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GERIATRIC FIELD EDUCATION IN SOCIAL WORK: A MODEL FOR PRACTICE

Geri Adler Graduate College of Social Work, University of Houston, Houston, Texas, USA It is expeeted that the demand for gerontologieal social workers will increase as the elderly population continues to grow. However, many practitioners enter the aging field with little or no formal training. Successful gerontological social work practice requires workers to be knowledgeable and technically competent. Fieldwork plays a critical role in social work students' development and training. This paper describes a specialized social work practicum which instructs graduate social work students in the skills and abilities required to work in contemporary geriatric practice. The setting for the internship, its format, its major goals, and student experiences are described.

As the number and proportion of older adults continues to expand, the demand for aging-competent practitioners also increases. While social work is well suited to meet these needs, many practitioners enter the aging field with little or no formal training. Successful social work practice in health care requires workers to be knowledgeable and technically competent in aging. Field work plays a critical role in social work students' development and training, providing them with a structured format to apply classroom learning to practice. Because there is paucity of course work in gerontology at many social work programs (Scharlach, Damron-Rodriguez, Robinson, & Feldman, 2000), most student training in aging occurs at agency-based field sites (Berkman, Silverstone, A version of this paper was presented at the Annual Meeting of the Association for Gerontology in Higher Education (AGHE), in Richmond, VA, February 2004. Names and identifying features have been changed to protect interns' identities. Address correspondence to Geri Adler, Graduate College of Social Work, University of Houston, 237 Social Work Building, Houston, TX 77204-4013, USA. E-mail: [email protected]

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Simmons, Volland, & Howe, 2000). The Geriatric Research, Education, and Clinical Center (GRECC), at the Minneapolis Veterans Affairs Medical Center (VAMC), has developed a specialized social work training program. It instructs graduate social work students in the skills and abilities required to work in contemporary geriatric practice. This paper discusses the social work practicum offered at the GRECC program. The setting for the internship, its format, its major goals and student experiences are described. Utilized throughout this paper are materials collected from the 15 interns assigned to the GRECC program from 1989 through 2003. After securing institutional review board (IRB) approval, the author examined several types of such material: preinternship data forms, learning contracts, and student evaluations. Together, these add greater depth to this manuscript. VHA AND GRECC OVERVIEW To provide a background for the GRECC social work practicum, it is necessary first to examine the role of the Veterans Health Administration (VHA) in the education of healthcare professionals and in the development of the GRECC programs. The VHA is a leader in the training of health care professionals, educating over 80,000 annually (Roswell, 2002). Through affiliations with individual schools and colleges, the VHA offers residencies, traineeships, and fellowships to students in over 40 fields including medicine, nursing, pharmacy, occupational therapy, psychology, and social work (Roswell, 2002). Over 100 graduate schools of social work are affiliated with the VHA. In fact, the VHA is the largest training program for social work students, educating over 600 students every year (VA Social Work, 2004). Geriatric Research, Education and Clinical Centers (GRECCs) were created in the 1970s by the VHA in response to the growing needs of the aging veteran population. These "geriatric centers of excellence" were designed for the advancement and integration of research, education, and clinical care in geriatrics and gerontology. Between 1975 and 1980, 8 GRECCS were established. Minneapolis was one of the original sites (Goodwin & Morley, 1994). Today, there are 21 GRECC programs in the United States (Department of Veterans Affairs, 2004). The Minneapolis GRECC program is maintained in an urban tertiary referral medical center with 237 acute care diagnostic and treatment beds and a 104-bed extended care unit. The facility serves as

