Aging and Demographic Trends

America is aging and this growth in the aging population is well documented. Between 1980 and 2000, the population over age 65 grew by 36%; the number of people 85 and older has doubled and the number of people over 100 has tripled (Administration on Aging, 2000a). Life expectancy in the United States continues to be extended from age 47 in 1890 to age 75.5 in 1993 (Rouche, 1996). This is attributable in part to advances in pharmaceutical therapies and biomedical breakthroughs.

In the next 20 years the population over 65 is expected to grow by 53% (Dill, 2001). Fastest growing of all is the frailest group, those aged 85 and over, whose numbers are expected to triple to 8.8 million by 2030 (U.S. Bureau of the Census, 1996).

The rapid and breathtaking growth of older populations is accompanied by another profound set of emerging demographic trends. The composition of the American family is changing. As the aging population is growing in the U.S., younger populations are shrinking. According to the U.S. Census Bureau, by 2025, the number of people age sixty to sixty-nine will be expanding at a faster rate than the number of people age 20 to 29 (Health Care Financing Administration, 2001).

This specter of rising numbers of aging populations, who are also living longer, against the backdrop of shrinking numbers of family caregivers, creates what Drucker (2001) calls the most dominant aspect of the "Next Society". These compounding demographics will "challenge our nation's financial and human resources and enrich traditional notions of old age. They will require more elder qualified health professionals and force our nation to reshape and improve health care delivery to meet the needs of the elderly" (John A. Hartford Foundation, 2000).

Aging in the "Next Society"

These transformational demographic changes will accentuate the gaps in health care, transportation, housing, and social support needs for the aging. This compels the expansion of aging competent professionals who are able to navigate and expedite a highly sophisticated, complex, health care and social service system.

The "Next Society" will demand more efficient systems of care designed to meet the needs of an aging population with disabilities. While hospitalization is increasingly effective in serving those with acute and severe health care needs, those with chronic health disabilities require alternative, less costly and intrusive health care systems.

The Olmstead Act of 1999 requires a system of care that is less institutional and intrusive. The Supreme Court ruled that unjustified institutionalization of people with disabilities is illegal. This act has accelerated the need for assisted living, home or community based health care services, and supports for the elderly (U.S. Department of Health and Human Services, 1999).

Aging is a quality of life challenge:

• The "Next Society" will require a competent and cost-effective workforce with more professionals assuming the backbone of the care system than in the past.
• Currently, serious gaps already exist, which compromise society's ability to preserve the independence and quality of life for older adults. Needed are affordable, supportive housing, adequate transportation that maintains personal autonomy, wellness programs that enhance the quality of life, integrated services in rural areas, protective services that include temporary emergency shelters, respite care for caregivers, specialized services for disadvantaged minorities (Scharlach, et al., 2000).
• The elderly, especially those with disabilities, require health services that are flexible and tailored to meet individual needs. Older adults with cardio-vascular disease, mental illnesses, tuberculosis, HIV infection, and other chronic diseases, involve complicated medication schedules that require monitoring, treatment compliance, and specialized intervention models that link these persons to systems of care. Coordinated, tailored care creates more enhanced quality of life for the aging and their families and lower costs for government reimbursement programs such as Medicare and Medicaid (Grimier and Gorey, 1998).
• Timely interventions result in higher quality of life and lower utilization of medical resources in the future (New York Academy of Medicine, 2000). Promoting health and preventing disease among targeted populations such as the elderly, have proven more cost-effective by as much as a factor of ten than prevention initiatives with the general public (Russell, 1993).

Aging is a long-term care challenge:

• The chronically ill are aging, which has immense financial and workforce implications for our health care system. Chronic illnesses such as diabetes and heart disease affect more than 45% of Americans and account for three quarters of health care expenditures (Hoffman, Rice, & Sung, 1996). Most of the leading causes of morbidity and mortality are now related to chronic diseases (Pawlson, 1994).
• America's health care and financing systems were designed to address the acute health needs of a society that experienced an explosion of births following World War II (Shortell, Gillies, & Devers, 1995). Managing healthcare outside of acute settings will require an informed, highly trained, and well-developed work force that is competent in age related, chronic, health care management. Research indicates that home and community based programs save money (Liu, Manton & Aragon, 2000).
• Managed care has accelerated the numbers of aging being discharged earlier from hospitals (Health Care Financing Administration, 2001). When elderly patients are discharged from hospitals 'quicker and sicker,' they require more complex and extensive long-term care at home by a host of community care providers.

