JULIANNE S. OKTAY FRANCINE SHEPPARD
Vol. 3, No.3, August 1978 0360-7283/78/0303-0035 $0.50 © 1978.
HEALTH AND SOCIAL WORK,
National Association of Social Workers, Inc.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
Home Health Care jor the Elderly
have begun to focus the attention of social workers on home-care services for the elderly. First, the growing power of the elderly population has begun to sensitize society to its special needs. Second, alarm about the skyrocketing cost of medical services is widespread in the general population. Finally, the human service field has moved away from the use of institutions to deal with people who cannot care for themselves. Social workers and other professionals in the health field, then, are viewing home health services from several angles: as a way of expanding services to the elderly, as a way of keeping health costs down, and as a more humane way of solving the problems of functional limitation.
SEVERAL RECENT TRENDS
36
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
Social workers have much to offer the large and growing population of elderly people in need of home health service. These programs need to be expanded substantially. This article discusses their role in increasing the quantity and quality of home-care services.
37
This article presents an overview of the population in need of home health care and a description of the development and content of such services in the United States. It will demonstrate the need for social work services in this area and give recommendations for the role of social workers in home health care. There has been a dramatic increase in the size of the elderly population in the United States during the 20th century. Persons over 65 years now make up over 10 percent of the total population. In addition, not only is the older population growing faster than those under age 65, but the oldest group, 75 years and older, is growing at the greatest rate. 1 Although the majority of elderly persons report good or excellent health, the elderly are more likely than younger persons to have some form of disability or chronic illness. From 12 to 17 percent of older persons are disabled, about 80 percent have a chronic illness, and many elderly persons suffer from two or more chronic conditions simultane0usly. 2 Contrary to popular belief, only 5 percent of the elderly population reside in institutions at anyone time. However, the figure rises to 20 percent for those 85 years and older. Of the noninstitutionalized aged, about 18 percent are limited in mobility, and about one-third of these are home bound. 3 Thus, the growth of the elderly popUlation has greatly increased the number of persons who are in need of long-term health services because of chronic disease or functional limitation.
GROWTH OF HOME CARE Although there is evidence of the existence of home health care in the United States as early as 1796, home
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEALTH AND SOCIAL WORK
"Perhaps the most powerful [reason why home health services should be expanded] is that the majority of elderly persons prefer to stay at home."
health agencies were not given an impetus for growth until 1965, with the passage of Medicare or federal health insurance for the aged. Medicare covers up to 100 visits for home health care per illness under hospital insurance (Part A) and 100 visits per year under supplementary medical insurance (Part B). In 1970, under the provision of 1967 amendments to the Social Security Act, home health care became a mandated service for every state participating in Medicaid, stimulating its further growth. Today, any state-certified home health agency may receive reimbursement for services provided to patients who are eligible for Medicare or Medicaid. According to these laws, covered services include, in addition to social services, intermittent nursing care, physical therapy, occupational therapy, speech therapy, home health aides, housekeeping services, laboratory investigation, and medical equipment and supplies as ordered by the physician. In 1974, 2,329 home health agencies were certified by Medicare in the United States. Of these, about half were official health agencies, such as city health departments, one-fourth were Visiting Nurses Associations, and one-eighth were hospitalbased agencies. 4 The types of patients eligible for home health care are those with acute illness, the disabled, those with exacerbations of chronic illness, and those recovering from surgery. In spite of Medicare and Medicaid cover-
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
38
39
age, however, the vast majority of persons in need of home health care do not receive this service from any federal program, often because of gaps in coverage. For example, patients may be ineligible for the federal programs but unable to afford the cost of numerous home-care visits, or they may be excluded because they need more than the 100 visits provided for in the Medicare legislation. Another problem is that the services actually covered vary from state to state. Only two states provide complete coverage. In fact, 70 percent of Medicaid expenditures for home health care are in New York State. 5 The lack of available home-care services is an even greater problem. Only 450 of the nation's 6,000 hospitals provide any type of home-care program. The sad fact is that most communities do not have home services to offer to their populations in need, whether they are eligible for coverage or not. 6 Thus expenditures for home-care services come to no more than 1 percent of both Medicare and Medicaid budgets. Out of an estimated 5-10 million persons in need of long-term care, less than 300,000 are receiving home-care services. In addition, a great many persons are being maintained at home through health care provided by family, friends, and neighbors. 7 A study of all persons receiving health services in the home shows that 80 percent are receiving care from relatives and not from health agencies. 8 WHY HOME CARE?