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a major health care site to surrounding states providing medical services to over 45,000 veterans annually (Facility Locator & Directory, 2004). As an academic teaching center, the Minneapolis facility assists in the training of over 2,500 health professionals per year from a variety of disciplines (Facility Locator & Directory, 2004). The mission of the Minneapolis GRECC program is to improve the delivery of health care to elderly veterans through a multidisciplinary program emphasizing disorders of the aging nervous system, primarily Alzheimer's disease (AD) and other dementias. As such, the GRECC program integrates models of clinical care, basic and applied research, and geriatric education with existing Department of Veteran Affairs (DVA) and community programs and resources (GRECC, 2004). The Minneapolis GRECC has three integrated program components: clinical care, education, and research. Using a multidisciplinary team approach, the clinical care component provides diagnostic and treatment services to aging veterans with memory loss in an outpatient clinic. It also provides training to students, residents, fellows, and health care providers in various disciplines. The educational component offers training opportunities to medical center staff and community professionals through workshops, seminars, and national meetings. In addition, it provides administrative oversight to GRECC-affiliated trainees. The research component conducts a wide range of investigations from cellular biology to caregiving. The National Institutes of Health, Alzheimer's Association, Minnesota Department of Public Safety, and various pharmaceutical companies have funded studies at the Minneapolis GRECC (GRECC, 2004). THE GRECC SOCIAL WORK PRACTICUM The GRECC social work practicum is a sought after internship because of its multidisciplinary treatment team, research focus, emphasis on AD and related disorders, and offerings of well-rounded educational activities. The GRECC student is usually one of several social work interns at the VAMC; the others are assigned to units such as the adult day care center, homeless veterans program, and outpatient mental health clinic. All are graduate students in the final year of their masters program. Interns are either advanced standing students—those having earned a bachelor's degree from an accredited baccalaureate social work program and completing their degrees in a shortened period of time—or they are traditional students, those completing coursework on a full- or part-time basis over at least a 2-year period (Occupational Outlook, 2004). The advanced field

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experience at the GRECC builds on earlier coursework and is expected to maximize skill and knowledge development in a student's chosen concentration of practice. All GRECC interns receive a stipend for their traineeship. Students are required to complete 500 hours of training, averaging 16-20 hours per week during a 9-month academic year schedule or 40 hours per week during a summer block placement. Most social work interns come from three different universities in the Minneapolis area: one a large public institution, the second a large private school, and the third a smaller private institution. To become a GRECC social work intern first requires that a student take part in a multistage intern selection process. Once a student is chosen for the GRECC practicum and the school year begins, he or she attends a 1-day general orientation session along with other VAMC social work interns. At this meeting, students are oriented to the medical center and general social work roles and responsibilities within the facility. Following the general orientation, students return to their assigned unit. The GRECC social work intern is supervised by a mastersprepared and licensed clinical social worker with a certificate in gerontology. This GRECC field instructor has oversight of the placement experience and is responsible for the trainee throughout the internship. Interns receive at least 1 hour per week of individual supervision from the field instructor. Performance is assessed through case presentation, direct observation, and/or process recording. A written evaluation is completed each semester, and its results are communicated to the student's respective university field office. The GRECC field instructor orients the student to the responsibilities and expectations of the program. The intern is familiarized with the program's mission, its role within the medical center and community, and its activities. Students will begin to attend the weekly outpatient clinic, be apprised of active and proposed research protocols, and be alerted to upcoming educational opportunities. While social work interns are integrated into all the components of the GRECC, their primary responsibilities are to the clinical program. The weekly outpatient clinic is the cornerstone for all clinical activities. At each clinic, 6 to 10 veterans are seen with 2 to 3 of these clients being new to the clinic each week. The veterans new to the clinic undergo a 2-hour comprehensive diagnostic assessment by a multidisciplinary team comprised of several physicians (neurologist, psychiatrist, and internist), a social worker, and a PharmD (doctor of pharmacy). The assessment includes a medical examination, review

