Interview with Laura Burns, MSW on Geriatric Social Work
About Laura Burns, MSW: Laura Burns is a medical social worker who works at On Lok Lifeways, Inc., a non-profit organization that offers comprehensive health care to low-income, elderly individuals. Prior to working at On Lok, Inc., Ms. Burns interned at Lucile Packard Children’s Hospital at Stanford, where she screened patients for clinical risk factors. She also interned at Kaiser Permanente, where she conducted psychosocial assessments of elderly patients.
Ms. Burns was a Kathryn Davis Fellow for Peace at Middlebury Language School, and was also the recipient of the William E. Valentine & Jonathan Pannor Fellowship at UC Berkeley. She earned her bachelor’s degree in Feminist Studies and Community Studies from UC Santa Cruz in 2008, and received her MSW from UC Berkeley in 2014. Laura Burns was compensated to participate in this interview.
[OnlineMSWPrograms.com] Could you please give an overview of your team at On Lok, and how social workers interact with other health care professionals in a geriatric health care setting?
[Laura Burns, MSW] On Lok is a PACE program, which stands for Program for All-inclusive Care for the Elderly. Most of our patients are pretty low income and the majority have Medicare and Medical. In order to qualify for the program they have to be 65 or older, frail and elderly and there are some other requirements as well. Once candidates qualify to receive medical care with On Lok, they are able to choose whether or not to enroll in On Lok as they are required to give up their IHHS (In Home Support Services), and their primary physician and receive care from On Lok physicians and home care nurses. We’re a capitated healthcare program, so their Medical gets paid to On Lok, and then On Lok provides for all of their healthcare needs.
We have a day health center (DHC) where participants come to receive different types of activities, socialization, and cognitive stimulation including pet therapy and bingo. Sometimes we have kids from the community come in and perform for the participants, which they love. Patients attend the day health center anywhere from zero times a month to five days a week, depending on their care plan.
There’s also a clinic on site with three doctors and one nurse practitioner and several nurses. All of our participants are given a full physical exam before they are enrolled and they are evaluated every 6 months, or as health conditions occur. Our health care team monitors participants’ chronic conditions and evaluate participants when a medical complaint is reported either by the participant or by their caregiver. We also have a dietician on site who oversees our meal program; participants are given lunch and snacks when they attend the DHC and those who are unable to cook for themselves receive portable meals (frozen meals). We also have specialists that see participants at the DHC about once per week. We have an audiologist, a podiatrist, a dentist, a geriatric psychologist and a speech therapist.
We also have a rehab team, which includes occupational therapists and physical therapists. The rehab team determines if someone needs Durable Medical Equipment (DME) or a Functional Maintenance Program (FMP). Many of our participants use DME, which include wheelchairs, front wheel walkers, single-point canes, and quad canes. Physical Therapists work with participants with an FMP one to two times a week to strengthen either their lower or upper extremities or improve their safety ambulating in the community. The physical therapists and the occupational therapists share a gym in the Day Health Center. The occupational therapists focus on fall prevention and making sure that participants’ homes are safe. Occupational therapists conduct home safety assessments to ensure that patients have clear paths, their showers have grab bars and shower chairs or hospital beds if needed. The rehab team is an essential part of the interdisciplinary team (IDT).
We have a home care team of nurses and aids who provide people with showers, assist them with meals, provide medication reminders, and assist them with chores and laundry in their home.
Social workers are connected to all of the aforementioned teams. It is our job to connect our patients with the services that these teams provide, and to connect the teams with one another as necessary to ensure proper emotional, mental, and physical care for our participants. We also are the primary point of contact for our participants’ family members. Social workers at On Lok also play an important role in the initial assessment of patients, and in the development of their care plan.
On Lok candidates are assessed before they join On Lok and each discipline writes up on an assessment and determines their care plan. We then send our assessment and care plan to the state and the state determines whether or not they are approved to join On Lok. If the candidate is approved and they decide to enroll, then the interdisciplinary team works with them to achieve their care plan and every 6 months conducts a reassessment and adjusts their care plan according. The doctors, the clinic, the occupational therapist, the physical therapist, the social worker, the dietician and activities therapist all report on how is this participant is doing every six months, and if they’ve changed their care plan. Each discipline has to get concurrence with the participant or family for the new care plan.
