When 5-year-old Stefanie Small, dressed in a pink tutu, stepped onstage at a New York nursing home to perform a dance number for about 30 older adults, she looked out into the crowd, then suddenly ran offstage, terrified.
“I was petrified of older people,” she says now. “All those eyes on me!”
Small’s view of older adults had changed drastically by the time she got to college. In her senior year, she interned at an adult day care center that specialized in patients with dementia. Soon she was helping to lead the patients in exercises, serving them lunch, and just enjoying being around them.
“Dementia is really about being in the moment, because there is no past or future,” says Small. “And being able to help people in the moment really was a remarkable transformation for me.”
Her love of practicing directly with the aging population stayed with her. Now a successful geriatric social worker, Small (MSW ’01) has been at Jewish Family and Community Services in Pittsburgh’s Squirrel Hill neighborhood for the past 20 years. She helps to link clients to the resources they need to keep living safely and independently in their own homes. For example, she assists a 73-year-old woman who has anxiety with paying her bills and making doctor’s appointments and offers her general support. “She has no close family, so we are really it,” she says.
Small and thousands of geriatric social workers like her are busy helping older adults to cope with a frightening pandemic and, when possible, ease back into society, ever mindful of the issues facing their clients and the potential problems they see coming down the pike. Right now, approximately 45 million Americans are 65 or older. By 2030, that number will reach 73 million. And by 2034, the U.S. Census Bureau projects the United States will—for the first time—be a nation with a larger number of older adults than children. All this comes at a time when geriatric social work is not attracting droves of new skilled workers.
The University of Pittsburgh School of Social Work has had a gerontology certificate program since the early 1980s. In 2005, the program received a grant to grow the certificate by establishing the two-year Hartford Partnership Program for Aging Education, a fellowship designed to provide students with a solid foundation for working with older adults based on deep community engagement. And it is expanding. Hartford fellows now include MSW and BASW students (for one year) and, among the MSW students, include those in both specialization tracks. Students seeking a joint degree (for example, a Master of Public Health or Master of Divinity) with social work also may apply. Unlike at other Hartford programs across the country, Pitt’s MSW fellows are engaged with older adults for the entire two years of their degree program and have ongoing access to faculty and peers. During that time, they rotate assignments, working and learning in hospice settings, various residential facilities, or other environments serving older adults. They also complete a capstone project.
Rotation of placements is an important piece of students’ training, says Clinical Assistant Professor Elizabeth Mulvaney, who ran the program for six years. When the students see older adults in more than one setting, they see the range of their capabilities and strengths as well as the challenges they face.
“The stereotype of an older adult is that they are dependent and sick,” she says. “The reality is that most are not. Part of the purpose of rotation is to help our students see that.”
Her colleague, Rafael “Ray” Engel, principal investigator of the Hartford Program, appreciates the leadership component of the capstone project, which allows fellows to take their work directly to the community. And there are many forms that a capstone project might take. It could be a resource guide about how important pets are to older adults or lessons for dementia patients on how to create art that reflects life memories. A student-created exhibition that included educational posters on hoarding was viewed by some 1,000 people coming through Wesley W. Posvar Hall one weekend. “The lessons learned by that event could help staff at community agencies carry out their own projects,” says Engel.
The fellows also complete a program developed with Pitt’s Aging Institute called Ageless Wisdom, which allows students to directly experience the physical impairments older people have. They move around with popcorn kernels in their shoes to simulate peripheral neuropathy, which interferes with walking and comfort. Wearing gloves that decrease sensation in the fingers, they manipulate items in their wallet, count cash, or open a snack. They wear glasses that simulate cataracts as they sort through fake pills, trying to distinguish the white ones from the yellow ones.
Ageless Wisdom has been offered to more than 600 students throughout the School of Social Work. MSW students also are trained to deliver these valuable lessons in the community after they graduate.
More Alumni Answering the Call
For Jennifer Marasco-Kuhn (MSW ’10), her focus has been on people with memory impairment. As cochair of Dementia-Friendly Greater Pittsburgh (DFGP), the former Pitt Hartford fellow collaborates with a network of agencies to educate the public about dementia and to train caregivers. She hopes to tailor dementia training for specific businesses—in the arts sector, for example, or transportation providers. DGFP is working with faith-based organizations and the Pittsburgh Cultural District to make outings for people with dementia less confusing or jarring. A partner agency soon will be working with a local gym to introduce dementia-friendly practices to its employees.
“If we educate individuals on how to spot the signs and how to interact with people living with dementia, it will make the community more accepting, inclusive, and safe,” she says.