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of prescribed and over-the-counter medications, and biopsychosocial evaluation. The remaining clients receive a routine examination completed by a physician and are seen by other staff as needed. After all the clients are evaluated, the team reconvenes and follow-up plans are made. New clients are given a preliminary diagnosis and recommendations are made for further testing. When all assessments are complete, the client and family meet with the physician and social worker for a conference where findings are summarized, a diagnosis is given, a treatment plan is developed, and educational resources are provided. Veterans with dementia are followed by the clinic indefinitely and are free to consult with staff between visits. Social work interns are required to attend the weekly outpatient clinic. Under direct supervision, interns complete biopsychosocial assessments, administer select standardized assessment instruments, secure resources, provide supportive counseling, and record their contacts with veterans and their families. Once the student develops a rudimentary understanding of the program, a learning contract is developed which identifies individual learning goals and objectives to be accomplished during the field placement. A schedule for weekly individualized supervisory meetings with the GRECC field instructor is arranged. In addition, the intern will continue to meet formally for 1 hour monthly with the MSWintern group and the medical center's social work field coordinator. This meeting provides interns an opportunity to get to know each other better, a forum to discuss issues and concerns, and a venue for training particular to the field, such as social work ethics and program eligibility.

Practicum Goals The GRECC experience provides aging-related learning opportunities essential to the development of a gerontological-social-work practitioner. Building specialized knowledge, developing assessment skills, working with a multidisciplinary team, having opportunities for gerontological training, and developing research skills form the basis of an aging-rich practicum. These core areas are in addition to the general foundation all MSW interns are expected to develop for practice in a health care setting. GRECC interns, like their MSW colleagues, develop basic skills in interviewing, workload management, and documentation. They also gain a working knowledge of community resources and programs and an understanding of the historical origins and funding sources of the DVA.

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Specialized Knowledge

When working with persons with dementia and their families, social workers are exposed to a broad range of social, medical, and legal issues. Interns must develop specialized knowledge of AD and related disorders as well as the aging process. A 2-hour training video, "Assessing Dementia in the Chnic: Interview and Examination Skills" (Juntunen Media Group, 1997), created by the GRECC clinical program, introduces interns to the dementia assessment. Like all other students, social work interns receive a packet of reading materials which include recent journal articles on diagnosis and management of dementia and multidisciplinary teamwork. Social work trainees supplement this packet with additional articles and books of their choice and are encouraged to explore the medical center's extensive library. Students also visit the local Alzheimer's Association chapter office where they meet staff, learn about available services, and collect additional educational materials. Along with developing specialized knowledge of AD and other dementias, the GRECC experience further enhances students' knowledge of aging. Interns are able to capitalize on the diverse array of staff available within the GRECC program. As part of their learning contract, trainees self-select clinicians to meet with. For example, students' learn how the occupational therapist uses the Cognitive Performance Test (Burns, Mortimer, & Merchak, 1994) to assess functional status in patients with dementia. Most spend time with the PharmD, where they develop a beginning understanding of the interaction of medications affecting the elderly. Interns also interview research and education staffs to learn about grant funding and educational programming. Interns benefit further from exposure to the range of social work roles and responsibilities within the VAMC. Students often "shadow" other social workers. They may spend a day with a medical social worker or a morning in the adult day health care program. Other interns have wanted to gain greater familiarity with a certain practice skill or patient population group. For those students, a lengthier shadowing experience is arranged. For example, an intern was interested in developing group work skills. She spent several hours every week with the social worker in the geriatric psychiatry clinic where she initially observed a psychotherapy group for elders experiencing grief and loss. Later in the year she cofacilitated the group. Another intern was interested in the special needs of rural elders. She completed a literature review of the topic, read several articles.

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and went out on home visits with a social worker in the Rural Care Program. Interns are encouraged to become familiar with aging settings outside the medical center as well. Interns make plans in their learning contracts to visit sites in the community such as nursing homes, assisted living environments, retirement housing, senior centers, and adult day care programs. Assessment Skills Working in the GRECC outpatient clinic requires interns to develop strong biopsychosocial assessment skills. As explained by MclnnisDittrich (2005), a biopsychosocial assessment is a dynamic, interactive process whereby social workers evaluate strengths, potential resources, and obstacles in order to identify supports and interventions that maximize an elder's potential. Because of the complex nature of dementia and the clinic's educational focus, increased time is available to interns in order to obtain a detailed history and to meet their learning objectives. The biopsychosocial interview includes questions about recent life events, living arrangements, family relationships, coping skills, social support networks, and use of community resources. Legal issues such as advanced directives, powers-of-attorney, and financial planning are explored. Questions are asked about the client's memory loss, particularly changes in behavior and mood. Because persons with dementia may be unable to accurately report declines in function, the clinic requests that veterans be accompanied by a family member or friend who can provide corroborating information. To gain skills in completing a biopsychosocial assessment, the student is given materials explaining its purpose and components in addition to observing the field instructor. As the intern gains confidence, he or she will colead interviews. Within a few weeks, depending on the intern's developmental needs, he or she then begins to conduct interviews independently. During these first assessments, the field instructor directly observes the intern. Throughout the internship, the field instructor periodically observes the intern, remains available for questions and support during clinic, and diseusses specific practice skills and situations during supervisory sessions. Because of the wide variety of information collected during an assessment, one intern developed a checklist of topics to cover during an interview. This template proved to be popular with subsequent students who often relied upon it, particularly during the first few months of placement.