The social workers’ intake of a candidate is focused on the person as a whole and explores their support systems, psychosocial risks, cognition and mood. We conduct standardized cognitive tests that indicate whether or not they are mildly cognitively impaired, moderately cognitively impaired or severely cognitive impaired. These tests determine if the participant is able give concurrence to their health care plan or if they need someone else to concur to the care plan.
The three main things that we assess for are changes in mood, behavior and cognition. We test for changes in cognition and mood every six months. So each time I’m checking in on someone, even if it seems just like a social visit, I’m also checking in on their emotional well-being. If someone is usually pretty chipper and they are super agitated, I need to determine what is wrong and who needs to be informed. As social workers we don’t just do formal screenings; we also do informal check-ins with the participants all the time. Also we don’t have to wait until a participant is due for a formal assessment to make an adjustment in their care plan; we are able to modify it at any time.
I would say for most of my participants, one of the goals in their care plans is to adjust to the day health center because it is a really big change for many of them. One of my participants told me just the other day, it’s really scary to have the lack of control when you first enroll in On Lok. A nurse now dispenses your medication, and you’re no longer in charge of that. A driver from our transportation service picks them up and takes them home. Not being in charge of their own medications or transportation can be a big transition for our participants. It’s a big change to go from living more independently to relying on other people to help you care for yourself.
[OnlineMSWPrograms.com] Can you please give an overview of your core responsibilities as a geriatric social worker, including how you help elderly patients?
[Laura Burns, MSW] In many ways, social workers coordinate the delivery of care for each of the 50-60 participants that we serve. We are the connection between the family and the health services that On Lok offers. We collaborate with the IDT and partner with our participants’ caregivers to ensure that our participants are receiving high quality care. I would say the family sees the social worker as the main point person to talk to about issues that come up in their family member’s health care plan. Even if it’s a medical issue, such as obtaining the right medications, family members are more likely to have our phone number than the physicians’ phone number. I receive calls from a participant’s family member if the participant did not get picked up on one of their attendance days and then I speak with the transportation coordinator to get the situation sorted out. Or a family member might call me to tell me that their loved one is feeling weaker, and then I’ll say I’ll have the physical therapist call you and check in about the care plan and see if they need to adjust that. So all of these things are kind of funneled through social work.
In addition to working with the IDT at On Lok, we collaborate with members of other medical teams when our participants are admitted to other health care agencies. For example, when someone’s in the hospital, if they’re being discharged, we work with the case manager at that hospital to find a safe place for them to be discharged to. Or if a participant’s family member and primary caregiver is going on vacation, then we can arrange for them to be cared for at a residential care facility under our caregiver respite grant.
On a day-to-day level, it’s hard to say what my schedule will be like. Every day is different. Some days we are out doing home visits to conduct cognitive testing on a participant who cannot or will not attend the DHC, other days I am on the phone with participants’ family members for most of the day. Most of the time I work from the DHC because the majority of my participants have attendance at the DHC so it is easy for me to check in on them at least once a week if not every day that they’re there.
Since we screen for changes in mood, if someone is doing fine emotionally and then all of a sudden they’re severely depressed or suicidal or homicidal, that’s obviously something to communicate immediately to the medical team and the participant’s family. We consult with Adult Protective Services to report cases of abuse or neglect. We let their doctor know to see if they need to have a medication adjustment, and we’ll usually also recommend meetings with the chaplain or the mental health counselor who works on site as well. The mental health counselor provides 1:1 sessions with participants who require longer counseling sessions than the social workers can provide.
Social workers also help participants complete their Advanced Healthcare forms. We request that all our participants complete a POLST form, which stands for Physician’s Orders for Life-Sustaining Treatment, and it basically outlines, if your heart were to stop: Do you want someone to perform CPR on you or do you want to have a natural death? Do you want all possible medical interventions, limited medical interventions or comfort-focused measures? Do you want long term artificial nutrition, trail artificial nutrition, or no artificial nutrition? When we assist participants in completing their POLST, usually the doctor and their family member or caregiver are present and actively involved in the conversation and decision. We also assist participants in completing an advanced healthcare directive, which appoints a health care decision maker for when the participant loses their capacity to make their own decisions. These are often difficult conversations as many people are uncomfortable thinking about losing capacity and thinking about the end of their life, but they are important forms to complete so when the time comes that they are no longer able to verbalize their desires, their family and their healthcare providers can follow their wishes.
