For data use, Mapes said social workers, utilization review nurses and data analysts must use a single database. They should study the rules and regulations of social services with staff, stakeholders and supervisors each separately and develop an understanding of the material.

“[You should ask, ‘are we on the] right track? Priorities [may have] shifted,” he said. [If you notice any] trends [in the manner in which social service is delivered or in the medical conditions of patients, you will see] red flags.”

Mapes said that there are many positive outcomes of performing this data activity and some
“tried-and-true methods” of examining and interpreting senior care data. Social workers, utilization review nurses and data analysts can successfully obtain funding from private organizations to support their work because of its nature and value.

To secure such funding, medical facilities must have cultivated a proof of concept (POC) theory of their work, he said. The proof is the full execution or demonstration of a particular method or idea to show its effectiveness and potential for being used.

“Proof of concept data [is important],” Mapes said. “It gives your effort] greater exposure [to possible influential supporters such as other medical facilities, nonprofits or government agencies.]”

However, there are negative outcomes to this activity, he added.

“[The] requirements [call for the use and expenses of] significant resources,” Mapes said. “[You must have] grantwriting relations [with personnel who have the qualifications, the time, energy and resources to write grant proposals for funding.]

“[Certain aspects of the data analysis and interpretation activity may be] inconsistent. [This makes room, unfortunately, for] mission drift [or creep]. When funding cuts [are implemented], so [are cuts to the] program. [This is, unfortunately, at the expense of] FTEs [full-time employees.]”

Additionally, he said that writing grants to obtain funding from government agencies and private foundations to support data generation and analysis takes a great deal of time, which may dampen social workers, nurses and analysts’ efforts if they do not locate a grant writer for the task.

“Grant[writing] is time consuming,” Mapes said. “[But] hospitals and clinics [need it and engage in it nonetheless to carry out their duties in] inpatient social work, case management, transitional care and outpatient social work.”

Both federal agencies, the Centers for Medicare and Medicaid (CMS) and the Administration on Aging (AoA), provide funding for such research by making it available through the states. In particular, the state of Illinois is a recipient of the CMS Transitions grant with support from the multi-organizational Illinois Transitional Care Consortium (ITCC). Their funds and technical assistance, he said, “strengthen the role of Aging and Disability Resource Centers (ADRCs) in implementing evidence‐based care transition models.” The Medicaid Waiver program and Older Americans Act both regulate federal funding for these grants, enabling community-based care for disabled patients.

Ultimately, the research work of social workers, nurses and data analysts engage seniors, people with disabilities and caregivers in transitioning from one form of care to another – namely, from care in the medical hospital to that of a skilled nursing facility, rehabilitation center, nursing home or hospice care.

“We want to try to meet you where you are,” Mapes said to listening other medical facility leaders and managers outside of Rush medical center at the presentation. “Our hope is to show you models of participation that will encourage you to join in and begin this work, no matter your organization’s stage.”

After analyzing and interpreting the research conclusively, medical facilities form Patient-Centered Medical Homes (PCMAs), a program of primary care emphasizing care coordination and communication among care providers and their patients.”

These “medical homes” are meant to lead to higher quality care for the patients and lower costs for the providers. To operate these medical homes, Mapes said facilities must create Account Care Organizations (ACOs), which are teams of doctors, hospitals, and other health care providers to provide coordinated care to Medicare patients.

Specifically, he added, PCMAs and ACOs work well for providing psychotherapy and physical wrap-around services to seniors.

“We don’t see social workers integrated into clinics anyway,” he said. “Some physicians will take a cut in bottom line and invest [in the medical facility they work for]. They believe in the quality of care. Hospitals can use a different pot of money.”

Gayle Shier, program coordinator for Rush Health and Aging at Rush University Medical Center and a panelist, said more social workers should be engaged in this effort.

“[We] need more social workers,” Shier said. “[We have a total of] 20 social workers. One doctor said, ‘I’m embarrassed we don’t have [more] social workers.’ That’s the best way to get to nurses. [The] hard work they do can go to nurses.”

Mapes said medical facilities can develop partnerships with their private and public funders and supporters to form an aging healthcare network working “within hospital walls.” This would mean patient care integration with inpatient learning and greater access to a patient’s electronic medical record for community-based care transitions.

With this, Rush medical center and other participating facilities may develop new Current Procedural Terminology (CPT) codes already started and maintained by the Centers for Medicare and Medicaid and the American Medical Association (AMA).

After the delivery of care to senior patients and their families, Walter Rosenberg, M.S.W., program coordinator for Health and Aging at Rush University Medical Center and another panelist, said Medicare’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) implements a complete set of ongoing surveys that ask patients to recall and evaluate the social aspects of their health care experience.

“Social work is quality care,” Rosenberg said. “Going by [a person’s] medical needs makes patients feel truly cared for.”

He explained that Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) is linked to “value-based purchasing” while Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGAHPS) is tied to reimbursement.

Continued: Part Two

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.