Aging is a poverty challenge:

• Many elderly fall below poverty lines and subsequently rely upon Medicaid for their health and mental health care (Matthews, 2000). Accompanying these trends are the rising numbers of elderly Americans without supplemental health insurance, with the poorest of Americans most likely to be uninsured.
• Elderly persons living in poverty require the management of innovative, cost effective care that maximizes limited resources. Twenty three per cent of the population over 65 comprises Medicaid beneficiaries (Health Care Financing Administration, 2001).

Aging is an intergenerational family support challenge:

• Family members provide the vast majority of all eldercare (Administration on Aging, 2000b). Historically, much of this care giving has been performed by women, who work to preserve the independence and well being of older parents and relatives while caring for them in frail health (Johnson & Sasso, 2000). The monetary value of time devoted to informal care giving for the elderly in 1997 was estimated at 196 million dollars (Arno, Levine & Memmott, 1999). The number of family members caring for an elderly person more than tripled from 7 million to 22.4 million from 1986 to 1997 (American Association of Retired Persons, 2001). Rather than just being sandwiched in between both dependent children and dependent parents, family caregivers may be called on to perform multiple care giving roles across two or three generations of "young-old" (65+) and "old-old" (85+) relatives.
• Aging is also a cross-generational care giving challenge. In 1997, 3.9 million children were living in homes maintained by grandparents (Bryson & Casper, 1999)

Social Work Challenges in an Aging Society

The social work profession plays an integral role, along with other health care professions, in responding effectively and efficiently to these challenges. Through case management, advocacy, policy development and effective and efficient service delivery, social workers facilitate diverse and complex relationships among the elderly, their caregivers and the institutions and agencies that serve them (Wallace, 2001).

Social workers safeguard and enhance the quality of life for an aging population:

• Social workers are trained to work with older adults and provide supports and capacity building for family caregivers. Social workers help the aging and their families navigate their way through complex and seemingly impenetrable systems to access needed services (New York Academy of Medicine, 2000). Research consistently shows the efficacy of the broad range of social work interventions (Grimier & Gorey, 1998).
• Social workers are equipped to monitor effectiveness and appropriateness of health and social services to ensure cost effectiveness (Scharlach, et al., 2000). This strategic work can promote considerable savings in Medicare, Medicaid and out of pocket health care costs. (Beless, 2002).

Social workers are well trained in case management:

• Case management is defined under Section 1915 (g)(2) of the Social Security Act (SSA) as "services that will assist individuals, eligible under the plan, in ongoing access to needed medical, social, educational, and other services. Case management services are often used to foster the transitioning of a person from institutional care to a more integrated setting or to help maintain a person in the community" (U. S. Department of Health & Human Services, 1999).
• Social workers provide medical case management, remove barriers to service, foster collaboration and coordination among professionals, and mobilize services to address gaps in care. Social work case management encompasses more psychosocial, environmental, and ethical considerations than that of other professions (Scharlach, et al., 2000).
• Social workers provide targeted case management (TCM) defined in Section 1915 (g) of the Social Security Act: "TCM facilitates transition to community services from an institution in order to enable the person to gain access to medical, social, educational and other services" (U. S. Department Health & Human Services, 1999). Secondly, persons receive case management services while still institutionalized, which include advocacy, supportive services and quality of care issues. Social workers serve as administrative case managers, a necessary and cost efficient administration of the state plan for service delivery. (U. S. Department of Health & Human Services, 1999).
• Social workers are adept at intensive and targeted case management responding to the specialized needs of the aging. Managed care requires brief treatment and solution focused health and mental health interventions. These are hallmarks of a social work approaches (New York Academy of Medicine, 2000). Social work is critical in increasing health care supports and service delivery efficiencies that lower the risk for more costly inpatient and residential care for the elderly (American Association Retired Persons, 2001). Such efforts help to reduce duplicated efforts, unnecessary costs and costly re-hospitalization (Scharlach, et al., 2000).