[OnlineMSWPrograms.com] In what ways is geriatric social work different from other fields of social work, in terms of the skills it requires and the people and organizations you must interact with to ensure patients’ well-being?
[Laura Burns, MSW] Geriatric social work is similar to other fields of social work in that you identify various risk factors and protective factors. It is important to gain rapport with participants so that they trust you enough to answer when you ask probing questions like, “Have you ever experienced anxiety or been on medications for anti-depressants?”
One aspect of geriatric social work that may be different than other kinds of social work is that death is a more constant presence in our participants’ lives. Obviously people across the lifespan die, but I think it’s more expected to happen towards the end of someone’s life. However, everyone has a different level of comfort thinking and talking about this topic. Some of our participants think more about their deaths than others, yet we discuss it with all of them when we complete the POLST form. We begin these conversations by asking questions such as, “How do you want the end of your life to be?” and “What would your goals be for the last weeks or last days here?”
Part of the challenge of geriatric social work is how you talk with participants about death or other sensitive topics. You have to adjust your style of engagement to the person that you’re working with. Just this morning, I was talking with someone about his advanced directive, and he said he wanted to be cremated, and I asked, “Do you have a place that you’ve chosen to be cremated?” adding, “I know it’s early in the day to be talking about this,” and he replied, “Yeah I try not to think too much about it.” These conversations are necessary though.
Working with the elderly is definitely different from working in a pediatric care setting. When I interned at Lucile Packard Children’s Hospital in the Neonatal Intensive Care Unit (NICU) there was a pretty high mortality rate, which you don’t really expect. Working with the elderly, you expect more of your participants to die. We provide such great care for someone when they’re alive, and we do our best to do the same when someone dies. Following a participant’s death, our activities department sets up memorial in a small room with pictures of the participant and a card that we can write to the family. It’s nice for both staff and participants to have that closure. We also have had a remembrance ceremony that the chaplain led for staff to honor our participants’ lives and deaths. I think as social workers, we get close to our participants and their families. I feel really appreciative that I work for an agency that recognizes and honors the sanctity of life and death.
[OnlineMSWPrograms.com] What have been some of the most rewarding experiences so far at On Lok, Inc.? As a recent MSW graduate, do you see yourself staying in geriatric social work as a career?
[Laura Burns, MSW] One of the most rewarding experiences are the long-term relationships I have with my participants and knowing that I am able to make a difference in their lives. For example, when I talk with some of my participants, I sit down next to them and hold their hand. I think that physical touch is a way of connecting and showing you care.
The other day–I was doing a cognitive test with one of my participants and the instructions were to write a complete sentence. She wrote, “I like you a lot.” I was so touched, and I told her, “I like you a lot too!” She is someone I’ve worked with since I first started working at On Lok and I have been very involved in her care. With another participant I asked her if she remembered what my name was–I had given her a way to remember my name, yet she has very severe dementia, and when I asked her five or ten minutes later what my name was, she said, “I’ll just call you Beautiful.”
I find it very rewarding to build relationships with my participants and know that part of my treatment plan is to check in with them. I feel really blessed that I get paid to do this work, to connect and learn about people who have lived very interesting lives–very different, often, from the life that I have led. Families are sometimes very supportive and super on board and sometimes super checked out, and then I have to advocate to have them be more supportive, but the gratification I get is truly hard to describe.
One of the participants always shows me pictures of his grandkids and we talk about how cute they are. I know that some of these people whom I’ve really connected to, they’re not going to live forever, and it’ll probably be really sad when they leave, when it’s their time to die, but I’ll know that when they were here I was able to advocate for them and make sure that they got the very best services that we could.
[OnlineMSWPrograms.com] On the other hand, what are the most challenging aspects of your job? How do you recommend students who wish to enter geriatric social work prepare themselves to face these challenges and hardships?
