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NASW Standards for Social Work Practice with Family Caregivers of Older Adults

5 Introduction
7 Background
9 Goals of the Standards
10 Definitions
14 Guiding Principles
18 Standards for Social Work Practice
18 Standard 1: Ethics and Values
21 Standard 2: Qualifications
22 Standard 3: Knowledge
25 Standard 4: Cultural and Linguistic Competence
27 Standard 5: Assessment
30 Standard 6: Service Planning, Delivery, and Monitoring
32 Standard 7: Advocacy
33 Standard 8: Collaboration
35 Standard 9: Practice Evaluation and Improvement
37 Standard 10: Documentation
39 Standard 11: Workload
39 Standard 12: Professional Development and Competence
41 References
44 Resources
47 Acknowledgments

Introduction

The aging of the population presents social, economic, and political implications for families, the social work profession, and the global community. Social workers, other professionals, and the public increasingly recognize that advanced age is a time of continued growth and that older adults contribute significantly to their families, communities, and society. At the same time, many individuals face multiple biopsychosocial challenges as they age: changes in physical and cognitive abilities; barriers to accessing comprehensive, affordable, and high-quality health and mental/behavioral health care; decreased economic security; lack of affordable, accessible housing; increased vulnerability to abuse and exploitation; and loss of meaningful social roles and opportunities to remain engaged in society. These challenges often affect entire families, who struggle to provide physical, emotional, financial, and practical support to their aging members.

According to the Institute of Medicine (IOM) (2008), “Family members, friends, and other unpaid caregivers provide the backbone for much of the care that is received by older adults in the United States” (p. 241)—care valued, for the year 2007, at approximately $375 billion (AARP, 2008). Yet, their role is “often underappreciated” (IOM, p. 263), and many family caregivers support their loved ones at significant cost to their own physical, emotional, and financial well-being (National Alliance for Caregiving, 2009).

Numerous studies have indicated that the need for services for older adults, including social work, will increase exponentially as the population ages (IOM, 2008; U.S. Department of Health and Human Services, 2006; Whitaker, Weismiller, & Clark, 2006). At the same time, strengthening relationships between family caregivers and health care practitioners benefits both caregivers and older adults (IOM).

Social workers interact with family caregivers of older adults not only throughout the network of aging services and across the health, mental/behavioral health, and long-term care continuum, but also in diverse settings such as child welfare agencies, employee assistance programs, faith-based organizations, housing programs, schools, and veterans’ service programs. With its strengths-based,
person-in-environment perspective, the social work profession is well positioned and trained to advocate for and support family caregivers of older adults (NASW, 2009). These standards are designed to enhance social work practice with family caregivers of older adults and to help the public understand the role of professional social work in supporting family caregivers.
Furthermore, although the challenges of caring for an older adult may differ in some ways from those of caring for a younger person living with illness or disability, the standards may also be useful in informing social work practice with families caring for younger people.

Background

During the past decade, consumer advocacy groups, health professional organizations, and government agencies have paid increased attention to the role of family caregivers in supporting older adults and to the needs of family caregivers. As a result, health care professions are focusing on their own ability to train members of their respective disciplines and to contribute to the building of a knowledge base for excellence in gerontology and in supporting family caregivers. Social work is no exception. The Council on Social Work Education (CSWE) developed a guide, Advanced Gero Social Work Practice (2009), which links gerontological social work competencies to:

Specific practice behaviors, outlined in CSWE’s 2008 Educational Policy and Accreditation Standards (EPAS), that are common to all social work practice
Knowledge in aging for generalist practice
Advanced gerontological social work knowledge and practice behaviors

The guide also identifies course exercises, assignments to measure student attainment of gerontological social work practice behaviors, and research articles providing evidence-based social work practice. Content specific to family caregiving is included in the document.

Social workers, nurses, family caregiver advocates, and other experts in family caregiving met in 2008 to identify the knowledge and skills social workers and nurses need to support family

caregivers of older adults. This invitational symposium, State of the Science: Professional Partners Supporting Family Caregivers, was developed under a grant from the John A. Hartford Foundation to the AARP Foundation. Meeting proceedings were published and widely disseminated in both The Journal of Social Work Education (Kelly, Brooks-Danso, & Reinhard, 2008) and The American Journal of Nursing (Reinhard, Kelly, and Brooks-Danso, 2008).

Building on this foundation, the National Association of Social Workers has developed Standards for Social Work Practice with Family Caregivers of Older Adults. The standards reflect core elements of social work practice with, and on behalf of, family caregivers and are targeted toward social workers who address family caregiving needs in various professional settings. For many social workers, these standards reinforce current practices. For others, they provide objectives to achieve and guidelines to assist in practice.

Goals of the Standards

These standards address family caregiving for older adults as an expanding field of knowledge for social workers. The standards are designed to enhance social workers’ awareness of the skills, knowledge, values, methods, and sensitivity needed to work effectively with family caregivers.