Advocates of home health services often argue that such services are less costly than institutional alternatives. This argument is based on the difference in the cost of a nursing home ($45 per day) and that of maintaining a
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
patient through home-care services ($12-14 per visit). However, although there is some evidence that homecare services can prevent institutionalization, home care does not appear to be a viable alternative for the majority of nursing home patients. Assessments indicate that no more than 15-25 percent of these persons could be maintained in their homes. Home care is cost effective primarily for cases in which the disability is not severe. In addition, expansion of home-care services to the large number of persons in need of long-term care who are not in institutions and who are now receiving no services would undoubte~ly increase expenses rather than conserve them. 9 Although the cost argument has not been settled, in part because of the extreme difficulty of doing experimental research in this area, there are other reasons why home health services should be expanded. to Perhaps the most powerful is that the large majority of elderly persons prefer to stay at home. Clearly there are psychological and social benefits for the patient who can avoid the disruption, isolation, and impersonalization of institutional placement. Another question is how the quality of health care offered by home health agencies compares to that in nursing homes or hospitals. Although there has been little careful research on this issue, there is some evidence that patients maintained in home health care have better health outcomes than those in more traditional medical settings. l l There is a critical need for more research in this area.
ROLE OF SOCIAL WORKERS In sum, there is a large population in need of long-term services, and home health services are desirable for
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
40
41
"Although there is some evidence that home-care services can prevent institutionalization, home care does not appear to be a viable alternative for the majority of nursing home patients. Assessments indicate that no more than 15-25 percent of these persons could be maintained in their homes." quality if not also for cost reasons. Social workers have several roles to play in providing this care. The first is as advocate regarding the quantity and quality of services. Social workers can be effective in their local communities as well as at the national level in encouraging the expansion of home-care services. Appropriate activities might include conducting research to demonstrate the need for these services, bringing evidence of this need to the attention of social action groups and legislators, and generating public support for home health services. Furthermore, there has been general concern that the proprietary agencies in the home field will repeat the scandals of the nursing home industry, in which quality of care is too often sacrificed for increased profits. Social workers must help communities develop high standards and serve as watchdogs to insure that home health agencies are carefully regulated. It is well known that the needs of home-care patients extend beyond those directly related to health. The loss of almost all social roles is an important problem for any elderly or disabled person. Unemployment can result in a loss of self-esteem as well as in financial problems. Inability to maintain contact with friends and family members brings increasing isolation. Physiological and psychological changes resulting in increased
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
dependency on others cause difficult adjustments for both patients and their families. When their condition deteriorates over time, patients need increasing support from family, friends, and community agencies to prolong independent functioning and to maintain a high quality of life. Financial resources must be stretched to cover ongoing medical expenses. Resources for housing, income, food, transportation, and recreation, as well as health care, are frequently needed. Thus the homebound elderly need many services that social workers traditionally provide. As mentioned earlier, social services are covered by Medicare and Medicaid as part of home health services. According to guidelines of the Department of Health, Education, and Welfare, the social worker's functions in home health services include the following: 1. Working with other members of the health team to assess the social and emotional factors related to the patient's health problems, and participating in the development of the patient care plan, 2. Helping the patient and his family to understand, accept, and follow medical recommendations and providing services that are planned to restore the patient to optimum social and health adjustment within his capacity, 3. Assisting the patient and his family with personal, emotional, and environmental difficulties which predispose toward illness or interfere with obtaining maximum benefits from health care, 4. Utilizing resources, such as family and community agencies, to assist the patient to resume life in the community and to learn to live within his maximum capacity, 5. Participating in alternative and appropriate discharge planning.12
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
42
43