[Laura Burns, MSW] You know to be honest, participant deaths have not been as difficult for me as I thought they would be. I had one patient die in the course of the four months that I’ve been there, and I attended his funeral because I felt that it was important to honor and respect the family. I found that debriefing with other staff who knew that participant was helpful. I work with a very supportive team of people. I think for me personally, the emotional impact of having children that were my patients die was a lot harder, and I think that might be one reason why I’m working in geriatric social work.
I want to continue to explore how to talk with people about end of life issues because I think I’ve seen that modeled really well by the palliative care team when I was at Packard. When a parent was having to make the excruciating choice to change their child’s code status to Do Not Resuscitate (DNR) if the child was actively dying, the doctors would say, “Your child’s organs are stopping. They are dying. We can use modern medicine to prolong their suffering or we can let their body naturally pass.” I think that it makes such a huge difference how your phrase this because they could also say, “We’ve done all that we can do medically to save your child and now it’s up to you to decide whether or not you want them to stay full code or DNR.” In this second case it puts all the autonomy and responsibility on the family who are not medical experts to make this decision. The physicians that I work with at On Lok also broach death in a very respectful way.
Death is a really hard topic to learn about academically. I have read some books on death, but really the only way to learn how it’s going to affect you is to have the patient die and see how you cope with it. I have found that having a strong support system helps me. When I have asked other social workers how they process participant deaths, they have said that supporting the participant’s family helps to give them some closure. It is important to continue to support family members while they are grieving even though their loved one is no longer a participant. When I was recently talking with a family member I told her, “You can continue to call me as much as you want, I’m still here for you.”
While many families are wonderful to work with, other families are very difficult to work with. Families often are at one end or the other of the spectrum, very, very involved and high maintenance and then there are other families that you call and call and cannot get them to call you back. It is important to have strong relationships and build trust with all families that you work with. It’s very rewarding when you are able to build trust with a family that is hard to reach or get them to agree to provide care that they have been resistant to provide.
For example, I recently worked with a family, when I was covering for my colleague who was out on a medical leave, in which the participant had been staying at a skilled nursing facility and was medically ready to discharge home. I called and left her family a voicemail on Friday to inform them that she would be discharging home early the following week. Then on Monday I called and left a message and didn’t get any response, and did the same on Tuesday, and so finally on Wednesday I called all of her family members, not just the one who took care of her. One of the family members answered and told me that she would have her sister call me back, which of course never happened.
On Thursday I consulted my supervisor, and she said, “This could technically be considered abandonment because they’re just leaving her at this skilled nursing facility. She’s ready to go home, we can’t just keep her there.”
So I called all the family members again and one of the family members finally called me back. I told him “You really need to talk with your family about what the plan is–because your mom’s ready to go home.” I then asked “When can you call me back tomorrow?” and he said “11.” I told him “I’ll expect to hear from someone in your family before 11:00 letting me know what the plan is, and if I don’t hear back from you, I will have to call the County to consult with them to see if this is considered abandonment. That’s not really the route I want to take but unfortunately, I might have to do that if I don’t hear back from you, and I really hope I don’t have to.”
I received two calls from his sister that night, and at 8:00 am the next morning she called and told me, “We can definitely take her home tomorrow.” And I said, “Well she really needs to go home today,” and they said, “Okay she can go home today.” This was rewarding because I had worked so hard to find a way for this participant to discharge home. I had to apply a little pressure to the situation, but I really had no other choice because the family didn’t give me anything to work with. I think that how you finesse the words and how you present it to the family can really impact how they receive your message.
Another potentially challenging aspect of social work is collaboration with other disciplines. I don’t think you ever work in a place where you work with all social workers. Social work is never the highest on the totem pole. If the doctor and social worker need to see the participant, the doctor is probably going to come first. It’s important to figure out how to work within the system and know when to advocate for your role, and for your clients since sometimes there are competing demands. If your participant is in the hospital and the hospital case manager tells you, “None of the places that we have contacted will take this person and you need to find a place,” and it’s actually their responsibility, how do you work with the case manager and make sure the patient has a place to go? You have to maintain relationships with people who have very different styles than you have or expect things from you that are a little bit outside of the scope of your job. Any job working with an interdisciplinary team can be really great if you’re working with people who are great partners and sometimes, when people have different styles than you, you have to figure out how you’re going to work with them. It’s important to have strong relationships with every single member on your own team and on the external teams at various hospitals and skilled nursing facilities or residential care facilities.