Ideally, these standards will stimulate the development of clear guidelines, goals, and objectives related to family caregiving and gerontology in social work practice, research, policy, and education. The specific goals of the standards are

■ To inform social workers about family caregiving as an expanding field of social work knowledge
■ To improve the quality of social work services provided to family caregivers of older adults
■ To provide a basis for the development of continuing education materials and programs related to family caregiving
■ To ensure that social work services to family caregivers of older adults are guided by the NASW Code of Ethics (2008)
■ To advocate for family caregivers’ right to self-determination, confidentiality, access to supportive services, and appropriate inclusion in decision making affecting older adults
■ To encourage social workers to participate in the development and refinement of public policy, at the local, state, and federal levels, to support family caregivers of older adults

Definitions

Social worker
Within the United States, social worker refers to an individual who possesses a degree in social work from a school or program accredited by the Council on Social Work Education.
Although all 50 states and the District of Columbia license or certify social workers, licensure and certification laws vary by state. Each social worker should be licensed or certified, as applicable, at the level appropriate for her or his jurisdiction.

Family, family caregiver, and family system The terms family and family caregiver refer to family of origin, extended family, domestic partners, friends, or other individuals who support an older adult. These individuals may cross the lifespan from childhood to advanced age; together, they constitute the family system. For the most part, family caregivers support their aging family members without financial compensation, although some family members may receive remuneration for their services through consumer-directed programs. However, for purposes of these standards, family does not include individuals whose primary relationship with the older adult is based on a financial or professional agreement.

In some families, an older adult designates one individual as a primary caregiver or decision- maker, or an individual voluntarily assumes such a role. In many families, different individuals assume responsibility for a variety of caregiving tasks. For example, an adult daughter may assist an older parent with financial matters; a son may be designated to make health care

decisions; a spouse or partner may help with activities of daily living; a grandchild may help with grocery shopping; a niece or nephew may take an older relative to religious services; and a neighbor may provide transportation to appointments. For still other families, caregiving and decision-making roles are not clearly defined—or there may be a discrepancy between defined roles and day-to-day fulfillment of such responsibilities.

The importance of assessment of family caregiving roles notwithstanding, for the purposes of these standards the term family caregiver is not limited to individuals with either well-defined or assumed primary caregiving roles. The term is also not restricted to individuals who self-identify as caregivers, because many family members do not identify with this label even though they support an older adult in one or more of the ways outlined in the next definition.

Family caregiving
Family caregiving may include a variety of supports and services that enhance or maintain older adults’ quality of life:

■ Emotional, social, and spiritual support
■ Assistance with decision making related to health care, financial matters, and lifespan planning
■ Assistance with physical tasks, such as bathing, dressing, or walking
■ Support in navigating and negotiating health and social service systems, such as dealing with health and long-term care insurance, arranging and overseeing paid helpers in the

home, communicating with health care professionals, or advocating for quality care and services
■ Assistance with practical matters, such as housekeeping, processing paperwork, or going to medical and other appointments
■ Financial support, including direct financial assistance and help with bill-paying
■ Shared housing

Caregiving may occur on an intermittent, part-time, or full-time basis. It includes support provided both from a distance and in an older adult’s home or other setting. For the purposes of these standards, the term caregiving refers to the supports and services provided primarily on a voluntary basis, not to professional or contractual services—such as social work or home health aide services—that are provided for a fee to the public.

Culture
Culture has been described as “the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group” (Cross, Bazron, Dennis, & Isaacs, 1992). Cultural identification may include, but is not limited to, race, ethnicity, and national origin; migration background, degree of acculturation, and documentation status; biological sex, gender identity, and gender expression; sexual orientation and marital or partnership status; spiritual, religious, and political belief or affiliation; physical, mental, and cognitive ability; literacy, including health and financial literacy; and age.

Cultural competence
The process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, and other diversity factors (including, but not limited to, gender identity and expression, sexual orientation, and marital or partnership status) in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each (NASW, 2007).

Guiding Principles

The scope of social work practice with family caregivers of older adults extends across many practice settings and requires action at the individual, family, group, community, and organizational levels. These standards serve as a basic tool to guide social work practice with family caregivers of older adults, although practice priorities may vary among settings.

Some practice settings prioritize the needs and goals of the entire family system and encourage social workers to assess, and intervene on behalf of, both older adults and their family caregivers. For example, support for both patients and families is inherent in the hospice model. In other settings, however, older adults may constitute the primary clientele for many social workers using these standards. In such cases, social workers’ primary responsibility is usually to the well-being of the older adult, and social workers may have little or no opportunity to interact with family caregivers.

On the other hand, many social workers have—or can establish (following appropriate ethical and legal guidelines)—at least some contact with their older clients’ family caregivers. For example, home health social workers frequently encounter family caregivers when visiting older adults. When this occurs, social workers have a responsibility to support family caregivers, both to maximize the quality of life of their older adult clients and to enhance the well-being of caregivers themselves.

Although practice setting and funding source may influence the extent to which social workers can support family caregivers, attention to caregivers’ contributions, assets, needs, and goals remains critical.

Conversely, family caregivers of older adults may constitute the primary clientele for other social workers using these standards. For example, a family caregiver who is struggling to balance job and family responsibilities may be referred, voluntarily or involuntarily, to a social worker in an employee assistance program.