Unfortunately, the same problems that cause inadequate levels of home health services apply to social services. Although many communities have no home health agencies at all, the majority of the home health agencies that do exist provide no social services. Out of the total of 2,329 home health agencies certified by Medicare, only 607 provide social services. About 75 percent of hospital-based home health programs provide social services, but only about 15 percent of state or local health departments do. IS Even in agencies that do offer social services, the social worker is often involved only in initial assessments. In some cases, one social worker is expected to serve the entire caseload, which may involve hundreds of patients. Clearly, this limits the service to crisis situations only. Thus, although social work services are badly needed by the home health care population, and although social services are covered by federal programs, their availability is currently limited. CASE ILLUSTRATIONS
Three case descriptions illustrate the importance of social work services in home health care and provide examples of some typical home health patients. Fortunately, these cases were all cared for by one of the few home health agencies that provides ongoing social work services. Mrs. F was a 77-year-old woman who had high blood pressure, edema of the legs, and was suffering from loss of memory. She lived in a two-bedroom apartment with her son and his five children. She was home-bound but could get around with the aid of a walker. The home health aide visited the patient twice a week to do personal care, take vital
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
signs, and aid her in the use of the walker. The home-care nurse visited every other week and provided health services. Mrs. F and the children were dependent on her son for the supply and preparation of food. The social worker discovered that the son was a chronic alcoholic, that there was often no food in the house, and that the patient and children were frequ.ently hungry. The social worker was able to work in close conjunction with the son's social worker to insure adequate nutrition for the dependents. Mrs. W, also 77, suffered from cancer of the colon and heart disease, and spent every day in bed on the second floor of her house. Mrs. W said it was impossible for her to get out of bed-she was in too much pain. However, her physician said there was no reason that she could not walk. The home health aide visited twice a week to take vital signs and to do personal care. The social worker explored the situation of the patient's husband and found that he had recently retired and was deriving great satisfaction from his role as caretaker for his wife. Because of this, he was not anxious to see her gain independence. In this case, the social worker was able to help the other members of the health team understand the situation. The social worker was then able to begin work with Mr. W, assisting him to realize that he would be helping in his wife's health care by encouraging her to walk. Mr. S, an 81-year-old man, had been recently released from the hospital. He was admitted because he was physically weak. His diagnosis after testing was severe malnutrition. The home-care nurse visited Mr. S once a week to teach him about nutrition. Mr.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
44
45
S lived alone in an 85-year-old house with no electricity. The social worker learned that Mr. S was living on a small amount of savings and had not applied for any benefits because he "didn't want to take handouts." With the social worker's help, Mr. S was able to apply for Social Security, food stamps, and a home repair grant to provide electricity for his home.
In each of these cases, the social worker was able to help the home health agency to meet its goals by contributing directly to the health and social welfare of the patients. TECHNIQUES AND TRAINING To be optimally effective in the home health field, social workers will need to develop techniques that are effective in this setting. For example, many home-care patients have difficulties that stem from inappropriate behavior. A logical behavioral approach combined with humane behavior modification techniques could be helpful in situations in which patients' behavior is detrimental to their health. Another area that is often overlooked is the needs of the family members who share the responsibility for patients' care. Social workers could be important sources of support for these people. As social workers gain more experience in the home health field, it will be important to determine which techniques are most effective. In addition, social work schools will need to begin training students to be effective workers in this field. Another important role for social workers will be involvement in the education of other members of the home health team, for example, in training physicians,
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
nurses, and new health practitioners to recognize the importance of social problems and to utilize social resources effectively. This may occur within the agency itself or in institutions of medical education. SUMMARY
Home health services must be expanded and must include ongoing social work services. In addition to the provision of direct service, social workers are encouraged to advocate for quality home health services, to develop effective techniques for providing social services to home-care patients, to incorporate these techniques into social work education, and to become involved in the education of their medical colleagues. In this way, the home health field can begin to fulfill its goals by providing patients with quality care in the home setting, thus allowing them to remain independent and at the same time meeting their health and social needs.