Social workers engaged with people living with dementia must be at the top of their game, says Marasco-Kuhn. “You might be helping them with dinner, and they suddenly change their mind or are in a different timeline. They are not stupid or inept. They are very aware of what they believe is their world, and they will call you out if you try to force a detail in their life they believe is not true,” she says. She tries to meet them, emotionally, where they are. “We let them take the lead.”
Marasco-Kuhn also explains that the lived environment plays a role in how people with dementia cope. She has worked in communities with inclusive design features, such as a favorite grocery store or market or bus stops that don’t actually have bus service. This way, residents can still have freedom of movement without risk of harm.
Much farther south, Chris Messersmith (MSW ’10) is applying what he learned as a Hartford fellow as operations manager of Suncoast PACE in Florida, a state with a high number of aging adults. Suncoast PACE is a state- and federally funded program that delivers services through an adult day center and primary care and therapy clinics. In his work, Messersmith engages with his older clients and their caregivers at his site in Clearwater, works with vendors, and helps to address issues of compliance to ensure a safe and inclusive environment for seniors.
Facing Down the Challenges
All three of these social workers face daily challenges in their work. Small feels that one of the biggest is trying to help people who don’t feel they need help. She clearly remembers the mantra of one of her Pitt professors: “You can’t want it more than the client.” Small says that she has heard that phrase in her head for decades and shares it with social work students and trainees.
“You have to learn that early on, because everything we do is client directed,” she says. “If they want to do something you would not choose, you have to learn to live with that.”
Small says that’s when family consultations can help, usually with adult children. Social workers tackle three questions with them: What does your parent need now? What will they need in a few years? What will they need in a crisis?
“At the very least, the family members leave knowing what to do in a crisis,” says Small. “Even if older adults don’t want to hear it, the families have to be prepared. Then we slowly work on the older adult.”
Family members often play the role of caregiver (or “care partner,” which some social workers note is a more appropriate term, because not all scenarios are a one-way flow of care and support). And while the public may assume that social workers suffer from burnout in their careers, Small says it is actually unpaid caregivers who burn out most quickly (see sidebar on page 12). “Especially in spousal caregiving, they are also dealing with strong feelings of loss in their situation—what could have been and what will not be,” she says.
Prior to the pandemic, Small’s support group for caregivers, which usually attracted eight to 12 people, met once a month. When the COVID-19 pandemic hit, she says that stressors for caregivers intensified, and the group now meets virtually twice a month and has doubled in size.
Marasco-Kuhn sees a lot of burnout among those who provide dementia care. Working with families who are experiencing anticipatory grief is emotionally charged work. “They are losing their loved one while they are still alive,” she says. “It is a lot of grief work. And if you don’t have boundaries or are not practicing self-care, it can really wear on you.”
She says that it is important not to forget members of the LGBTQ+ population who have impaired memories. Some of them may have special circumstances, and their caregivers need enhanced skills to provide support. Through DFGP, Marasco-Kuhn learned about an ongoing national study conducted by the University of Washington called Aging with Pride: Innovations in Dementia Empowerment and Action that explores this topic. DFGP plans to share information on this study locally with interested participants.
“This is something communities will experience more and more, whether it is in independent living or in a nursing home,” says Marasco-Kuhn.
At Suncoast PACE in Florida, Messersmith says that his primary challenge is an uptick in the number of seniors needing help with substance abuse or overall mental health. And the funding is just not there. “We need increased investment in home- and community-based services here in Florida and across the nation,” he says. “Health care companies and politicians are learning it is cheaper to care for people in their homes rather than in facilities. And most people want to remain in their homes, so it is a win-win.”
Despite these challenges, these social workers feel that they benefit from engaging with older adults. They love the personal connection and the wise advice they receive from clients. They enjoy clients’ stories about their childhood adventures, their experiences in military service, their careers, how they met their spouse, or their world travels. They also learn skills they can apply to aging members of their own family. As Marasco-Kuhn says, “[My older clients] have provided me [with] life wisdom for my own journey.”
Always a Social Worker
Joy Starzl (MSW ’97) has always had a special spot in her heart for older adults. A longtime social worker at the former Lemington Home for the Aged, she eventually became executive director of nearby Lemington Community Services. With the 80-unit Eva P. Mitchell Residence for seniors right next door, Starzl began offering more services for that population.
“We put in a personal care home, a gift shop, podiatrist, hairdresser—putting that all together was exciting,” says Starzl. When the Lemington Center closed in 2005, Starzl eventually set up shop in the basement of Cornerstone Baptist Church so that the meals, outreach, recreation, and referrals could continue.