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Standardized instruments augment clinical interviews. A widely used measure of cognitive functioning is the Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). It provides a brief but formal measure of cognition and documentation of serial change in status. Students watch an instructional video developed by the GRECC on the tool's administration before attending clinic. They then observe its administration and scoring by clinic staff before giving it themselves. Assessing for depression is an important part of the initial evaluation for—and ongoing management of—dementia. It is common for depression to coexist with a dementing illness and, in fact, may exacerbate cognitive deficits (Draper, MacCuspie-Moore, & Brodaty, 1998; Lundquist, Bernens, & Olsen, 1997). The 15-item short form of the Geriatric Depression Scale (GDS-SF) is used in the GRECC clinic to screen for depressive symptoms (Sheikh & Yesavage, 1986). MSW students are provided written materials describing the instrument's use and scoring before they administer it. A thorough biopsychosocial assessment requires students to use their clinical judgment in integrating all components of the evaluation to form a comprehensive plan of care for their clients. Interns must consider their own evaluation along with standardized test scores, laboratory results, and other team members' recommendations. Exposure to the Multidisciplinary Team Interns witness a coordinated response by the multidisciplinary team to the myriad of issues facing clients with dementia and their families. Interns work alongside the core team of physicians and a pharmacist in the clinic. They also become familiar with other allied health professionals that augment the team including a psychologist, a nurse, and an occupational therapist. Together the team delivers comprehensive care to clients and their families from initial diagnosis through disease progression. The intern is able to see and experience the distinguishing role played by the social worker on the team. Social work is essential to the assessment, treatment planning, and ongoing care of persons with memory loss and their families (Damron-Rodriguez & Corley, 2002). It is considered the expert in identifying and linking clients to community resources. Social work is also the liaison between family members and between health care systems (Mellor & Lindeman, 1998). Moreover social work is able to use its knowledge of group work and interpersonal relationships to facilitate successful team functioning (Mellor & Lindeman, 1998). Consequently, the social worker is a

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valued and central multidisciplinary team member. This influential role aids in the development of the intern's professional identity and fosters a positive self-image. In addition to social work, interns develop an appreciation for, and understanding of, other disciplines' contribution to the care of the client and family and to the multidisciplinary team. Interns are able to see the many roles and functions of the various disciplines. As such, they are better able to make appropriate referrals and use consultation effectively (Schrader et al., 1999). The foundation for effective teamwork is made. Gerontologieal Training Opportunities

Training is a strong component of the GRECC experience. A variety of learning opportunities are available through workshops, seminars, grand rounds, and conferences. Students are encouraged to examine and expand their knowledge of gerontology by taking advantage of educational offerings. One opportunity readily available to the intern is attending the GRECC Seminar Series on Aging, the longest running continuing education series on geriatrics and gerontology in Minnesota. Once or twice every month, an hour-long educational program is offered to medical center staff and community professionals. Topics are chosen based on current needs and interest of staff. It is not uncommon for presenters to be of national stature in the fields of geriatrics and gerontology, including social work experts. Interns are able to attend these sessions and to meet individually with the presenters. Research Skill Development Because of the GRECC's belief in the importance of research to understanding the needs of the elderly, social work interns are required to complete a research project which addresses an area of interest to gerontological social work. Interns have taken different approaches to explore a variety of topics. One intern completed a program evaluation ofa four-part educational series offered to family caregivers. She developed a pre- and posttest measuring diseasespecific knowledge and satisfaction with the sessions. Another student completed a retrospective study examining the relationship between cognitive status and hazardous driving performance. Interns can devote up to 4 hours per week to their research project. In addition to assistance from their field instructor, other GRECC staff are available to the intern for research support. For example.

