Empowering Social Workers for Practice with Vulnerable Older Adults

Social workers are frequently the first responders in situations that require assessment of an older person’s ability for independent decision making and self-care. Social workers in a variety of practice settings have to make decisions about when to refer cases for adult protective services (APS), crisis mental health interventions, or legal services; these decisions often involve assessing functional capacity and risks. Social workers in senior centers and senior volunteer programs are sometimes called on to discharge older persons when they experience diminished capacity to continue to participate in senior programs or exhibit inappropriate, inconsistent, or unsafe behaviors because of changes in functional capacity. Social workers also work in settings that provide opportunities for early identification of older persons who may be developing problems managing their care in the community. There is limited professional literature to inform and guide social work practice in the area of assessing capacity and working with vulnerable and at-risk older adults. Other disciplines also recognize the need for professional guidance in working with those persons who have diminished capacity. In 2005, the American Bar Association (ABA), in partnership with the American Psychological Association (APA), published Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers. This extremely timely document was the culmination of 10 years of collaboration between the ABA and APA. Subsequent products that were derived from the collaboration include a handbook for judges on determining capacity (ABA, APA, & National College of Probate Judges, 2006) and a handbook for psychologists on assessing capacity (ABA & APA, 2008).

This text provides guidance for social workers who are assessing capacity and making intervention decisions involving older adults with diminished capacity. Part One provides background information about social work practice with vulnerable older adults. Chapter 1 presents the demographic challenges that make it imperative that geriatric social workers are empowered with knowledge and skilled for community-based practice with the elderly. We describe the population of vulnerable older adults who are likely to require ethically guided, culturally sensitive assessment of their capacity to exercise their rights to self-determination. We also summarize concepts related to assessing capacity used in the medical, psychiatric, and legal arenas and recognize the reality that evaluating capacity (or “competence”) goes beyond the legal arena. Chapter 2 discusses geriatric social work with a particular emphasis on community-based practice. This chapter emphasizes the need to empower geriatric social workers to recognize their own expertise and the important role they play with the growing population of vulnerable older adults. We also identify the assessment of capacity as an emerging area of practice within the field of social work and promote the social work “person-in-environment” perspective as well suited to offer a valuable contribution toward improving the quality of capacity assessments. Chapter 3 discusses the value issues and ethical dilemmas that surface in work with this population. Chapter 4 covers the theoretical basis for the capacity–risk model.

Part Two, chapters 5 through 8, discusses use of the capacity–risk model for assessing vulnerable older adults. This includes a chapter on the importance of establishing a therapeutic alliance with the older adult, chapters applying the biopsychosocial framework to the assessment of capacity and risk, and a chapter on assessing the ability of the individual to function in his or her environment using the capacity–risk model. Part Two ends with illustrations of how social workers can use the capacity–risk model to guide decisions about interventions with vulnerable older adults.

Part Three uses cases to demonstrate the capacity–risk model in working with specific populations of vulnerable older adults, such as older adults with compulsive hoarding behaviors, and those who neglect their self-care needs.

Social workers who practice in geriatric, mental health, and APS settings play critical roles in assessing functional capacity and risks encountered by vulnerable older adults living in homes and communities. This population includes older persons at various stages of dementia (some of whom have become disengaged from the healthcare system), older persons with chronic mental illnesses and those who are without family and informal support networks. In hospital settings, social workers routinely carry out some level of evaluation of their patients’ capacity when they work with them on discharge plans. At times, this evaluation identifies older patients who need guardians appointed to make healthcare decisions, legal interventions to facilitate placement in nursing homes when they lack close kin, or conservators to protect their finances, property, and assets. Community-based social workers often are involved in working with attorneys to implement interventions for their older clients that provide “less restrictive alternatives” to court interventions. Geriatric social workers often collaborate with physicians, psychiatrists, psychologists, and attorneys throughout the process of addressing the needs of vulnerable older adults, including those with diminished capacity.

Both of us have served as directors of community-based geriatric assessment and case management programs. We have observed that social workers were often frustrated by their efforts to work with older clients who needed assistance but refused to accept help. In these situations, the social worker often grapples with difficult ethical and legal issues concerning when to intervene against a person’s will and when to respect his or her right to self-determination. In the early 1990s, we collaborated with professional case managers and graduate social work interns to develop the capacity–risk model, a conceptual guide for assessment and interventions with vulnerable older adults who live in high-risk situations, but resist accepting help (Soniat & Micklos, 1996). We have used the capacity–risk model in educational, training, consultation, and supervision sessions with professional social workers and social work students. The capacity–risk model also has been used in interdisciplinary training and consultations with physicians, psychiatrists, nurses, and attorneys. The presentation of the capacity–risk model at the 1993 Southern Gerontological Society Annual Meeting (Soniat & Micklos, 1993) resulted in requests for consultations, in-service trainings, and follow-up presentations at local, regional, and national conferences such as conference workshop presentations for: the District of Columbia Office on Aging (Soniat & Micklos, 1994), the American Society on Aging (Soniat & Micklos, 1995a), the Maryland Gerontological Society (Soniat & Micklos, 1995b), the Network of Episcopal Professionals Providing Aging Services (Soniat & Micklos, 1998), the NASW DC Metro Chapter (Soniat & Micklos, 2007), and ESM Cares and Sunrise Assisted Living (Soniat & Micklos, 2008). Over the past 15 years, it has become an integral part of the statewide training program for APS workers in Virginia; part of the content of the two-day course titled “Assessing Capacity” is based on the capacity–risk model (Virginia State Board of Social Services, 2001).

This book addresses the gap in knowledge about the role of social workers in assessing and treating the problems of vulnerable older adults. The text discusses skills effective for working with this population and presents the capacity–risk model to guide social workers with assessment and intervention decisions. The use of the capacity–risk model can help social workers generate evidence to support client self-determination and guide recommendations for sustaining older adults in community settings when appropriate. Use of the model can also, conversely, generate evidence that guides social workers toward protective interventions and alternative placements when these are more appropriate for a particular situation. This text also provides information to strengthen the knowledge base and skills of the general population of social workers whose practice involves assessing and intervening with vulnerable older adults. Demographic trends and the expanding demand for highly skilled geriatric social work practitioners to work with increasingly complex situations encountered by vulnerable older adults living in communities across the country and globally support the need for this text.