Assessing Older Community Members Using a Social Work Tool: Developing an Organizational Response.

Social Worker's undertake psycho-social assessments and facilitate access to evidence-informed psychological and practical supports to optimize the physical, psychological, and social wellbeing of the community members in their care. Social workers employed at an aged and community care organization undertook a review of the gray and peer reviewed literature and did not identify any existing evidence-based tools. However, 10 key domains were identified from the search. Gaps in the domains were discovered, together with the need for guidance and prompts for less experienced staff and students. Five Social Workers, using co-design principles, reviewed the domains, and added further domains from their social work practice. An evidence-based assessment tool was developed which incorporated 11 domains. The tool can be used to assess the needs of people living in the community who are older and/or have compromised health and wellbeing. Further work is required to pilot test the tool.

No evidence-based psycho-social assessment tools exist to guide social workers working in aged and community care;

An 11-domain Social Work assessment tool has been compiled, together with guidance questions, specifically for use in the aged and community care context, by practitioners with variable levels of experience;

Inclusion of Social Workers who would utilize the tool ensured the translation of evidence into a fit-for-purpose assessment tool.

This tool was developed with social workers, for social workers, and includes the domains most relevant to maintaining independence and optimizing holistic wellbeing for people living in the community who are older and/or have compromised health and wellbeing.

Further work is required to field test the tool, to ensure that it captures meaningful data for the development of effective management plans and interventions in partnership with the person seeking support and their family or carers.

This tool has the potential to be used by nurses and other healthcare providers who wish to conduct holistic psycho-social assessments.

Introduction and Background

Social workers play a central role in the assessment of people who are older and/or have compromised health and wellbeing, both in the community and in hospital settings. Social workers are “context specialists” and seek to understand the needs of these people by considering the micro, macro, and meso factors that impact on a person’s life (Austin et al., 2016). Social Work is informed by a holistic understanding of the “person in environment.” Practitioners assess situations to identify the most appropriate interventions in partnership with service users. Aligned with this perspective, assessment in Social Work is underpinned by the bio-psycho-social approach (Whittington, 2007).

Australia, like other countries worldwide, has an ageing population and a significant population with compromised health and wellbeing. Australia’s aged care system provides services that range from basic supports to enable people to remain independent at home, through to living in a residential aged care home with access to full-time care (Australian Institute of Health and Welfare [AIHW], 2021a). Most people want to remain living at home, and most aged care is provided to people in their homes to support them to do this (AIHW, 2021a). As people grow older, multimorbidity and psychosocial issues may increase, leading to more complex care needs (McGilton et al., 2018; Thiyagarajan et al., 2019; World Health Organization [WHO], 2015b). It is not only older people with compromised health; more than 50% of Australians reported at least one chronic condition in 2014 to 2015 (AIHW, 2021b). While chronic conditions impact all Australians, those people living in a situation where physical environment, social and cultural determinants, and biomedical and behavioral risk factors interact to increase their likelihood of poorer health outcomes (Brotherhood of St Laurence & MIAESR (Melbourne Institute of Applied Economic and Social Research), 2019). Therefore comprehensive assessments to identify issues and develop plans to address them would be required, and assessment tools would support this complex activity (Taylor, 2012).

The Australian Association of Social Workers (AASW, 2015) has published Scope of Social Work Practice: Aged Care. This document recognizes this area of practice is vast, but the work of social workers includes “assisting older people, and in some cases their families, to make significant life decisions based on the best aged care related information and resources available (p4).”

There are currently no evidence-based assessment tools available to social workers to work with older people incorporating needs of those with compromised health and wellbeing in the community. Social workers currently undertaking assessment and management of people living in the community who are older and/or have compromised health and well-being in an aged and community care organization, identified the lack of evidence-based tools available to them. This project sought to address this gap.

Methods

The available literature, practice guidelines, and resources used by social workers in the practice setting were interrogated. A purposive sample of social workers, working in aged and community care, were asked to review and refine the collated information to assist in the development of the proposed tool using a co-design approach. Co-design is a way for individuals with expertise to work together collaboratively. It involves the inclusion of both explicit (e.g., sourced from literature) and tacit (e.g., insights and experiences) forms of knowledge (e.g., as identified through literature or clinical guidelines), where they are complementary in the synthesis into new knowledge (Bennett, 2011; Rynes et al., 2001). Outputs from a co-design process are likely to be fit-for-purpose, acceptable, valuable, and enduring (Greenhalgh et al., 2016). Our approach draws on the Double Diamond design framework, with four phases of: (1) Discover; (2) Define; (3) Develop; and (4) Deliver (adapted in Figure 1 below), with this paper outlining the first three phases.

