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The Story of Beatrice

The Essential Role of Geriatric Social Workers

The essential role of geriatric social workers, like those trained through programs funded by the Hartford Foundation, is demonstrated in this story of 86-year-old Beatrice as she recovers from a traumatic injury.

Managing the Transition from Hospital to Rehab to Home

At age 86, Beatrice was living in her own home. Her husband had passed away several years ago, and she was just barely managing financially on Social Security benefits. One day, while making breakfast, she slipped on a puddle of water on the kitchen floor. The fall was frightening, especially because she couldn’t stand up and the telephone was across the room. She crawled to it and dialed 911.

Beatrice had fractured her hip and would require surgery. Before undergoing the procedure, Beatrice received a visit in her hospital room from Ellen, the hospital social worker and discharge planner. Ellen, who has a master’s degree in social work, came to evaluate Beatrice.

During her education in social work, Ellen’s first inclination had been to specialize in child welfare. However, a professor she admired encouraged her to explore geriatric social work. The professor was a Hartford Faculty Scholar and was conducting research on stress and coping in older adults with functional disability. At first, Ellen thought working with older adults would be depressing, but she gave it a try. She received a Hartford Partnership Program for Aging Education grant, which provided a stipend and the opportunity to rotate among field placements at a senior center, a Veterans Affairs hospital, and an adult day center. She realized the remarkable personal and professional rewards that come from improving care for older adults like Beatrice. She took a position as a geriatric social worker and discharge planner at the hospital after graduation.

Ellen was familiar with all the community resources and entitlement programs available to Beatrice. She conducted a psychosocial evaluation, which provided information on Beatrice’s functional ability, both mental and physical, and her social and supportive network. She wanted a snapshot of Beatrice’s life before the fall so she could put in place the resources to allow her to return to normal life as soon as possible. She called Beatrice’s daughter Kathy, who lived in a different state, to determine the availability of family support. Kathy’s job prevented her from devoting a long stretch of time to caring for her mother. Ellen began to make preparations for the services Beatrice would need after the surgery.

The next day, Beatrice underwent a hip operation. This marked the beginning of a journey through the complex systems of health care and social services. For older adults, transitions between the hospital, other health care facilities, and home represent a vulnerable time, and hip fractures in older adults can initiate a decline into increasing frailty and the need to move permanently to a nursing home. With the proper care and appropriate services, however, many older adults are able to regain function and return to their normal lives.

For Beatrice, geriatric social workers helped smooth this transition. Ellen consulted with Beatrice’s physician and occupational and physical therapists to assess her prognosis and ability to return home and live independently. Ellen made arrangements for Beatrice to be discharged from the hospital to a rehabilitation facility for 20 days of physical therapy. This would be covered by Medicare. Once at home, Beatrice would need physical therapy and other assistance. Ellen prepared a detailed plan that included recommendations for a home health agency, an emergency response system, Meals On Wheels, and a home visit from a social worker upon discharge from the rehabilitation facility.

She realized that due to Beatrice’s low income she was eligible for Medicaid to cover the cost of home health care services and assist in paying for medications.

Before leaving the hospital, Ellen visited Beatrice and her daughter Kathy to review the plan for her care after discharge. Beatrice would continue to need support and care from professionals, including other geriatric social workers as she moves through the health care system towards independent living at home.

Beatrice Gets Support At Home

After her fall, Beatrice was fortunate to encounter skilled geriatric social workers through-out her recovery and beyond. As an older woman living alone with no family close by and managing on a tight budget, she would have struggled with the complexities of her situation.

Having spent three weeks in a rehabilitation facility receiving physical therapy, Beatrice was discharged home. The social worker in the rehab facility reassessed Beatrice’s functional ability in the home and implemented the discharge recommendations for home health care and community-based services. Lois, a social worker in the home health agency, kept track of Beatrice’s progress.

The aftereffects of anesthesia had left Beatrice disoriented for weeks. She was forgetful and had difficulty keeping track of the nurses and physical therapists coming to her home. She worried that she was developing dementia, and she fretted about the possibility of falling again. Beatrice’s financial situation was deteriorating and she fell behind in paying her bills. The electric company was threatening to cut off service and the hospital bills were arriving. Beatrice placed them unopened in a pile.

Lois visited Beatrice to assess her progress. As a social work student Lois’s required courses included content on aging, which motivated her to take a course on lifespan development. This gave her a new perspective on aging issues and sparked her interest in pursuing geriatric social work. As a graduate student, through a Hartford Partnership Program for Aging Education grant, one of her internships had been at the case management agency where she now worked full time.

After assessing Beatrice’s physical, economic, and psychological needs, Lois began making appropriate arrangements. She consulted with the physical therapists and visiting nurses, and followed up on the walker that had been ordered so Beatrice would be less fearful about falling. She assured Beatrice that the forgetfulness was temporary. Lois made sure that Beatrice was receiving a daily lunch from Meals On Wheels. She also helped Beatrice straighten out the paperwork involved in getting the hospital bills taken care of by Medicare and Medicaid, and she set up an automatic bill paying system.

After four months Beatrice no longer needed home health care services. But she was not completely recovered. She was homebound, lonely and depressed. Lois discussed community resources with Beatrice, who agreed to go to a local senior center. Lois arranged for transportation services, and also arranged to have Judy, the social worker at the senior center, greet Beatrice, have her observe various activities, and introduce her to other participants.

Beatrice at a Senior Center

Now that Beatrice is able to walk (albeit with the aid of a cane) and her mental confusion has subsided, she has become more mobile and desirous of social interaction. Judy, the social worker at the senior center, has made sure that a van service picks Beatrice up every day to come to the senior center for lunch and activities. She attends a water aerobics class to continue building her strength. She has also made friends in the weekly Mah Jong game. Her favorite activity is a computer class. An intern in the Hartford Partnership Program for Aging Education teaches older adults at the senior center how to use a computer. He has set up an account for Beatrice on a social networking site, which allows her to stay in contact with her daughter Kathy and her grandchildren.

Meanwhile, Judy has helped Beatrice apply for benefit programs, such as the Senior Citizen Rent Increase Exemption (to freeze rent increases on her apartment), and has made arrangements for transportation to and from doctor visits.

Beatrice is grateful to remain living in her home while she regains her independence. All of the social workers who helped Beatrice during this transition take great satisfaction from knowing they played an integral role in making sure Beatrice has access to the health and social services she needs to live her life to the fullest.



Next: The John A. Hartford Foundation Geriatric Social Work Initiative ›