Social workers are competent service providers for the poor:

• The social work profession has historically served poor, diverse, vulnerable populations, and those without health insurance. Social workers are the largest group of service providers for people who are poor, especially those living in isolated rural areas and inner city populations. Social workers are the backbone for service delivery to Medicaid populations (Berkman, Damron-Rodriguez, Dobrof & Harry, 1996). Often, these populations have inequitable access to services and supports.
• Social workers are adept at service coordination and the mobilization of tailored approaches to meet the needs of diverse populations of the aging.
• Social workers are especially trained to navigate the Medicaid system and to expedite optimal care in addressing disabilities associated with chronic illness. Along with this, social workers are adept at interprofessional, collaborative practice and managing complex, ethical dilemmas inherent in the care of the elderly, especially those who are poor (Scharlach, et al., 2000).
• The disproportionate morbidity rate for persons of low socioeconomic status with certain diseases accelerate the need for social workers who are responsive to the unique needs of the poor and vulnerable.

Social workers are effective in providing meaningful roles and opportunities for the aging:

• Social workers foster equitable access to career opportunities and support the elderly who are entering second careers after retirement.
• Social workers tap into the abundance of talents, skills and wisdom that the elderly offer as mentors, volunteers and role models.

Social workers are skilled in addressing intergenerational family needs:

• Social workers identify untapped resources in family or social support systems, linking formal and informal health care and related services to the family system.
• Collaborating with other health care professionals, social workers are ready to meet the intergenerational health care needs of the "Next Society" by:
  • Serving as 'navigators' and 'expeditors' enabling older adults and their families to understand and move among the bewildering array of available health and social services (Gerontological Society of America, 2001).
  • Working to create a continuum of care in housing, transportation, and geriatric case management in urban, suburban and rural environments
  • Addressing the needs of culturally, ethnically and racially diverse families and being culturally competent in service delivery and case management
  • Providing optimal mental health, substance abuse treatments and health supports for the elderly and their families
  • Fostering safety and preventing neglect, self-neglect and abuse among the elderly
  • Promoting care in the least restrictive environment including in-home medical and end of life care
  • Linking the role of nutrition, exercise, and self-care in successful aging
  • Creating technology based services for the aging and their caregivers

Workforce Shortages in an Aging Society

There is a scarcity of adequately trained social workers to meet the needs of an aging population (Administration on Aging, 2000a). A major study indicates that there are national shortages of geriatric care personnel in the medical, mental health, and social service professions who are prepared to provide effective services for the nation's older population (Dawson & Santos, 2000). Labor force projections indicate that approximately 60,000 to 70,000 social workers trained in aging will be needed within the next twenty years (Council on Social Work Education, 2000). Social work educators report that geriatric programs are loosing interested students and faculty due to a lack of grant support for aging related programs (Dawson & Santos, 2000). Only 2.7% (938) of the nearly 35,000 students pursuing social work degrees select an aging concentration (Lennon, 1999).

The workforce shortage will be acute as the need for social workers competent in aging issues increases over the next decades. Educational outreach, career incentives, and financial opportunities are needed to attract qualified social workers with specialization in gerontology. Moreover, all social workers should have basic competence in aging (Council on Social Work Education, 1992). This is necessary, since most social workers serve older persons and their families either directly or indirectly (Scharlach et al., 2000).

Barriers to creating a competent and qualified geriatric social work force have been identified (Lubben, Damron-Rodriguez & Beck, 1992). Lack of trained faculty, aging curricula and financial incentives contribute to these barriers and are obstacles in attracting students to the field of gerontology. In contrast, when these barriers are creatively and competently addressed, student interest rises (Lubben, et. al., 1992).