Likewise, a family member may also turn to a caregiving support group when his or her mental or physical health is adversely affected by caregiving responsibilities. When a family caregiver of an older adult is the identified client, the social worker’s contact with the older adult may be nonexistent, limited, or extensive. Although biopsychosocial assessment of family caregivers’ goals, life experiences, abilities, and needs guides care planning and service delivery, understanding the abilities, needs, and goals of the older adults they support is also important. Family members often have years of experience in caregiving roles and can readily provide this history. Social work solicitation of family caregivers’ expertise and validation of caregivers’ role as partners on the care team builds a foundation of trust. Having established this foundation, social workers can support family caregivers not only in making informed decisions and fulfilling caregiving roles, but also in identifying and addressing stress related to caregiving responsibilities. In some cases, social workers help family caregivers modify their caregiving roles to improve or maintain their own health and well-being.

Social workers also recognize that caregiving roles may not be clearly defined and that caregiving is often a reciprocal phenomenon within a family. For example, a middle-aged woman supporting her mother may also rely on her parent for child care or financial assistance. Similarly, an older man may assume management of household finances because his wife is in the early stages of Alzheimer’s disease. At the same time, his wife may perform physical tasks, such as carrying laundry to and from the basement, that he cannot accomplish because he uses a wheelchair. In such cases, social workers may find that the individuals identified as caregivers and care recipients may, in fact, fulfill both roles. Even in cases in which caregiving roles are clearly defined, emotional caregiving is often reciprocal (though family caregivers may struggle with the loss of such reciprocity as a parent’s dementia progresses, for example, or as a partner withdraws during the dying process). Thus, social workers can support both older adults and family caregivers by affirming that caregiving relationships are partnerships with mutual benefits.

Social workers also play a critical role in helping individuals who support older adults, but do not self-identify as family caregivers, in naming their roles. This recognition is often caregivers’ first step in identifying and accessing supports, both to care for their family members and to maintain their own wellness. Validation of the caregiving role can be especially helpful for caregivers who have complicated relationship histories with the older adults whom they support.

Even individuals and families who self-identify as caregivers, however, may not be connected with social workers, turning instead to community organizations (such as cultural centers or religious communities) for support. Collaborative relationships between social workers and community organizations may promote family caregivers’ understanding of and access to social work services.

Regardless of practice setting or primary clientele, social workers who interface with older adults or family caregivers of older adults must balance the needs and goals of both populations and must recognize that those needs and goals may sometimes result in conflict.

Conflicts among family members in various formal or informal caregiving roles are also quite common. Assessment of the family system (to the extent possible), careful consideration of social work values and ethics, and application of listening, empathy, and conflict resolution and mediation skills can guide social workers in facilitating optimal outcomes for all involved. Again, practice setting and funding sources may influence social workers’ ability to assess and intervene with both older adults and family caregivers or to interact with all family caregivers in a given situation. Nonetheless, attention to the contributions, strengths, needs, and goals of family caregivers of older adults is integral to social work practice.

Standards for Social Work Practice with Family Caregivers of Older Adults

Standard 1. Ethics and Values

Social workers practicing with family caregivers of older adults shall adhere to the ethics and values of the social work profession, using the NASW Code of Ethics (2008) as a guide to ethical decision making.

Interpretation
The primary mission of the social work profession is to enhance human well-being and to help meet the basic needs of all people, with particular attention to the needs of people who are vulnerable and oppressed. This mission is rooted in a set of core values that constitutes the foundation of social work and relates closely to social work with family caregivers of older adults:

Service: Social workers apply their knowledge and skills to support the well-being of family caregivers of older adults and to address challenges faced by family caregivers.
Social justice: Social workers act on individual and systemic levels to ensure access to needed information, services, and resources for family caregivers of older adults and to facilitate family caregivers’ meaningful and comfortable participation in decision making.
Human dignity and worth: Social workers treat family caregivers of older adults in a respectful and caring manner. They promote family caregivers’ self-determination, with sensitivity and respect for the self-determination of older adults when confronted with conflicting values and goals.
Importance of human relationships: Social workers engage family caregivers, to the extent possible, as partners in goal identification, progress, and achievement. They strive to strengthen relationships between family caregivers and older adults so as to maintain and enhance the well-being of the family system.
Integrity: Social workers use the power inherent in their professional role responsibly, exercising judicious use of self and avoiding conflicts of interest. Their practice with, and on behalf of, family caregivers of older adults is consistent with the profession’s mission and ethics.
Competence: Social workers practice within their areas of competence and continually strive to enhance their knowledge and skills related to family caregiving and aging. Competence also requires that social workers recognize the importance of, and attend to, their own self-care.

The very term family is, in fact, rooted in ethical values. For the purposes of these standards, family refers to family of origin, extended family, domestic partners, friends, or other individuals who support an older adult and whose primary relationship with the older adult is not based on a financial or professional agreement. Social work practice with family caregivers of older adults begins with honoring the uniqueness of each family system.

Effective practice with family caregivers of older adults requires social workers to identify their own values and perspectives regarding aging and family caregiving, including their personal experiences as family caregivers or with aging family members. Social workers have an ethical responsibility to assess how their own experiences influence their practice with family caregivers of older adults, to ensure they are not imposing their own values on family caregivers of older adults.

Differences in the wishes, perceptions, and capacity of older adults and family caregivers can present complex ethical and legal challenges to social workers. Social workers must know and comply with federal, state, local, and tribal laws, regulations, and policies related to older adults, such as reporting requirements for elder abuse and neglect, guardianship, and advance directives. Obtaining informed consent, maintaining confidentiality, and protecting privacy are critical. Careful application of ethical principles is especially important when older adults or family caregivers have limited
decision-making capacity or are experiencing or perpetuating mistreatment. Collaboration with colleagues can also help resolve ethical dilemmas.