[OnlineMSWPrograms.com] For MSW students who are interested in becoming geriatric social workers, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Laura Burns, MSW] If you’re interested in working with the elderly, it’s good to have experience working with them to see if you like it because I think some people really find it fascinating and others, it’s just not their cup of tea. I waitressed at an assisted living facility one summer when I was in college and when I finished my undergrad degree, I was trained as a long-term care ombudsman. However, there are tons of ways to gain experience: reading books, watching movies, taking classes or training, and just talking with your own family. If you’re interested in geriatric social work, talk with your grandparents about their lives and their health problems. I think one thing that I’ve noticed in geriatric social work is because I have such long-term relationships with people, you’re able to share a little bit more of yourself. In hospitals you’re working with someone for a short amount of time, and you just need to focus on them, and they don’t get as much of an opportunity to also learn a little about you.
Field placement is a good way to get a variety of experience, but really if you know the type of work you want to do to, be really, really clear about that during your program. I knew that I wanted to work in healthcare, so I went and found internships in healthcare. I know some schools won’t let you do that, but thankfully my school did, and the healthcare experiences I had were really different in terms of medical charting and the medical terminology.
Since I do a lot of work with families, I’m glad that I took a class on family therapy. I also took the class on human sexuality, where we talked a little bit about sexuality for the elderly, and sexuality for people with disabilities. My favorite class in social work school was motivational interviewing, which is the technique of counseling where you use open-ended questions and don’t provide people with answers to their problems but rather have them come up with the solutions themselves. In motivational interviewing, the goal is to have the individual assert solutions themselves. For example, it’s more effective to ask someone, “What do you think you could do about losing weight?” rather than saying, “You really need to eat less,” because the person is going to say, “No I don’t, I love eating.” In Motivational Interviewing the social worker takes a supportive approach such as, “Ok, you’ve gained some weight. I’m sure there are a lot of good reasons for this.” In Motivational Interviewing the counselor mirrors the clients’ ideas back to them. This is a technique that I have used a lot in the hospital setting as well as my current job.
If people want to get paid while they get experience, they might want to try being a caretaker for someone who is elderly. For example, Care.com or other websites connect you to individuals who need that type of care. Providing care for someone in that way, while it tends to be more personal care with activities of daily living (ADL’s), like feeding and dressing, can help you to see if you like working with elderly individuals. I’ve actually done a little bit of that for a family friend after she was in a car accident. It’s just another way of getting experience working with the elderly, to be a caretaker. And to get familiar with all the aspects of elderly care that might initially intimidate you. For example, the family friend I cared for–she had a bladder bag and I helped her with her showers. At On Lok we talk about incontinence of bowel and incontinence of bladder and incontinence supplies–that’s all part of working with the elderly too. It can be really helpful to get exposure to these parts of elderly care. I’ve become a little desensitized to it, and now it’s totally normal for me talk about these topics with my participants and their families.
[OnlineMSWPrograms.com] Since you have had a wide range of social work experiences in medical settings, could you clarify what the difference is between inpatient and outpatient social work?
[Laura Burns, MSW] Inpatient work is in the hospital. As an inpatient social worker, you have more access to your patients and their families. Outpatient work is typically in a clinic. So when you or I go to the doctor for a routine medical appointment, that’s more of an outpatient setting. In outpatient settings I’ve seen people who need help applying for disability or recently lost their job. Outpatient social workers often follow up with a patient who was recently discharged from the hospital. Outpatient is more task-oriented, whereas inpatient it tends to be a more helping the patients and their families come to terms with the severity of an illness, injury or condition. For outpatient social work, a lot of the work tends to be kind of telephonic. For inpatient social work, patients are at the hospital, so you interact with them more directly, and often their families are at the bedside.
Thank you Ms. Burns for your time and insights into geriatric social work.