Figure 1.

Adapted co-design framework (reprinted Figure 1. Adapted co-design framework from Meyer et al. (2022).

Phase 1: Discover

This phase gathered (i) information and insights from the literature and (ii) incorporated experience-based design (Donetto et al., 2014) to understand the experience of social work assessment from the perspective of staff undertaking assessments in the field.

A review of the literature

A comprehensive search of the literature was conducted to, firstly, identify any pre-existing social work assessment tools applicable to the community aged care sector. Electronic databases (SocINDEX, CINAHL, Psych-Info, Health, and Society) with key words (and derivatives) of social work assessment, aged, and community were used. Papers published in the English language, between 2008 and 2018 were retrieved. Hand searching of reference lists of the relevant articles was conducted, along with a review of gray literature. Titles and abstracts of studies were screened for inclusion by two reviewers (author CM and a Master of Social Work student), with discrepancies resolved through discussion.

Secondly, the same literature search was used to identify relevant domains for social work practice.

Engagement with community-based social workers and exploration of their experiences

Within the Australian aged care system, older community members wishing to receive services are directed through the My Aged Care portal for a comprehensive generalized assessment (Commonwealth of Australia, 2021). Following this assessment, referrals to appropriate services, including social work, are made. This generalized assessment is critical for optimal care but does not include social work specific items necessary for best practice when working with older people in the community.

In response to a lack of consistency in social work assessment across an aged care provider, and limited best practice guidance for less experienced aged care social workers, a working group of eight people was convened to address this issue. As the activities of this project were less than low risk, it was deemed a quality improvement activity and did not require Human Research Ethics Committee review. The working group comprised social workers (n = 2), an operational manager (n = 1), researchers (n = 2), and Masters of Social Work students (n = 2). This group was tasked with identifying current social work assessment practices across an aged care service organization in Melbourne, Australia. In addition, all members were asked to identify other community-based social work assessment tools through their professional networks.

Once this work was completed, the working group engaged with all the social workers working in the organization (n = 5) to seek further information and clarification of current social work practices in a focus group. This focus group explored: (a) positive and negatives aspects of the tools and resources available; (b) challenges for students and less experienced social workers when using the tools and resources; and (c) potential opportunities for improvement.

Phase 2: Define

This phase synthesized the outcomes of the literature review, both for overall social work assessment tools and the optimal domains within a tool. Domains identified in the previous work were discussed with the working group and in a second focus group with the Social Workers. The following questions were posed:

Do these domains comprehensively address social work concerns in the community?

Are there any domains currently not included?

What detail is needed to guide correct assessment of the domains?

Phase 3: Develop

Next, members of the working group used information from the literature review and focus groups to guide specific questions for each domain. Research team members were responsible for searching for any validated screening tools to support the assessment of these domains (e.g., the Rowland Universal Dementia Assessment Scale (RUDAS) is a cognitive screening instrument validated in populations where cultural learning and language diversity occurs (Storey et al., 2004). A third focus group with the social workers reviewed the information collected and provided feedback and analysis to form a final version.

Results

An initial search strategy retrieved 420 articles which fitted the inclusion criteria. After eliminating duplicates and screening titles for relevance, 419 abstracts remained for review. Of these, six met the eligibility criteria for inclusion, see Table 1 below. A review of documents within the gray literature related to aged care assessment identified three more resources: The NATFRAME (National Framework for Documenting Care in Residential Aged Care Services; Department of Health and Ageing, 2005); The Assessment for the Aged Care Assessment Program (ACAP), developed by the University of Wollongong (Sansoni et al., 2010, 2012); and The NSAF (National Screening and Assessment Form; Australian Government, 2018). The NATFRAME included assessment tools for four domains: social, cultural and spiritual, physical and functional, and cognitive and mental domains; The assessment for ACAP also included four domains, but these were slightly different: physical, cognitive, behavioral, and psychological and social domains; while the NSAF included five domains, which were: Social, Physical, Medical, Psychological, and complexity/vulnerability domains.

Table 1.

Assessment Tools in the Community Aged Care Sector Applicable to Social Work Identified in the Peer Reviewed Literature.