Standard 2. Qualifications

Social workers who practice with family caregivers of older adults shall possess a degree in social work from a school or program accredited by the Council on Social Work Education; shall comply with state-based licensing and certification requirements; and shall have knowledge, skills, and professional experience in aging and family caregiving.¹

Interpretation
Social work degree programs provide education and training in social work values, ethics, theories, practice, policy, and research. This training is essential for any individual engaging in the practice of social work. Social work licensing and certification laws vary by state. It is each social worker’s responsibility to ensure compliance with the licensing and certification laws of her or his respective state.

Social work practice with (or on behalf of) family caregivers of older adults requires specialized knowledge and skills as outlined in these standards. Ideally, social workers attain such knowledge and skills during their degree programs through coursework and field practice experience related to aging and family caregiving. Specialty practice certifications may also indicate expertise in areas relevant to practice with family caregivers of older adults, such as gerontological social work, geriatric care management, case management, or health care. Whether through certification, continuing education, or professional experience, social workers should continually enhance their skills and knowledge related to aging and family caregiving.

As the aging population grows and family caregiving becomes increasingly central to health care and social service delivery, social workers will increasingly interface with older adults and family caregivers, regardless of practice specialty or setting. Social workers specializing in areas other than aging and family caregiving should seek supervision, consultation, and continuing professional development, as described in these standards, to ensure they have the requisite knowledge of systems of care and skills for practice with older adults and family caregivers (or to make responsible referrals to other social workers with expertise in this area).

(1) Degree and licensure requirements are specific to social work practice in the United States. NASW recognizes that qualifications may differ outside the United States.

Standard 3. Knowledge

Social workers shall acquire and maintain a working knowledge of current theory, practice, sociohistorical context, policy, evidence-based research, and evaluation methods related to aging and family caregiving and shall integrate such information into practice.

Interpretation
Social work with family caregivers of older adults is a specialized practice area requiring focused preparation and continuing education. Social workers apply knowledge about aging, resilience, disability, health conditions, and caregiving to enhance the well-being of family

caregivers of older adults. Social workers also support family caregivers in navigating health care and social service systems, accessing resources, and identifying service gaps and barriers.

Knowledge essential to social work with family caregivers of older adults includes, but is not limited to, the following areas:

• Aging

Concepts and theories associated with aging, such as cohorts and lifespan development
Physiological and cognitive processes associated with healthy aging
Grief, loss, death, dying, and bereavement
Effects of ageism on medical and social service delivery to older adults

• Physical health

Physiological and cognitive processes associated with acute and chronic conditions and medication use and misuse
Psychosocial effects of acute, chronic, and life-limiting illness
Psychosocial effects of physical and cognitive disability

• Mental and behavioral health

Depression, anxiety, and other mental health conditions
Addictive behaviors and their effect on the family system
Elder abuse, neglect, and exploitation

• Family caregiving experiences

Family systems, interpersonal dynamics, and the complexity of caregiving relationships
Interdependence in care partnerships (i.e., between caregivers and care recipients)
Family caregivers’ central role in health care delivery
Growth and rewards associated with family caregiving
Physical, emotional, and financial challenges associated with family caregiving at various points in the individual lifespan and family life cycle
Signs of caregiver strain
Reengagement and healing after death of care recipient

• Resources

Health care, long-term care, social service, and housing systems and programs
Policies, eligibility requirements, and financial concerns affecting family caregivers and older adults
Resources available to family caregivers and older adults, such as respite care, family medical leave, and assistive technology

• Professional social work role

The multifaceted social work roles and functions related to family caregiving and aging
Interdisciplinary collaboration
Appropriate professional boundaries and use of self, including managing countertransference when social workers are personally involved in family caregiving outside of the workplace
Signs of, and strategies to address, ethical dilemmas, compassion fatigue, burnout, secondary traumatization, and professional grief

Standard 4. Cultural and Linguistic Competence

Social workers shall provide and facilitate access to culturally and linguistically appropriate services to family caregivers of older adults, consistent with the NASW Indicators for the Achievement of the NASW Standards for Cultural Competence in Social Work Practice (2007).

Interpretation
The increasing cultural and linguistic diversity of family caregivers and older adults requires social workers to strive continually for cultural and linguistic competence. Social workers’ recognition and affirmation of cultural and linguistic diversity are critical both to the formation of therapeutic alliances with family caregivers and to cooperative working relationships with colleagues. Such diversity includes, but is not limited to, race, ethnicity, socioeconomic class, biological sex, gender identity, sexual orientation, religion, age, health status, preferred language, migration background, documentation status, degree of acculturation, and literacy (including health and financial literacy). It can also include vocational affiliations, such as participation in the military or involvement in veterans’ services.

Cultural competence begins with each social worker’s cultural self-identification. Cultural self-awareness is fundamental to recognizing and addressing how one’s own cultural values, beliefs, experiences, and practices affect interactions with family caregivers and colleagues. Social workers who practice such self-assessment can then recognize how cultural identity, in its multifaceted expressions, is central to the resilience of the individuals, families, and communities with which they interact.

