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With the rising number of frail older persons needing care, someone asked me where social work fits in the modern models of care. One can assume that underpining the question is a concern about whether there are sufficient facilities to provide care. From one perspective, this is an opportunity to bring in the human aspect into the work that we do. So let’s explore what might be involved.
What most people will tell us is that they want care to be provided when they need it in an integrated way. And many people think of integration either through a health lens, as "integrated healthcare", or health and social care. We should however not forget the important role of other services, such as housing and leisure. So the aim of modern models is to see the integration of health, social care and housing. And person-centred coordinated care should be the starting point for any move towards integrating services. The SCAN Foundation defines care coordination as a service based on consultations and information with and among the individual, the person’s providers, and family members where appropriate, facilitated by a knowledgeable and trained professional that leads to the individual obtaining the right care, in the right place, at the right time to address the person’s needs with an appropriate use of resources1. This is the ideal and indeed a tall order for any professional given that there are finite resources at their disposal.
Another useful reference point comes from the US Center for Disease Control and Prevention which has a good definition of “Aging in Place”2. Aging in place is "The ability to live in one's own home and community safely, independently, and comfortably, regardless of age, income, or ability level." Taking these ideals into the modern models of care, what then is the role of social work in contributing to achieving these ideals?
It should perhaps begin with supporting moves out of acute care into the community with agencies supporting the interests of service users. Modern social work is about promoting choice and control, supporting people to live independently as active citizens in their communities. In this light, the social workers’ responsibility for assessment and care management is critical.
We must appreciate that assessment is only the start of a new phase for a service user and social workers will often need to be involved at various stages of the journey if life chances are to be maximised. Effective assessment requires highly skilled assessors, otherwise there is a danger of decisions being made that result in a poor care plan.
Service users often do not come with sets of readily identifiable needs, but require those needs to be teased out, interpreted and met creatively with the social assets of the family and local communities. In particular, older people (who form the majority of the social care assessment population) do not always present their needs accurately on first or subsequent contacts. Therefore, we should not underestimate the range, depth and analysis provided by social work assessments and interventions.
Time is needed for effective assessment to be carried out but time is often not on the side of social workers or care coordinators. Training, good knowledge of resources and relationship building are crucial for the work to be done. The approach that is required is one that uses the skills of relationship-building and reflecting. This is especially relevant in complex situations, particularly where there are issues of loss or identity, to look below the surface of presenting needs and understand more about what is going on. It is about dealing with the underlying human condition and not just about buying services to alleviate social distress.
There is a critical skill required in knowing when and how to intervene in somebody’s life, taking into account the requirements of self-determination, public protection and the duty of care. Tragedy is often preventable when systems work and practitioners are properly trained, supervised, and skilled in observation and theory, as social workers are, and properly supported by their employers and the systems within which they work. A good assessor sets out to create a complete picture of someone’s situation, strengths, capabilities and aspirations despite their age and condition. Social workers are trained and recruited on the basis that they have the cognitive and emotional depth to grasp people’s care and support needs and networks through the assessment process. They will want to ascertain the individual’s desire and the way in which the person wants to achieve it, as well as the risk factors involved and the possible measures to manage them.
The challenge remains as to how to help people who could live independently with the right support. One way is to have more agencies in the communities to take an “assetbased‟ approach to assessment that rests on a deep knowledge of the strengths of the individual, the family and the community. Communities can play an important role in befriending, keeping-a-lookout and complementing the work of home care services. What is underestimated is the role of neighbours and communities in easing loneliness for older people. Social work is not just about assessment, or putting in a care plan or putting in equipment or focusing on interpersonal support. It is more complex and looks at the inclusion of older people in community solutions. The challenge for social work is to promote active and inclusive communities, and to empower people to make their own decisions about their care. Can social work harness the networks in communities as part of the care plan to enable people to live with assisted support?
Social work with adults, carers and families is about supporting people to live as independently as possible, striving to promote choice and control over the care and support they need to overcome the difficulties presented by disability, age or mental health problems, among other things. Social work’s distinct contribution is to make sure that services are personalised. To do this, social work aims to:
a) Build professional relationships and empower people as individuals in their families and in communities;
b) Work through conflict and supporting people to manage their own risks;
c) Know and apply legislation;
d) Access practical support and services; and
e) Work with other professionals to achieve best outcomes for people.
Social Work and Interpersonal Support: There is now more information, advice and advocacy services, and social workers need to be current on what is available, expand their application and play a brokerage role. These may include support for carers and services for people who pay for their own social care.
Social Work and Safeguarding Rights: Social work has an important role in community development work and promoting social cohesion, for example where disabled, mentally ill or substance misusing people are ostracised. To some extent, social workers are entrusted with the role of using the powers and duties of the law to their best effect in order to promote the welfare and safety of vulnerable people. This calls for specialist knowledge of social welfare policy and law, a unique set of skills in understanding and working with people, and a specific set of professional values.
Social Work with Families: Social workers will continue to help to break the cycle of individuals trapped in abusive relationships, crime, substance misuse, poor health, unemployment and other factors. People have complex lives and there are complex cases out there. Social workers can help to construct the family and community networks that people require to live independently.
Social work through the training it provides will play a key role in modern social care models beginning with effective assessment. It covers a wide range, depth and analysis in social work assessment and intervention that puts the individual at the centre. To be increasingly effective, support for individuals must incorporate resources from the community in locus such as neighbours, befrienders and organised volunteerism. These are aspects of community development work which social workers are equipped to do. A good care model will require the coming together of various aspects of casework, groups and communities to support aging in place. The extent to which this can happen will depend on how social work is resourced to do this, the support from communities that each of us live in and small acts of support that we can give to each other.
1 The Scan Foundation. (Dec 2013). Achieving Person-Centred Care Through Care Coordination. Policy Brief, No. 8. Retrieved from http://thescanfoundation.org/achieving-person-centered-care-through-care-coordination
2 Aging in Place. (Aug 2013). Healthy Places Terminology. Retrieved from http://www.cdc.gov/healthyplaces/terminology.htm
Director of Social Welfare
Ministry of Social and Family Development