Starzl retired in 2010 but is active on the Eva P. Mitchell Residence board and remains a strong advocate for seniors. She says that when the Lemington Center closed, the Port Authority of Allegheny County bus service was cut. Now she watches seniors trudging up a hill carrying bags to get the closest bus while she and others appeal to Port Authority to restore the original bus service.
“Our society just keeps putting Band-Aids on things, especially for older adults,” says Starzl, although she is encouraged by recent news that the old Lemington Home will be redeveloped as 54 housing units for seniors with a first-floor health center. “Maybe the bus will return,” she says.
Starzl speaks daily to people who live at the Mitchell Residence and connects them to services, be it a dinner companion or someone who can assist with small home repairs. “It is such a big reward when a senior calls me and says what we did made their life easier,” she says. “I can’t put a price on it. It just makes me feel I can do even more.”
Starzl recognizes the struggles of seniors in her own life. Before the pandemic, she was a regular Sunday-night dinner guest at the home of a 90-year-old friend, with meals delivered by Grace Memorial Presbyterian Church. When the pandemic prevented those in-home visits, the church meals kept coming, and to Starzl’s home as well. Even the brief encounter with the delivery person was a comfort. “I was overwhelmed,” says Starzl, who became a widow in 2017.
“I didn’t realize how lonely I was.”
Issues Looming on the Horizon
A laundry list of issues lies ahead for geriatric social workers and the millions of older adults they serve. As Starzl points out, transportation is a big one. While Port Authority offers free rides for seniors, not everyone lives close to a bus stop. Uber and Lyft are too expensive for many. Free senior transit through ACCESS is helpful, says Small, but you have to allow a lot of time for pick-up and drop-off. Volunteer transportation programs can be unreliable. Starzl and Mulvaney both suggest eventually introducing the older population to driverless cars.
Loneliness and isolation also are concerns. “Some older adults are so isolated that it scares me,” says Starzl, who has tapped on the door of an older adult’s home to check in on them only to spot them lying on the floor or unable to get to the door. Many seniors living at home have struggled to have enough social contact and support, especially during the COVID-19 pandemic.
Housing challenges persist, with long waiting lists for the Housing Choice Voucher Program homes and senior high-rises. The pandemic also frightened some family members, who pulled their loved ones out of congregate living.
Engel feels it is time to rethink institutional care and reassess how it can be delivered safely. Are our current nursing homes and institutions really the model to use going forward? Small says that too many people think moving an 83-year-old widow from her familiar home into an assisted living center will solve all her problems.
“Now you’re paying $6,000 a month for her to isolate in a room that she is not familiar with and where she doesn’t have her own things. So yes, now she is getting help, but now she is depressed,” says Small.
Messersmith says that the current system that serves older adults overall is the same one that has been in place for decades, dating back to a time when that population was much smaller. Starzl hopes to see more social workers employed in the policy arena, helping to shape a better geriatric care system for the future.
Today, Messersmith says, we need more funds and interest in preventative health care to reduce the stress on the system. And he thinks Americans need to change their outlook: “We will most likely need some degree of cultural shift in how families view their personal responsibilities in caring for older family members.”
Marasco-Kuhn agrees. She notes that studies have shown that intergenerational living arrangements between older adults and college students can benefit both. She feels that college students, many of whom have lost their connection to their grandparents, have a lot to gain as well as to contribute from living near or with older adults.
The pandemic made very clear the problem of nursing home staffing shortages, and many think that trend will continue. Mulvaney says that the industry needs more geriatric social workers who must be well paid to do this very hard and important work. And they don’t just need bodies to fill positions but high-quality, compassionate professionals.
Engel admits that the geriatric
path is not necessarily a popular one for social work students. “They don’t see it as a sexy field,” he says. “It’s not like mental health, where one works with broader populations across any
Affordability for the patient also is a concern, says Mulvaney, in an insurance system that she says is very “disease focused.” Insurance provides good coverage if a patient has an acute illness or is very low income. But those with long-term challenges and disabilities or who are middle income can struggle.
Technology continues to play a key role in assisting older adults, with innovations like a wristwatch that monitors movements and can detect a fall or phones that provide large print and can follow voice commands. Telehealth also has come a long way, though Small cautions that there are still seniors who do not have access to the internet. “Technology has been a boon, but it has not been an equal boon,” she says.
Nonetheless, this once timid ballerina who has grown up to become a confident social worker relishes getting up in the morning and heading to work to serve this population. She says that early on, when she told her friends she was going into geriatrics, a common response was, “Oh, that’s so depressing.” But nothing could be further from the truth.
“It is amazing what you can gain from them and do for them,” she says. “There is so much positivity on the horizon. I think it far outweighs any problems that may crop up.”