Specifically, social workers need to support family caregivers’ resilience by appreciating and affirming the cultural values, beliefs, and practices of family caregivers with whom they work, especially the ways in which culture influences perceptions and practices related to aging, illness, and disability; physical and psychosocial pain; health care treatments; providing care to, or receiving care from, family members; help-seeking behaviors; health care, financial, and other decision making; and death and dying.

Social workers also need to recognize that culture varies within families. These differences may manifest in multiple ways, such as different perceptions of caregiving responsibilities or varying levels of fluency in the dominant language of the country of residence. In such instances, social workers should honor the differences within the family system and facilitate maximal participation of all members with whom they interact — by using professional interpreters rather than relying on family caregivers to interpret for older adults, for example.

Cultural and linguistic factors influence not only practitioner-client relationships but also organizational structures and societal structures and dynamics. Social workers should comprehend how systemic or institutional oppression related to cultural and linguistic diversity (such as ageism, racism, or sexism) affects family caregivers’ role in care, access to and utilization of resources, health care outcomes, and well-being. Identification of ageism in policy, the media, and systems of care is especially useful in helping families contextualize the challenges they face — and, sometimes, in identifying and addressing their own ageism. Action to eliminate ageism and other forms of institutional oppression on organizational, community, and broader levels is essential to optimizing family caregiving roles and reducing economic, health, and social disparities experienced by family caregivers and older adults.

Standard 5. Assessment

Social workers shall assess family caregivers of older adults on an ongoing basis, gathering comprehensive information to develop and amend plans for care or services.

Interpretation
Biopsychosocial assessment is the foundation of social work practice and is conducted in collaboration with the family system.

Assessment is a complex function requiring openness to a wide variety of information, both verbal and nonverbal, presented by the family system in the context of the social environment. Using empathy, client-centered interviewing skills, and methods appropriate to clients’ capacity, social workers engage family caregivers of older adults in identifying their strengths, resources, and concerns. Because assessment guides intervention, social workers need to complete initial assessments in a timely manner and then reassess and revise service plans in response to caregivers’ shifting needs and altered goals. Use of standardized assessment instruments, such as caregiver burden scales, can aid social workers in identifying and responding to caregivers’ concerns.

Social work assessments may vary based on practice setting and specialty. Comprehensive biopsychosocial social work assessments of family caregivers of older adults may include the following domains, as they pertain to service needs:

• Family characteristics and dynamics

Motivating factors in seeking social work services, if applicable
Family structure and roles, including the ways various family members provide care and identified decision-makers (both legally and informally designated)
Communication patterns, conflict management styles, and alliances within the family system, especially history of relationships between caregiver(s) and older adult receiving care
Living arrangements
Vocational history (e.g., work, school, or volunteering) and lifespan development
Language preferences and proficiency levels
Degrees of literacy, including health and financial literacy
Cultural values, beliefs, and practices (including spirituality and religion) related to caregiving and aging
Psychosocial strengths, protective factors, and points of resilience
Family system experiences, including generational patterns, related to illness, disability, loss, and death throughout the life cycle
Family’s relationships with community and religious organizations
Experiences specific to populations such as immigrants and refugees, survivors of violence or trauma, child or adolescent caregivers, and people who are homeless, and family system’s responses to those experiences

• Risk assessment

Physical, cognitive, and psychosocial functioning of older adults receiving care
Older adults’ desire and capacity for independence
Degree of adherence to plan of care, including medications
Household environment and need for adaptive equipment, home modification, or alternate living arrangements
Family caregivers’ self-care capacity (physical, emotional, and cognitive)
Family caregivers’ perceptions of older adults’ capacity for independence and tolerance of safety risks
Family caregivers’ physical, emotional, and cognitive capacity to fulfill caregiving responsibilities
Family system’s psychosocial supports, both formal and informal, and barriers to access
Family system’s financial resources and barriers to access
Family system’s ability to navigate health, long-term care, and social service systems
Advance care planning, including use and comprehension of advance directives and other legal documents
Family system’s behavioral and mental health functioning, including history, coping styles, crisis management skills, and risk of suicide or homicide
Risk of abuse, neglect, or exploitation by or of family caregivers, and underlying causes for such mistreatment

• Goals and effects of family caregiving

Caregivers’ goals for care of their older family member(s)
Indicators of caregiver burden, such as depression, anxiety, deteriorating health, financial insecurity, and social isolation
Impact of health conditions and caregiving on emotional intimacy and, if applicable, sexual relationships between family caregivers and older adults
Impact of caregiving on caregivers’ other relationships and responsibilities
Family caregivers’ need for physical assistance, emotional or social support, respite, financial resources, or other services
Changes in policies and programs needed to support family system

Standard 6. Service Planning, Delivery, and Monitoring

Social workers shall collaborate with family caregivers of older adults to plan, deliver, and monitor individualized services that promote caregivers’ strengths and well-being. Care plans shall be based on assessments and have measurable objectives.

Interpretation
Social work services should be designed to meet the biopsychosocial needs of family caregivers of older adults and should be delivered in a manner that ensures confidentiality in accordance with the NASW Code of Ethics (2008). Service planning, delivery, and monitoring draw not only on ongoing, comprehensive social work assessments but also, if appropriate and available, on the input of other service providers involved in supporting the family system. Collaborative engagement of family caregivers of older adults throughout the service planning, delivery, and monitoring process is critical to ensure that services are mutually agreed upon, appropriate to caregivers’ circumstances, clearly communicated, and delivered in a timely manner.