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a biostatistician can provide statistical consultation and a physician, who is a member of the human subjects subcommittee, can answer questions about securing IRB approval. Upon completion of their research project, interns present the results to GRECC staff, social workers, and other interested healthcare professionals within the VAMC. Four students have had the results of their projects published in peer reviewed journals. Student Evaluation of the Praetieum

At the end of the academic year the overall GRECC internship is evaluated by each intern. Feedback has been favorable of the GRECC experience. Overall, students found the practieum to be unique and of high-quality. One of the most frequently cited benefits of the GRECC practieum was working with the multidisciplinary team. Said Kathryn, a traditional student in her mid 20 s, "I felt that I learned a lot from every member of the team. I was able to observe almost everyone and felt like I learned from that. Also, being on a team not only taught me different ways to work with older adults, it has taught me how to work on a team." Mary, another traditional student in her mid 20 s, noted, "...enjoyed working in a team atmosphere.. .gleaned good information from all other disciplines." Clara, an advanced standing student in her late 20 s, noted that the, "most beneficial aspect of the field experience was the opportunity to practice within a team." The centrality of social work to the clinical program was noted. Explains Crystal, a traditional student in her late 20 s, "My opinion was very much valued here. My experience in other medical settings has not been that way. Social workers were the grunge work doers and the other people used them only when they had to. Not here! Social workers can participate on a team and help make the most effective plan for a client." Many interns spoke of the educational offerings available through the GRECC practieum. Crystal found the "ample learning opportunities—through seminars and conferences" most beneficial. In her learning contract, one of Kathryn's goals was to regularly attend seminars, staff development meetings, and psychiatric grand rounds. In her final evaluation, Kathryn states that, "A major strength about this placement is the variety of training opportunities that are provided." Working in a research environment was rated positively. Leslie, a traditional student in her late 20 s, reported that one of the most beneficial aspects of her GRECC field experience was "the opportunity

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to enhance my research skills." Kathryn noted ".. .an excitement around all of the research." Two students registered for independent studies after their formal social work internship ended in order to continue to work on their research. For both of these students their activities led to a peer reviewed publication. The most frequently cited concern about the placement was the difficulty of understanding the complex VA system of care. Clara stated, "The orientation to the overall VA needs to be immediate." Even with training, students still had questions. Explains Kathryn in her final evaluation, ".. .having a specific orientation to the VA system and services. I think it was provided.. .but I needed to hear it again." Postgraduation Employment

After graduation, 14 students entered the job market with 13 of them in a position working with older adults. Employed in health care settings were 9 of the 14 students. Including were hospitals, nursing homes, home health, and outpatient clinics. A total of 5 students worked in other geriatric-related settings. These included one as a researcher for a nonprofit human services organization studying the effectiveness of services provided to seniors in the community and another as the activities coordinator for senior services of a community center. In sum, most every intern who completed the GRECC internship worked immediately thereafter in a gerontological-related setting. CONCLUSION The demand for gerontological social workers in health and social services is expected to continue to increase in the upcoming years (Occupational Outlook, 2004), as an already aging population grows even larger with the addition of the baby boomer generation. In response, the social work profession has made attempts to foster the growth and development of social workers interested in agingrelated work. The Department of Veterans Affairs, long an advocate of medical social work and a leader in training social work students, has provided significant support in developing future gerontologicai social workers (Hudson, Gonyea, & Curley, 2003; VA Social Work, 2004). The social work internship offered at the Minneapolis GRECC is an exemplary training model for future practitioners. Its multidisciplinary clinical program within a larger gerontology center makes for a rich and well rounded experience for social work students. At