About the Authors Julianne S. Oktay, Ph.D., is Assistant Professor, Johns Hopkins School of Health Services, Baltimore, Maryland. Francine Sheppard, MSW, is Director, Howard County Rape Crisis Center, Columbia, Maryland. An earlier version of this paper was presented at a meeting of the American Public Health Association, Washington, D.C., November 1, 1977.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
46
47
Notes and References 1. Mary Grace Kovar, "Health of the Elderly and Use of Health Services," Public Health Reports (JanuaryFebruary 1977). 2. Phillip W. Brickner et al., "The Homebound Aged: A Medically Unreached Group," Annals of Internal Medicine, 82 (January 1975); and U.S. Congressional Budget Office, Long Term Care for Elderly and Disab!ed (Washington, D.C.: U.S. Government Printing Office, February 1977). 3. Kovar, op. cit. 4. Medicare: Health Insurance for the Aged, 1972-74 Participating Providers (Washington, D.C.: U.S. Social Security Administration, Office of Research and Statistics, 1976) . 5. U.S. Congressional Budget Office, op. cit. 6. Isadore Rossman, "Options for Care of the Aged Sick," Hospital Practice (March 1977), p. 113. 7. U.S. Congressional Budget Office, op. cit. 8. Mary H. Wilder, "Home Care for Persons 55 Years and Over," Vital and Health Statistics, Series 10, Number 73 (Rockville, Md.: National Center fOT Health Statistics, Department of Health, Education & Welfare, July 1972). 9. U.S. Congressional Budget Office, op. cit. 10. See Fredrick W. Seidl, Carol D. Austin, and D. Richard Greene, "Is Home Health Care Less Expensive?" Health and Social Work, 2 (May 1977), pp. 5-19; and Sonia Conly, "Critical Review of Research on Long-Term Care Alternatives" (Washington, D.C.: Office of Social Services and Human Development, Department of Health, Education & Welfare, June 1977). 11. U.S. Congressional Budget Office, op. cit. 12. Federal Health Insurance for the Aged, Conditions of Participation: Home Health Agencies (Washington, D.C.: Department of Health, Education & Welfare, September 1971). 13. Medicare: Hea!th Insurance for the Aged.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
Vol. 3, No.3, August 1978 0360-7283/78/0303-0035 $0.50 © 1978.
HEALTH AND SOCIAL WORK,
National Association of Social Workers, Inc.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
Home Health Care jor the Elderly
have begun to focus the attention of social workers on home-care services for the elderly. First, the growing power of the elderly population has begun to sensitize society to its special needs. Second, alarm about the skyrocketing cost of medical services is widespread in the general population. Finally, the human service field has moved away from the use of institutions to deal with people who cannot care for themselves. Social workers and other professionals in the health field, then, are viewing home health services from several angles: as a way of expanding services to the elderly, as a way of keeping health costs down, and as a more humane way of solving the problems of functional limitation.
SEVERAL RECENT TRENDS
36
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
Social workers have much to offer the large and growing population of elderly people in need of home health service. These programs need to be expanded substantially. This article discusses their role in increasing the quantity and quality of home-care services.
37
This article presents an overview of the population in need of home health care and a description of the development and content of such services in the United States. It will demonstrate the need for social work services in this area and give recommendations for the role of social workers in home health care. There has been a dramatic increase in the size of the elderly population in the United States during the 20th century. Persons over 65 years now make up over 10 percent of the total population. In addition, not only is the older population growing faster than those under age 65, but the oldest group, 75 years and older, is growing at the greatest rate. 1 Although the majority of elderly persons report good or excellent health, the elderly are more likely than younger persons to have some form of disability or chronic illness. From 12 to 17 percent of older persons are disabled, about 80 percent have a chronic illness, and many elderly persons suffer from two or more chronic conditions simultane0usly. 2 Contrary to popular belief, only 5 percent of the elderly population reside in institutions at anyone time. However, the figure rises to 20 percent for those 85 years and older. Of the noninstitutionalized aged, about 18 percent are limited in mobility, and about one-third of these are home bound. 3 Thus, the growth of the elderly popUlation has greatly increased the number of persons who are in need of long-term health services because of chronic disease or functional limitation.