Care plans should include short- and long-term goals centered on family caregivers of older adults. Service frequency and duration may be affected by practitioner role and setting parameters but, ideally, should be in accordance with the needs and goals identified in the assessment. Care plans also vary by the social worker’s scope of practice and may incorporate the following services:

Education and coaching (e.g., wellness promotion, disease management, and differentiating normal age-related changes from behaviors that may warrant professional evaluation)
Lifespan and advance care planning
Individual counseling and psychotherapy drawing on a variety of modalities (e.g., psychodynamic or cognitive-behavioral)
Couples and family counseling
Family-team conferences
Group interventions (e.g., caregiver or bereavement support groups)
Interventions addressing grief, loss, end-of-life issues, and bereavement
Mediation and conflict resolution
Crisis intervention
Client advocacy and systems navigation
Team, organizational, and interorganizational care planning and collaboration
Resource information and referral (e.g., medical, psychosocial, financial, and legal resources)
Case/care management and care coordination
Planning for service termination or discharge, including planning for cessation of family caregiving roles and supports associated with that transition

Standard 7. Advocacy

Social workers shall advocate for the needs, decisions, and rights of family caregivers of older adults. The social worker shall engage in social and political action that seeks to ensure that family caregivers of older adults have equitable access to resources to meet their biopsychosocial needs.

Interpretation
Effective advocacy involves helping family caregivers of older adults identify and define their strengths, needs, and goals, and to communicate those needs and goals to service providers and decision-makers. Social workers strive not only to promote family caregivers’ self-advocacy, but also to enhance the capacity of communities to integrate family caregivers’ contributions. Creativity and flexibility are central to successful advocacy efforts with, and on behalf of, family caregivers of older adults.

Social work advocacy takes place on both micro and macro levels and may involve the following activities:

Adaptation of organizational policy, procedures, and resources to facilitate service provision to multicultural clientele
Advocacy with other service providers and organizations to improve family caregivers’ access to high-quality services
Identification and development of strategies to address service gaps, fragmentation, discrimination, and other barriers that affect family caregivers of older adults
Inclusion of family caregivers of older adults in advocacy efforts and in program design, planning, and evaluation
Analysis of historical and current local, state, and national policies as they affect family caregivers of older adults, especially historically marginalized or underresourced populations
Education of the public, the media, corporations, and policymakers regarding the strengths, contributions, needs, and concerns of family caregivers of older adults
Advocacy to foster age-friendly community capacity and to enhance the contributions of family caregivers of older adults
Use of multiple media, including written materials, oral presentations, and computer technology, to achieve advocacy goals

Standard 8. Collaboration

Social workers shall promote interdisciplinary and interorganizational collaboration to support, enhance, and create services delivered to family caregivers of older adults.

Interpretation
Multiple service providers and organizations are often involved in supporting family caregivers of older adults. Collaboration within care teams and organizations, as well as among organizations and service delivery systems, is essential to continuity of care for family caregivers of older adults. Social workers play an integral role in fostering, maintaining, and strengthening such partnerships.

As members of teams and organizations serving older adults and family caregivers, social workers shall demonstrate the following abilities:

Differentiate social work perspectives, values, and interventions from other disciplines
Describe and support the roles of other disciplines and organizations involved in supporting family caregivers of older adults
Articulate and fulfill the missions and functions of their employing organizations
Communicate effectively with all professionals, direct care workers, and volunteers involved in supporting family caregivers of older adults
Advocate for family caregivers’ integral role in team communications and service planning, delivery, and monitoring
Communicate family system information in a respectful, objective manner while protecting clients’ confidentiality and privacy
Promote the strengths, contributions, needs, and goals of family caregivers of older adults
Facilitate communication between family caregivers and providers/organizations involved in supporting the family system
Share team leadership in planning and providing services to family caregivers of older adults
Create organizational culture that promotes effective, coordinated services for family caregivers of older adults
Foster and maintain partnerships across disciplines, organizations, and the service spectrum to enhance access to and continuity of care for family caregivers of older adults
Integrate a strengths perspective in program and organizational administration to maximize and sustain human and fiscal resources on behalf of family caregivers of older adults
Manage personal and interpersonal processes at the intraorganizational, interorganizational, and community levels to optimize services for family caregivers of older adults

Standard 9. Practice Evaluation and Improvement

Social workers serving family caregivers of older adults shall participate in ongoing, formal evaluation of their practice to maximize family caregivers’ well-being, assess quality and appropriateness of services, improve practice, and ensure competence.

Interpretation
Evaluation entails soliciting and integrating internal and external feedback on the process and outcomes of social work practice with family caregivers of older adults.

Practice evaluation is vital to ensuring that services provided to family caregivers of older adults are appropriate, effective, timely, and efficient in helping family caregivers achieve their goals. Such goals may include reduction of stress, enhanced ability to fulfill caregiving responsibilities, improved balance between caregiving responsibilities and other commitments, or increased time and strategies for self-care. Moreover, outcomes from evaluations are increasingly used for position justification, performance review, practice standards, goal setting, and research efforts. As in all phases of practice with family caregivers, caregiver involvement is essential, as is protecting the privacy of the family system and other service providers.