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the end of their practieum, interns have consistently rated their time spent at the GRECC positively. Almost all who have entered the job market after graduation have secured positions requiring agingrelated skills and knowledge. Similar training models should be considered as a means to develop a much-needed labor force of gerontological social work specialists. REFERENCES Berkman, B., Silverstone, B., Simmons, W. J., Volland, P. J., & Howe, J. L. (2000). Social work gerontological practice: The need for faculty development in the new millennium. Journai of Gerontological Social Work, 34(\), 5-23. Burns, T., Mortimer, J., & Merchak, P. (1994). Cognitive performance test: A new approach to functional assessment in Alzheimer's disease. Journal of Geriatric Psyciiiatry and Neurology, 7, 46-54. Damron-Rodriguez, J. & Corley, C. S. (2002). Social work education for interdisciplinary practice with older adults and their families. Journal of Gerontological Social Work, iP(l/2), 37-55. Department of Veterans Affairs. (2004). Geriatric researcii education & clinical centers. Retrieved on October 21, 2004, from http://wwwl.va.gov/grecc/. Draper, B., MacCuspie-Moore, C, & Brodaty, H. (1998). Suicidal ideation and the "wish to die" in dementia patients: The role of depression. Age and Ageing, 27(4,), 502-506. Facility Locator & Directory. (2004). Minneapolis VA Medical Center. Department of Veterans Affairs. Retrieved on June 1, 2004, from http://wwwl.va.gov/directory/guide/home.asp?isFlash = 1. Folstein, M. F., Folstein, S. E., & McHugh, P R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Goodwin, M. & Morley, J. E. (1994). Geriatric research, education and clinical centers: The impact in the development of American geriatrics. JAGS, 42(9% 10121019. GRECC. (2004). Minneapolis, MN: VA Medical Center. Geriatric Research, Education & Clinical Center. Retrieved on April 2, 2004, from http://james. psych.umn.edu/~grecc/. Hudson, R. B., Gonyea, J. G., & Curley, A. (2003). The geriatric social work labor force: Challenges and opportunities. The Public Policy and Aging Report, 13(2), 12-16. Juntunen Media Group (Producer). (1997). Assessing dementia in the clinic: Interview and examination skills [Film]. (Available from Juntunen Media Group, 708 North First Street, Minneapolis, MN 55401. Lundquist, R. S., Bernens, A., & Olsen, C. G. (1997). Comorbid disease in geriatric patients: Dementia and depression. American Family Physician, 55(8), 26872694. Mclnnis-Dittrich, K. (2005). Social work with elders: A biopsychosocial approach to assessment and intervention. Boston: Allyn & Bacon.

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Mellor, M. J. & Lindeman, D. (1998). The role of the social worker in interdisciplinary geriatric teams. Journal of Gerontological Social Work, 30(3/4), 3-7. Occupational Outlook. (2004). Social workers. U.S. Department of Labor, Bureau of Labor Statistics. Washington, DC. Retrieved on October 21, 2004, from http:// www.bls.gov. Roswell, R. H. (2002, December). Viewpoint: The state of the VHA is strong. AAMC Reporter. Retrieved July 16, 2004, from http://www.aamc.org/newsroom/ reporter/dec02/viewpoint.htm. Schrader, S. L., Blue, R., Miller, D., Jensen, G., Zawada, Jr., E. T., Johannsen, G., Elsberry, D. A., Nelson, D., & Lockwood, D. (1999). Strengthening geriatric knowledge and use of interdisciplinary teams among allied health students and practitioners. Educational Gerontology, 25, 51-65. Scharlach, A., Damron-Rodriguez, J., Robinson, B., & Feldman, R. (2000). Educating social workers for an aging society: A vision for the 21 st century. Journal of Social Work Education, 36, 521-538. Sheikh, J. I. & Yesavage, J. A. (1986). Geriatric depression scale: Recent evidence and development ofa shorter version. Clinical Gerontologist, 5, 165-173. VA Social Work. (2004). Department of Veterans Affairs. Washington, DC. Retrieved July 16, 2004, from http://wwwl.va.gov/socialwork.