GROWTH OF HOME CARE Although there is evidence of the existence of home health care in the United States as early as 1796, home
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEALTH AND SOCIAL WORK
"Perhaps the most powerful [reason why home health services should be expanded] is that the majority of elderly persons prefer to stay at home."
health agencies were not given an impetus for growth until 1965, with the passage of Medicare or federal health insurance for the aged. Medicare covers up to 100 visits for home health care per illness under hospital insurance (Part A) and 100 visits per year under supplementary medical insurance (Part B). In 1970, under the provision of 1967 amendments to the Social Security Act, home health care became a mandated service for every state participating in Medicaid, stimulating its further growth. Today, any state-certified home health agency may receive reimbursement for services provided to patients who are eligible for Medicare or Medicaid. According to these laws, covered services include, in addition to social services, intermittent nursing care, physical therapy, occupational therapy, speech therapy, home health aides, housekeeping services, laboratory investigation, and medical equipment and supplies as ordered by the physician. In 1974, 2,329 home health agencies were certified by Medicare in the United States. Of these, about half were official health agencies, such as city health departments, one-fourth were Visiting Nurses Associations, and one-eighth were hospitalbased agencies. 4 The types of patients eligible for home health care are those with acute illness, the disabled, those with exacerbations of chronic illness, and those recovering from surgery. In spite of Medicare and Medicaid cover-
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
38
39
age, however, the vast majority of persons in need of home health care do not receive this service from any federal program, often because of gaps in coverage. For example, patients may be ineligible for the federal programs but unable to afford the cost of numerous home-care visits, or they may be excluded because they need more than the 100 visits provided for in the Medicare legislation. Another problem is that the services actually covered vary from state to state. Only two states provide complete coverage. In fact, 70 percent of Medicaid expenditures for home health care are in New York State. 5 The lack of available home-care services is an even greater problem. Only 450 of the nation's 6,000 hospitals provide any type of home-care program. The sad fact is that most communities do not have home services to offer to their populations in need, whether they are eligible for coverage or not. 6 Thus expenditures for home-care services come to no more than 1 percent of both Medicare and Medicaid budgets. Out of an estimated 5-10 million persons in need of long-term care, less than 300,000 are receiving home-care services. In addition, a great many persons are being maintained at home through health care provided by family, friends, and neighbors. 7 A study of all persons receiving health services in the home shows that 80 percent are receiving care from relatives and not from health agencies. 8 WHY HOME CARE?
Advocates of home health services often argue that such services are less costly than institutional alternatives. This argument is based on the difference in the cost of a nursing home ($45 per day) and that of maintaining a
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
patient through home-care services ($12-14 per visit). However, although there is some evidence that homecare services can prevent institutionalization, home care does not appear to be a viable alternative for the majority of nursing home patients. Assessments indicate that no more than 15-25 percent of these persons could be maintained in their homes. Home care is cost effective primarily for cases in which the disability is not severe. In addition, expansion of home-care services to the large number of persons in need of long-term care who are not in institutions and who are now receiving no services would undoubte~ly increase expenses rather than conserve them. 9 Although the cost argument has not been settled, in part because of the extreme difficulty of doing experimental research in this area, there are other reasons why home health services should be expanded. to Perhaps the most powerful is that the large majority of elderly persons prefer to stay at home. Clearly there are psychological and social benefits for the patient who can avoid the disruption, isolation, and impersonalization of institutional placement. Another question is how the quality of health care offered by home health agencies compares to that in nursing homes or hospitals. Although there has been little careful research on this issue, there is some evidence that patients maintained in home health care have better health outcomes than those in more traditional medical settings. l l There is a critical need for more research in this area.