Evaluation practices may include the following activities:

Solicitation and incorporation of feedback from family caregivers of older adults regarding the extent to which social work services helped caregivers identify and achieve their goals
Strategic planning to reach measurable objectives in program, organizational, or community development for family caregivers of older adults
Development of program budgets that take into account diverse sources of financial support for family caregivers of older adults
Application of appropriate tools such as clinical indicators, practice guidelines, family caregiver satisfaction surveys, and standardized performance assessments
Measurement of both process and outcome objectives
Use of external practice or program evaluators, as appropriate
Practitioner, program, and organizational self-evaluation
Use of peer review, supervision, and consultation with other social workers and across disciplines
Incorporation of evaluation practices in the service transfer or termination process
Participation in social work research, including qualitative research
Application of evaluation and research findings (including evidence-based practice, when available) to enhance practice and program outcomes
Dissemination of evaluative data to clients, payers, and other professionals on request, and with consideration for privacy rights

Standard 10. Documentation

Social workers shall document all practice with family caregivers of older adults in the appropriate client record. Social work documentation may be recorded in writing or electronically and shall be completed, maintained, and disclosed in accordance with regulatory, legislative, statutory, and employer requirements.

Interpretation
Clear, concise, and ongoing documentation of social work practice facilitates clear communication with other service providers and organizations, thereby promoting continuity of care and services. Documentation also serves as a foundation for practice and program evaluation and for creating new service delivery models on behalf of family caregivers of older adults.

The purpose of documentation is not to supplant but, rather, to foster strong working relationships with, and services for, family caregivers. Thus, documentation should reflect family caregivers’ involvement in, and concordance with, all phases of social work practice: assessment; service planning, delivery, and monitoring; practice evaluation and improvement; and termination or transfer of services. Social workers can ensure their practice centers on family caregivers by incorporating in their documentation caregivers’ own words, stories, goals, and feedback.

Social work documentation should reflect the following elements:

Dates, times, and descriptions of contact with family caregivers, other members of the family system, and other service providers or organizations
Initial and subsequent psychosocial assessments of family caregivers
Concerns and services discussed with family caregivers
Plan of care, services, or treatment
Services provided, including education offered and written information presented to family caregivers
Outcomes of service provision
Referrals to or from other providers, organizations, or resources, including rationale for referrals
Supervision or consultation sought or provided to enhance practice with family caregivers

The client record should also include the following elements:

Follow-up and recommendations from external providers or organizations
Written permission, when appropriate, to release and obtain information
Compliance with confidentiality and privacy rights and responsibilities
Receipts and disbursements related to client service provision
Rationale for termination or transfer of services

Standard 11. Workload

Social workers shall advocate for a workload that allows for efficient, high-quality service delivery to family caregivers of older adults. The size of the social work staff shall represent both the scope and complexity of the organization and the nature and numbers of the populations served.

Interpretation
Social workers, social work managers, and organizations have joint responsibility for establishing and maintaining a workload that allows for adequate and appropriate interventions and monitoring of services and outcomes. A workload consists of any social work function, such as direct practice, administration, policy, research, or education, performed for the purpose of the social work position. The workload also reflects the needs and goals of the population served and may include social work coverage outside of regular office hours.

Standard 12. Professional Development and Competence

Social workers practicing with, or on behalf of, family caregivers of older adults shall assume personal responsibility for their professional development and competence in accordance with the NASW Code of Ethics (2008), the NASW Standards for Continuing Professional Education (2002), and state licensure or certification requirements.

Interpretation
Aging and family caregiving are rapidly expanding specialties that cross all practice settings. Social workers must engage in ongoing professional development to maintain competence in their practice with family caregivers of older adults. Employing organizations should encourage and support social workers’ participation in professional development activities. Such activities may include receiving or providing continuing education, training, supervision, or mentoring, as well as participating in peer review, research, and publication activities. Numerous opportunities for professional development exist within NASW, other professional organizations, schools of social work, and organizations providing services to or on behalf of older adults or family caregivers at the local, state, national, and international levels.

Professional development activities relevant to practice with family caregivers of older adults may address the following topics:

Developments in social work theory, practice, and research
Policies and legislation affecting family caregivers of older adults
Community resources available to family caregivers of older adults
Issues and experiences specific to aging, family systems, caregiver health and wellness, disability, grief and loss, death and dying, elder mistreatment, and ethics
Cultural and linguistic competence
Assessment of professional and personal strengths, learning needs, and goals as related to social work practice
Professional and personal self-care

References

AARP. (2008). Valuing the invaluable: The economic value of family caregiving, 2008 update. Washington, DC: Author. [Also available at http://assets.aarp.org/rgcenter/il/i13_ caregiving.pdf]

Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1992). Towards a culturally competent system of care: Vol. 1. A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center. (Original work published 1989)

Council on Social Work Education. (2008). Educational policy and accreditation standards. Retrieved from www.cswe.org/ File.aspx?id=13780

Council on Social Work Education. (2009). Advanced gero social work practice. Alexandria, VA: Author. [Also available at www.cswe.org/File.aspx?id=25501]

Institute of Medicine (IOM). (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press.

