Faces of Aging: Personal Struggles to Confront the Long-Term Care Crisis Before the United States Senate Special Committee on Aging

September 26, 2002

Good morning. I am Lisa Yagoda, a licensed clinical social worker and the Senior Staff Associate for Aging at the National Association of Social Workers (NASW). On behalf of our 150,000 members nationwide, I thank Chairman Breaux, Ranking Member Craig, and their fellow Senators serving on the Special Committee on Aging for convening this hearing on a critical piece of the long-term care matrix. NASW appreciates the opportunity to highlight some of the issues professional social workers encounter when helping older adults and their families to navigate the complex web of long-term care services that are available in the community.

As you are well aware, aging is a major catalyst in the changing landscape of our society. With the aging of the baby boomer cohort and the continued lengthening of the average life span, the number and proportion of older Americans is quickly rising. The U.S. Administration on Aging (AoA) has predicted that by 2030, our country will have roughly 70 million people over the age of 65--more than double the amount in 2000. Older Americans comprised 12.4% of the entire U.S. population in 2000, but are expected to increase substantially to 20% in 2030. Within that time frame, the number of those 85 and over is expected to double, while the number of those 100 and older is expected to triple. Given that the changing demographics of our older population will continue through the coming years, our nation will face many challenges in meeting the needs of older Americans.

As Americans age, they face a combination of physiological, psychological, and social changes. Although most older people enjoy relatively good health, more than a third, 34.7%, experience limiting chronic medical conditions according to AoA in its 2001 Profile of Older Americans. AoA also noted in the same publication that more than half of the older population, 54.5%, experience at least one disability, either physical or nonphysical, with more than a third (37.7%) having at least one severe disability. Likewise, more than 14% have some difficulty in carrying out activities of daily living, and more than 21% experience difficulties with instrumental activities of daily living. These combinations of factors have momentous, permanent effects on the quality of life for older Americans, often necessitating a need for supportive services and thereby the skills of a professional social worker.

Social work is a distinct profession with rigorous, specialized education and training requirements, state licensure, certification, and ethical standards. Depending on the requirements of the particular practice setting, social workers may hold a bachelor's, master's, or doctorate degree in social work. Social workers use a biopsychosocial approach, which examines the person, group, or community in the context of their environment and facilitates appropriate problem solving in that framework. Professional social workers are knowledgeable not only about human development and behavior, but also about social, economic, and cultural issues and how these areas interact and affect our daily lives.

Social work is unique among the health and mental health professions in that it considers the physical, mental, and social aspects of individuals-- an approach that is vital to the appropriate provision of services to older adults and their families. In working with older Americans, social work professionals practice in a wide variety of settings, including: Area Agencies on Aging, mental health facilities, family service agencies, ombudsman programs, educational institutions, veterans services programs, skilled nursing facilities, nursing homes, rehabilitation centers, hospices, adult day care facilities, assisted living facilities, nutrition programs, adult protective services, elder abuse programs, hospitals, and in private practice. Social workers provide services to active and healthy older people living in their communities as well as to those who reside in institutions.

Social workers are a vital link between older adults and the services designed to help them. Professional social workers provide services at many levels: direct service, supervision, management, policy development, research, planning, education, and training. In direct practice, professional social workers address a broad spectrum of issues in multiple roles and render a variety of services, such as assessment, case management, mental health, medical-social services, referral, service coordination, advocacy, community building, monitoring of care, mediation, investigation, intervention, and counseling. These social work services are provided not only to the older adult, but also to his or her family members or other caregivers in conjunction with other providers so the older adult's independence and well-being are maximized. The ultimate goal of social work services for older individuals is to reinforce their strengths and capacity.

NASW offers an Aging Section for our membership, which provides in-depth information on aging social work practice, policy, research, and advocacy. NASW is also involved in strategic partnerships with other research, policy, practice, and advocacy organizations regarding aging issues.  Currently, NASW is serving as an outreach partner with the Public Broadcasting Service (PBS) for an upcoming documentary series on caregiving for older and disabled Americans. "And Thou Shalt Honor: Caring for Our Aging Parents, Spouses and Friends" will air on October 9, 2002 on PBS stations.

It is important to note that the expected increase of older Americans will create a greater demand for both aging services and professionals with knowledge and expertise in aging. The Center for Health Workforce Studies, applying U.S. Bureau of Labor Statistics (BLS) data, projected that the need for health care workers will increase from 10.9 million workers in 2000 to more than 14 million in 2010. The projected rate of growth in health care occupations during that period is 28.8 percent, more than twice the rate for non-health-related occupations. A similar trend holds true for social workers in health care. In 2000, BLS reported that of roughly 601,000 self-identified social workers, 187,000 were employed in health care. The projected need in 2010 is estimated to be 252,000—an increase of 65,000, or 35 percent.

