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Article

Aging: Services  

Nancy Morrow-Howell and Leslie Hasche

Despite high levels of functioning among older adults, chronic health conditions lead to impairment and the need for help. Family members provide most of the assistance; yet formal services such as in-home personal and homemaker services, congregate and home-delivered meals, adult day services, employment and educational services, transportation, nursing homes, assisted and supportive living facilities, legal and financial services, and case management are available. Even with the growing number and type of services, unequal access and uneven quality persist. In these settings, social workers develop and administer programs, provide clinical care, offer case management and discharge planning, and contribute to policy development.

Article

Care Transitions, Patient Health, and System Performance in the United States  

June Simmons, Sandy Atkins, Janice Lynch Schuster, and Melissa Jones

Transitions in care occur when a patient moves from an institutional setting, such as a hospital or nursing home, to home or community, often with the hope or expectation of improving health status. At the very least, patients, clinicians, and caregivers aim to achieve stability and avoid complications that would precipitate a return to the emergency department (ED) or hospital. For some groups of vulnerable people, especially the very old and frail, such transitions often require specific, targeted coaching and supports that enable them to make the change successfully. Too often, as research indicates, these transitions are poorly executed and trigger a cycle of hospital readmissions and worsening health, even death. In recognizing these perils, organizations have begun to see that by improving the care transition process, they can improve health outcomes and reduce costs while ensuring safety, consistency, and continuity. While some of this improvement relies on medical care, coaching, social services and supports are often also essential. Lack of timely medical follow-up, transportation, inadequate nutrition, medication issues, low health literacy, and poverty present barriers to optimal health outcomes. By addressing social and environmental determinants of health and chronic disease self-management, social workers who make home visits or other proven timely interventions to assess and coach patients and their caregivers are demonstrating real results. This article describes care transitions interventions, research into barriers and opportunities, and specific programs aimed at improvement.

Article

Home-based Interventions  

Susan F. Allen and Elizabeth M. Tracy

Home visiting and home-based intervention are two strategies used by social workers when working with individuals or families in direct practice. The basic rationale for home-based work is the benefit to social workers’ assessments and understanding of clients, as well as the benefit of more relevant practice with families who are seen in the setting where difficulties are occurring. Home-based interventions have been shown to be effective in improving health and decreasing family discord. When visiting the home, the social worker has the added responsibility of respecting the privacy of families as a guest in their homes.