Submitted to the Special Committee on Aging United States Senate Hearing Patients in Peril: Critical Shortages in Geriatric Care

February 27, 2002

On behalf of the National Association of Social Workers (NASW), I thank Chairman Breaux, Ranking Member Craig, and the rest of the Special Committee for convening this hearing on this topic of great magnitude, namely the impending shortage of geriatric health care professionals.

Social work is a distinct profession with rigorous, specialized education and training requirements, state licensure, certification, and ethical standards. Social work professionals practice, with regard to geriatrics, in a variety of settings, including hospitals, skilled nursing facilities, nursing homes, mental health facilities, rehabilitation centers, hospice, adult day care facilities, assisted living facilities, nutrition programs, adult protective services, elder abuse programs, area agencies on aging, family service agencies, ombudsman programs, educational institutions, veterans services programs, and in private practice. The educational attainment level and professional experience necessary to perform a social work position varies significantly according to the requirements of the individual position, the setting, and the target clientele.

Social work practice uses a comprehensive approach, which examines the person, group, or community within the context of their environment and facilitates appropriate problem solving within that framework. Professional social workers are knowledgeable about how human development and behavior and social, economic, and cultural issues interact and affect our daily lives. This holistic approach is critical to ensure that quality, comprehensive health care services are provided to older Americans.

As Americans age, they face a combination of physiological, psychological, and social changes. This volatile cocktail of changes has momentous, permanent effects on individuals' quality of life and often result in a need for supportive services. The biopsychosocial framework embodied in direct social work practice makes the social worker an integral member of any interdisciplinary health care service delivery team. In that role, professional social workers render a variety of case management, clinical, mental health, and medical- social services. Social work services are provided to the older adult and to his or her family members so that independence and well being are maximized.

Given the rapid "graying of America" that will continue for many years, our nation will be challenged to meet the needs of older Americans. The U.S. Administration on Aging has predicted that by 2030, roughly 70 million people in the U.S. will be over age 65–more than double the number of people over 65 in 2000. Older adults comprised 12.4 percent of the entire U.S. population in 2000, but is expected to increase to 20 percent of the total in 2030. Within that time frame, the number of people aged 85 and is expected to double, and the number of people aged 100 and older is expected to triple. It is only logical to expect that accompanying this meteoric rise in the number of older Americans will be an increase in the need for health care services and providers to render those services.

The Center for Health Workforce Studies, applying U.S. Bureau of Labor Statistics (BLS) data, projected that the need for health care workers will be significant over the next ten years, increasing from a level of 10.9 million workers in 2000 to over 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 the health care arena. The projected need in 2010 is estimated to be 252,000—an increase of 65,000, or 35 percent.

It is difficult to know precisely how many social workers are working solely in the aging sector, because few social workers limit their practice to older clients. In fact, most social workers serve a mix of clients, young and old. Grace Dawson, PhD, and John F. Santos, PhD, through the Gerontology and Geriatrics Education Office of the University of Notre Dame, examined this issue in their July 2000 paper Combating Failure: An Investigation of Funding for the Education and Training of Geriatric-Care Personnel. They concluded that no uniform definition exists among the health care professions of the training necessary to be considered a specialist in gerontology. Moreover, the use of the term is subjective and can illustrate a variety of education, knowledge, and training.

 NASW is working to rectify the paucity of information through the creation of its Practice Research Network, which seeks to build the information resources of the social work profession. The initial survey, conducted in April 2000, found that only 5 percent of NASW members identified aging as their primary practice area; 5 percent identified aging as their secondary area; and 5 percent identified nursing homes and/or assisted living facilities as their primary practice setting.

The Practice Resource Network statistics reflect the national trend in projected shortages of health care providers, including social workers, pharmacists, and registered nurses. With the ever-increasing number of older Americans, these shortages will become more acute.

To avert this crisis, the social work profession is advocating for policy and service delivery innovations that will support and attract quality practitioners. 

Education has an effect.  Finding postgraduate training in geriatrics is a challenge—especially training that is comprehensive, useful, and affordable. And 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, there is little funding for specialized continuing education for the professional social work practitioners. Incentives such as scholarships, stipends, and loan forgiveness are needed to attract social workers to the field of gerontology.

Reimbursement under the Medicare program for all forms of social work services is a deterrent to those looking to enter the field and an obstacle to practitioners, agencies, and institutions. Medicare discriminates against mental health services provided under Part B through the imposition of a 50 percent copay whereas the copay for all other services is a significantly lower 20 percent. Exacerbating the situation is the complex maze that social workers must negotiate in order to receive reimbursement for Part B services. For example, the decision whether or not to reimburse clinical social workers directly for mental health services rendered to Part B beneficiaries in skilled nursing facilities rests with individual Medicare fiscal intermediaries. Some pay, others do not. If, in fact, clinical social work services are reimbursed, the 50 percent copay still applies. 

Retention is a factor in the shortage of social workers in geriatric settings. Social work professionals trained in geriatrics or who have work experience in geriatrics are not necessarily staying in the field of geriatrics. The decrease in public funding has forced many community agencies to rely more on private funding. This shift from public to private funding sources often translates into fewer resources to hire qualified staff. The existing staff is left to manage much higher caseloads with accompanying levels of stress.

 Another issue associated with reduced funding, is that agencies are cutting back on hiring social workers with a master's degree, who are more qualified to handle complicated cases and larger caseloads. Furthermore, large and complicated caseloads coupled with a fragmented service delivery system make it very difficult for professional social workers to provide quality services to their older clients. This environment can make social workers feel vulnerable and that they are perhaps compromising their professional ethics.

Public perception may be the proverbial straw that breaks the back of the professional social worker practicing in the geriatric setting. Common perceptions (or misperceptions) are that working with older Americans not only is depressing but is synonymous with working with the sick and the dying. A perception also exists that there are few personal, professional, and societal rewards for working with older Americans.

Social work would support efforts to shift the dominant notion of older Americans from deficits-based to strengths-based. Instead of pathologizing this part of the lifecycle, professional social workers can help our nation to consider older Americans as valuable resources to society.  Just as national policy and communication campaigns have proven effective in moving public perception, this same approach needs to be applied to the aging population.

Aside from the particular issues facing social work, there are the fundamental, widely stated issues underlying the health care workforce shortages that remain to be addressed: a sharp projected growth in demand for health care services; the unduly stressful working conditions; racial, gender, or ethnic imbalance; lack of career ladders and educational inflexibility; and the overall aging of the health care workforce. 

In conclusion, NASW agrees that the existing health care workforce will be inadequate to meet the needs of older Americans. NASW holds that in order to respond to this crisis, government must be an active participant in the solution through a number of strategies. Potential federal action may include the provision of funding for data collection and analysis, improvement of the societal value and respect accorded to non-physician health care providers, provision of funding for the development of geriatric curricula, and provision of adequate reimbursement rates for Medicare and Medicaid. Loan forgiveness, stipends for students and faculty, and financial support for field placements in geriatrics are other important steps the federal government can take to attract and retain social workers and other health care professionals in the field of geriatrics.

NASW looks forward to working with you on this and other issues of mutual concern so we may continue to enhance the lives of individuals, families, and communities through our professional service.