ROLE OF SOCIAL WORKERS In sum, there is a large population in need of long-term services, and home health services are desirable for
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
40
41
"Although there is some evidence that home-care services can prevent institutionalization, home care does not appear to be a viable alternative for the majority of nursing home patients. Assessments indicate that no more than 15-25 percent of these persons could be maintained in their homes." quality if not also for cost reasons. Social workers have several roles to play in providing this care. The first is as advocate regarding the quantity and quality of services. Social workers can be effective in their local communities as well as at the national level in encouraging the expansion of home-care services. Appropriate activities might include conducting research to demonstrate the need for these services, bringing evidence of this need to the attention of social action groups and legislators, and generating public support for home health services. Furthermore, there has been general concern that the proprietary agencies in the home field will repeat the scandals of the nursing home industry, in which quality of care is too often sacrificed for increased profits. Social workers must help communities develop high standards and serve as watchdogs to insure that home health agencies are carefully regulated. It is well known that the needs of home-care patients extend beyond those directly related to health. The loss of almost all social roles is an important problem for any elderly or disabled person. Unemployment can result in a loss of self-esteem as well as in financial problems. Inability to maintain contact with friends and family members brings increasing isolation. Physiological and psychological changes resulting in increased
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
dependency on others cause difficult adjustments for both patients and their families. When their condition deteriorates over time, patients need increasing support from family, friends, and community agencies to prolong independent functioning and to maintain a high quality of life. Financial resources must be stretched to cover ongoing medical expenses. Resources for housing, income, food, transportation, and recreation, as well as health care, are frequently needed. Thus the homebound elderly need many services that social workers traditionally provide. As mentioned earlier, social services are covered by Medicare and Medicaid as part of home health services. According to guidelines of the Department of Health, Education, and Welfare, the social worker's functions in home health services include the following: 1. Working with other members of the health team to assess the social and emotional factors related to the patient's health problems, and participating in the development of the patient care plan, 2. Helping the patient and his family to understand, accept, and follow medical recommendations and providing services that are planned to restore the patient to optimum social and health adjustment within his capacity, 3. Assisting the patient and his family with personal, emotional, and environmental difficulties which predispose toward illness or interfere with obtaining maximum benefits from health care, 4. Utilizing resources, such as family and community agencies, to assist the patient to resume life in the community and to learn to live within his maximum capacity, 5. Participating in alternative and appropriate discharge planning.12
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
42
43
Unfortunately, the same problems that cause inadequate levels of home health services apply to social services. Although many communities have no home health agencies at all, the majority of the home health agencies that do exist provide no social services. Out of the total of 2,329 home health agencies certified by Medicare, only 607 provide social services. About 75 percent of hospital-based home health programs provide social services, but only about 15 percent of state or local health departments do. IS Even in agencies that do offer social services, the social worker is often involved only in initial assessments. In some cases, one social worker is expected to serve the entire caseload, which may involve hundreds of patients. Clearly, this limits the service to crisis situations only. Thus, although social work services are badly needed by the home health care population, and although social services are covered by federal programs, their availability is currently limited. CASE ILLUSTRATIONS
Three case descriptions illustrate the importance of social work services in home health care and provide examples of some typical home health patients. Fortunately, these cases were all cared for by one of the few home health agencies that provides ongoing social work services. Mrs. F was a 77-year-old woman who had high blood pressure, edema of the legs, and was suffering from loss of memory. She lived in a two-bedroom apartment with her son and his five children. She was home-bound but could get around with the aid of a walker. The home health aide visited the patient twice a week to do personal care, take vital
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
signs, and aid her in the use of the walker. The home-care nurse visited every other week and provided health services. Mrs. F and the children were dependent on her son for the supply and preparation of food. The social worker discovered that the son was a chronic alcoholic, that there was often no food in the house, and that the patient and children were frequ.ently hungry. The social worker was able to work in close conjunction with the son's social worker to insure adequate nutrition for the dependents. Mrs. W, also 77, suffered from cancer of the colon and heart disease, and spent every day in bed on the second floor of her house. Mrs. W said it was impossible for her to get out of bed-she was in too much pain. However, her physician said there was no reason that she could not walk. The home health aide visited twice a week to take vital signs and to do personal care. The social worker explored the situation of the patient's husband and found that he had recently retired and was deriving great satisfaction from his role as caretaker for his wife. Because of this, he was not anxious to see her gain independence. In this case, the social worker was able to help the other members of the health team understand the situation. The social worker was then able to begin work with Mr. W, assisting him to realize that he would be helping in his wife's health care by encouraging her to walk. Mr. S, an 81-year-old man, had been recently released from the hospital. He was admitted because he was physically weak. His diagnosis after testing was severe malnutrition. The home-care nurse visited Mr. S once a week to teach him about nutrition. Mr.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
44
45
S lived alone in an 85-year-old house with no electricity. The social worker learned that Mr. S was living on a small amount of savings and had not applied for any benefits because he "didn't want to take handouts." With the social worker's help, Mr. S was able to apply for Social Security, food stamps, and a home repair grant to provide electricity for his home.
