Expanding the Boundaries of Primary Care for Elderly People
Netting, F. Ellen, Williams, Frank G., Health and Social Work
This article reports the results of a qualitative evaluation of the Generalist Physician Initiative, designed to enhance the care of older people provided by primary care physicians in nine demonstration projects around the country. A theme entitled "Pushing the Comfort Zone" examines activities in which physicians engage before collaboration: selecting elderly patients, "opening cans of worms," recognizing patient and family expectations, and going outside the comfort zone. A second theme called "Linking with Collaborators" reveals activities in which physicians engage as they collaborate: teaming, using intervention agents as eyes and ears, communicating, and tracking patients. Findings indicate that social workers are logical collaborators with primary care physicians as contemporary practice is expanding to be more holistic.
Recently primary care has been the subject of much attention as attempts have been made to rethink health care in light of managed care systems (Strom-Gottfried, 1997). Of particular concern is how primary care physicians address the needs of increasing numbers of older people with chronic conditions (Christianson, Taylor, & Knutson, 1998; Institute of Medicine, 1996; Mark, Gottlieb, Zellner, Chetty, & Midtling, 1996; Radecki, Kane, Solomon, Mendenhall, & Beck, 1988; Weiss & Blustein, 1996).
Social workers have roles to play in helping physicians and their staff assess, plan, and intervene with older patients (Berkman, 1996; Berkman, Damron-Rodriquez, Dobrof, & Harry, 1995; Browne, Smith, Ewalt, & Walker, 1996; Ell, 1996; Netting & Williams, 1996, 1998; Zayas & Dyche, 1992). For example, Azzarto (1993) examined five practices consisting of 34 family physicians in New Jersey in which the specialist--therapist role was played by social workers in intervening with older patients who frustrated physicians because they required extensive "reassurance, time, and attention" (p. 46). Berkman (1996) identified a list of tasks that social workers perform as clinical specialists and also identified the case manager role for social workers. Many writers have explored the role of geriatric case manager (Applebaum & Austin, 1990; Capitman, Haskins, & Bernstein, 1986; Gerber, 1994; Geron & Chassler, 1994; Kane, Penrod, & Kivnick, 1994; Netting & Williams, 1995, 1996, 1998).
In 1992 the John A. Hartford Foundation organized The Generalist Physician Initiative to support development of care management programs in primary care physician practices.
Building on what had been learned about challenges in everyday practice with older people in an earlier demonstration (White, Gundrum, Shearer, & Simmons, 1994), the foundation funded nine projects to develop care coordination models based in physicians' offices. Staff in each project selected comprehensive geriatric assessment tools, although methods varied. Each project had multiple sites. Sites varied in type of location (urban, suburban, and rural), patient incomes, and penetration of managed care. The intent was to create a diversity of relevant and feasible models, given local conditions, prior experience, the cultures of the systems in which they would be introduced, their traditions, and congruence with leaders' expectations. (For an overview of each project, see Netting & Williams, 1999).
In 1994 program officers from the John A. Hartford Foundation asked us to travel to each project to identify emerging themes that contributed to project development. This article reports the results of our examination and discusses implications for social workers.
We used a qualitative approach. We (a social worker and a health care administrator) visited the sites to interview key players, took field notes of informal encounters and observations, participated in joint meetings, read six-month and annual reports, and immersed ourselves in getting to know these projects. …