Kelly, K., Brooks-Danso, A., & Reinhard, S. C. (2008). State of the science: Professional partners supporting family caregivers. Journal of Social Work Education, 44(3, Suppl.). [Also available at www.cswe.org/CentersInitiatives/GeroEd Center/GECPublications/27835/16629.aspx]

National Alliance for Caregiving (with AARP). (2009). Caregiving in the U.S. 2009. Retrieved from http://assets.aarp.org/rgcenter/il/ caregiving_09_fr.pdf

National Association of Social Workers. (2002). NASW standards for continuing professional education. Washington, DC: NASW Press. [Also available at www.socialworkers.org/practice/ standards/NASWContinuingEdStandards.pdf]

National Association of Social Workers. (2007). Indicators for the achievement of the NASW standards for cultural competence in social work practice. Washington, DC: NASW Press. [Also available at www.socialworkers.org/practice/ standards/NASWCulturalStandardsIndicators 2006.pdf]

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Washington, DC: NASW Press. [Also available at www.socialworkers.org/pubs/ code/default.asp]

National Association of Social Workers. (2009). Aging and wellness. Social work speaks: National Association of Social Workers policy statements, 2009-2012 (8th ed., pp. 14-21). Washington, DC: NASW Press.

Reinhard, S. C., Brooks-Danso, A., & Kelly, K. (2008, September.) State of the science: Professional partners supporting family caregivers [Special issue]. American Journal of Nursing, 108 (Suppl. 9).

U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. (2006.) The supply and demand of professional social workers providing long-term care services: Report to Congress. Retrieved from http://aspe.hhs.gov/ daltcp/reports/2006/SWsupply.htm

Whitaker, T., Weismiller, T., & Clark, E. (2006). Assuring the sufficiency of a frontline workforce: A national study of licensed social workers. Executive summary. Washington, DC: National Association of Social Workers. [Also available at http://workforce.socialworkers.org/ studies/nasw_06_execsummary.pdf]

Resources

AARP
www.aarp.org

Administration on Aging
www.aoa.gov

Agency for Healthcare Research and Quality
www.ahrq.gov

Alzheimer’s Association
www.alz.org

American Society on Aging
www.asaging.org

Association for Gerontology in Higher Education
www.aghe.org

Centers for Disease Control and Prevention
www.cdc.gov

Centers for Medicare & Medicaid Services
www.cms.gov

Centers for Medicare & Medicaid Services Ask Medicare Caregiver Resources www.medicare.gov/caregivers

The Commonwealth Fund
www.commonwealthfund.org

Council on Social Work Education
www.cswe.org

Council on Social Work Education National Center for Gerontological Social Work Education (CSWE Gero-Ed Center) www.cswe.org/CentersInitiatives/GeroEd Center.aspx

Family Caregivers Alliance
www.caregiver.org

Geriatric Social Work Initiative
www.gswi.org

Gerontological Society of America
www.geron.org

Hartford Partnership Program for Aging Education (HPPAE) www.hartfordpartnership.org

Health and Aging Policy Fellows Program
www.healthandagingpolicy.org

Institute for Geriatric Social Work
www.bu.edu/igsw/

The Jacob & Valeria Langeloth Foundation
www.langeloth.org

MetLife Mature Market Institute
www.metlife.com/mmi

National Alliance for Caregiving
www.caregiving.org

National Association of Professional Geriatric Care Managers
www.caremanager.org

National Association of Social Workers www.SocialWorkers.org www.HelpStartsHere.org www.naswpress.org

National Council on Aging
www.ncoa.org

National Family Caregivers Association
www.thefamilycaregiver.org

National Institute on Aging at the U.S. National Institutes of Health
www.nia.nih.gov/

National Quality Forum
www.qualityforum.org

Practice Change Fellows: Leaders in Geriatric Care
www.practicechangefellows.org

Social Work Leadership Institute at the New York Academy of Medicine http://socialworkleadership.org

Acknowledgments

Development of the NASW Standards for Social Work Practice with Family Caregivers of Older Adults is part of Professional Partners Supporting Family Caregivers, an initiative done in partnership with the AARP Foundation, the
U.S. Administration on Aging, the Family Caregiver Alliance, and the National Association of Social Workers, and made possible by funding from the John A. Hartford Foundation.

NASW gratefully acknowledges the work of the following social work expert panelists and other external advisors for their contributions to the NASW Standards for Social Work Practice with Family Caregivers of Older Adults:

Amy Berman, BS, RN Patricia Brownell, PhD, MSW
Rita Choula, BS
Catherine A. Clancy, PhD, LCSW
JoAnn Damron-Rodriguez, PhD, LCSW
Sandra Edmonds Crewe, PhD, ACSW, MSW
Lorraine Hedtke, LCSW, PhD
Forrest Hong, PhD, LCSW, C-ASWCM
Jamie Huysman, PsyD, LCSW
Phyllis Mensh Brostoff, CISW, ACSW, CMC
Nora O’Brien-Suric, MA, PhD-c
Susan Reinhard, PhD, RN, FAAN
Miriam Sterk, LCSW, C-ASWCM
Cynthia Stuen, DSW/PhD, ACSW, LCSW

NASW also thanks its aging specialty certification holders, aging specialty practice section members, and other members for their input in the standards development process.