Furthermore, education has an effect on supply. Finding comprehensive, useful, and affordable postgraduate training in geriatrics is a challenge. Even when professional social workers have received training in gerontology, continuing education is needed to hone skills and to translate classroom learning into actual practice. However, little funding is available for gerontological continuing education for professional social work practitioners. Incentives such as scholarships, stipends, and loan forgiveness are also needed to attract social workers to the field.

It is imperative to recognize the diverse strengths and needs of older people when developing program and services for this population. The formidable task will be how we develop policies that best meet the needs of all older Americans, while at the same time providing a streamlined system of access, outreach, and service delivery.

Our society has rightly shouldered the responsibility of providing a wide range of services for older Americans, including those provided through Medicare, Medicaid, Social Security, and the Older Americans Act. However, several challenges exist in assessing the wide array of needs, in informing consumers and their families about available services, and guiding them to access points for services. These challenges include confusion about who is the client, what the services are and who can access them, the negative perception of services, and barriers to care and services. Note that each older person and his or her circumstances are distinct; an inflexible, cookie-cutter approach will not meet an older individual's needs in an optimal fashion.

 You may be surprised to learn that a major challenge is defining the client or consumer. Sometimes an older person seeks services directly. Oftentimes, a family member, trusted friend, neighbor, clergy member, service provider, or even a stranger will seek services for a senior. Also competing or conflicting needs may exist, such as concern for safety versus desire for independence. For example, an older adult who is competent may prefer to remain living in his or her own home, but family members may feel that the older person would be better served in a more structured living environment. Furthermore, means-tested services often are viewed negatively by older adults and their families; using these services may be seen as a personal failure. This process is particularly difficult for individuals who have always been self-reliant and never sought public services.

Other barriers to services may occur as well. Sometimes, the family does not recognize there is a problem. If strained family relationships exist, it may be too painful to acknowledge a problem with a loved one. Many families are geographically dispersed and unable to help provide hands on support. Also, in order to access many community-based services, the client must consent to receiving service. For several reasons, some clients may be unwilling or unable to provide consent. There are many reasons as to why this happens. The client might not recognize there is a problem because of mental illness, dementia, fear of loss of control, or an overarching need to be independent.

Given the wide continuum of needs experienced by older Americans, there is no central point of entry into home and community-based services.  Clients might be referred by an acute care hospital, skilled nursing facility, or rehabilitation hospital discharge planner or case manager, a health care provider in the community, a member of the clergy, a social service provider, or even the local Area Agency on Aging. Even when services are accessed, obstacles to the optimal use of the appropriate services may continue to exist.

 Even though these challenges will always exist in some fashion, we have opportunities to improve the situation and empower consumers in the process of seeking home and community-based services as well as other services for older Americans. When designing policies and programs to educate, support, and serve seniors, it is important to consider the goals of the program. Aging is a process. As such, education about aging needs to be interspersed throughout the entire life span. As an aging society, we need to be more aware of what lies ahead for all of us and what resources are available— before the inevitable crisis occurs.

 We need to understand that eventually we all will be care recipients at some point in our lives—some sooner rather than later. Early intervention and planning is key. Looking to the future, we all should evaluate our long-term care options and legal and financial issues well before the need arises. Advance directives, powers of attorney, wills and the like will minimize problems later on. After this analysis is finished, it is important to communicate personal preferences to those likely to be involved in future care decisions.

Outreach and education should take place at all the various points of entry. Information also should be available in places in the community where older Americans and their caregivers would most likely gain access. We should be mindful that caregivers and older people tend to seek information from different sources. For example, caregivers who are young might not always think of contacting a senior service organization, rather, they might look to the Internet. Support and information must be available in different venues so that older adults and caregivers will have access to information, which is an essential part of the decisionmaking process. We do a fine job of educating consumers about chronic illnesses; however, given the demographic shifts our nation is facing, we must try to do just as good of a job educating Americans about the various long-term care options open to seniors and their families.

Although a wide array of services exists in the community to maintain and improve the quality of life for older Americans, it is important for this Committee and all of us to continue to seek strategies for improvement. NASW appreciates the opportunity to come before you this morning and we look forward to continuing to work with the Committee as it pursues it's mission. Thank you and I am happy to answer any questions the Committee might have.