In each of these cases, the social worker was able to help the home health agency to meet its goals by contributing directly to the health and social welfare of the patients. TECHNIQUES AND TRAINING To be optimally effective in the home health field, social workers will need to develop techniques that are effective in this setting. For example, many home-care patients have difficulties that stem from inappropriate behavior. A logical behavioral approach combined with humane behavior modification techniques could be helpful in situations in which patients' behavior is detrimental to their health. Another area that is often overlooked is the needs of the family members who share the responsibility for patients' care. Social workers could be important sources of support for these people. As social workers gain more experience in the home health field, it will be important to determine which techniques are most effective. In addition, social work schools will need to begin training students to be effective workers in this field. Another important role for social workers will be involvement in the education of other members of the home health team, for example, in training physicians,
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
HEAL TH AND SOCIAL WORK
nurses, and new health practitioners to recognize the importance of social problems and to utilize social resources effectively. This may occur within the agency itself or in institutions of medical education. SUMMARY
Home health services must be expanded and must include ongoing social work services. In addition to the provision of direct service, social workers are encouraged to advocate for quality home health services, to develop effective techniques for providing social services to home-care patients, to incorporate these techniques into social work education, and to become involved in the education of their medical colleagues. In this way, the home health field can begin to fulfill its goals by providing patients with quality care in the home setting, thus allowing them to remain independent and at the same time meeting their health and social needs.
About the Authors Julianne S. Oktay, Ph.D., is Assistant Professor, Johns Hopkins School of Health Services, Baltimore, Maryland. Francine Sheppard, MSW, is Director, Howard County Rape Crisis Center, Columbia, Maryland. An earlier version of this paper was presented at a meeting of the American Public Health Association, Washington, D.C., November 1, 1977.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
46
47
Notes and References 1. Mary Grace Kovar, "Health of the Elderly and Use of Health Services," Public Health Reports (JanuaryFebruary 1977). 2. Phillip W. Brickner et al., "The Homebound Aged: A Medically Unreached Group," Annals of Internal Medicine, 82 (January 1975); and U.S. Congressional Budget Office, Long Term Care for Elderly and Disab!ed (Washington, D.C.: U.S. Government Printing Office, February 1977). 3. Kovar, op. cit. 4. Medicare: Health Insurance for the Aged, 1972-74 Participating Providers (Washington, D.C.: U.S. Social Security Administration, Office of Research and Statistics, 1976) . 5. U.S. Congressional Budget Office, op. cit. 6. Isadore Rossman, "Options for Care of the Aged Sick," Hospital Practice (March 1977), p. 113. 7. U.S. Congressional Budget Office, op. cit. 8. Mary H. Wilder, "Home Care for Persons 55 Years and Over," Vital and Health Statistics, Series 10, Number 73 (Rockville, Md.: National Center fOT Health Statistics, Department of Health, Education & Welfare, July 1972). 9. U.S. Congressional Budget Office, op. cit. 10. See Fredrick W. Seidl, Carol D. Austin, and D. Richard Greene, "Is Home Health Care Less Expensive?" Health and Social Work, 2 (May 1977), pp. 5-19; and Sonia Conly, "Critical Review of Research on Long-Term Care Alternatives" (Washington, D.C.: Office of Social Services and Human Development, Department of Health, Education & Welfare, June 1977). 11. U.S. Congressional Budget Office, op. cit. 12. Federal Health Insurance for the Aged, Conditions of Participation: Home Health Agencies (Washington, D.C.: Department of Health, Education & Welfare, September 1971). 13. Medicare: Hea!th Insurance for the Aged.
Downloaded from https://academic.oup.com/hsw/article-abstract/3/3/35/609689 by Duke University user on 11 January 2019
HOME HEALTH CARE FOR THE ELDERLY