Tool	Description	Assessment domains	Reported validity	Reported reliability
EASY-care (Craig et al., 2015)	Generalized assessment tool for assessing community-dwelling older people – can be self-completed but preference is for nurses to complete the tool.	Physical, mental, and social functioning, and unmet health and social needs.	Face, content, criterion, and cross-cultural validation. More studies required for concurrent and convergent validity.	Limited (test-retest yielded generally positive kappa values ranging from −.06 to .82)—more studies needed.
MED-SAIL (Mills et al., 2014)	A screening tool to assess safety of independent living for health and social service providers for referral for definitive capacity evaluation	Understanding, expressing a choice, problem solving/consequential reasoning, comparative reasoning, and generate consequences.	Preliminary criterion and concurrent validity.	Preliminary reliability testing (five items α = .85)
Northern Ireland Single Assessment Tool, NISAT (Taylor, 2012; Warburton et al., 2015)	Integrated care assessment tool including multi-professionals	Core components for all to complete: physical health, mental health, and emotional wellbeing, awareness, and decision making.Other domains to be completed as required:Medicines management, communication, and sensory functioning; walking and movement; personal care and daily tasks; living arrangements and accommodation; relationships; work, finance, and leisure.	Used vignettes to develop validity.	Used trained actors playing out vignettes, interviewed by pairs of professionals for testing reliability.
Integrated care aggregate assessment tool (Warburton et al., 2015)	Integrated care assessment tools used by three assessment services in rural Australia were aggregated – different care providers completed the tools.	Assessment details, demographics, client rights and consent, genogram, psychosocial profile, medical and psychiatric history, psychiatric risk assessment, cognitive-behavioral issues, drug and alcohol assessment, biological functioning, environmental hazards, referrals out, and care planning.	Not undertaken	Not undertaken
Spiritual assessment tools (Harrington, 2016)	Multiple tools to assess spirituality	Recommendations to use an array of tools to include:Spiritual assessment, spiritual needs, and spiritual history.	Not undertaken	Not undertaken
Minimum Data Set Resident Assessment Instrument, MDS-RAI (Lambert et al., 2009)	Comprehensive assessment of the health and care needs of older people living in long-term care settings	Cognitive functioning, communication, depression, Activities of Daily Living, continence, health conditions, and mediation.	Inconclusive (Hutchinson et al., 2010)	Inconclusive (Hutchinson et al., 2010)

Engagement with community-based social workers and exploration of their experiences: Existing assessment tool feedback

Social work staff articulated that the existing holistic assessment tool used by the aged care service included comprehensive and useful clinical information that impacted the lives of the community dwelling members they were assessing. However, the existing tool was not meeting the needs of the social workers, with staff using “cheat sheets” to enable them to collect the information that would inform their care. An example of the content of an existing cheat sheet is shown in Box 1. The social workers raised two key areas needing improvement:

Box 1.

Social Worker “Cheat” Sheet in use.

First questions asked by the social worker:

• What is the main health/social/family issues? (reason for referral)

• What do you require assistance with?

• What’s important to you/what do you want to achieve/improve/goals?

Followed by supplemental questions to suit the community member circumstances:

1. Self-management—How are you coping? What’s important to you? What current strategies in use?

2. Are there other programs involved? What other services/programs are currently involved? National Disability Insurance Scheme/Other funded package?

3. Medical Conditions, insight and personal impact, regular GP intervention, and vision/hearing.

4. What can you do? What can’t you do? What would you like to be able to do?

5. Medication management.

6. Drug and alcohol—How much, how often, and impact on daily living?

7. Pain, sleep, and condition management.

8. Do you have people who help you? Family, friends, and neighbors.

9. Employment—Current or previous.

10. Housing status and impact this might have.

11. Financial—Afford essential items, medicine, and rent/mortgage.

12. Transport and access to appointments and other places in community—½ price taxi.

13. Functional—Difficulty with, for example, personal care, housework, laundry, meals, shopping.

14. Aids and equipment around the house.

15. Enduring Power Of Attorney (EPOIs)/Advance Care Planning—Does someone assist with paying bills and/or making decisions regarding health, lifestyle, and living arrangements? Who would you consider appointing? What are your considerations?

16. Mobility—Difficulty walking indoors/outdoors, use of aids, assistance with transport, falls.

17. Continence—Urinary/fecal, aids, funding?

18. Nutrition and swallow, weight gain/loss, swallowing, and chewing food/liquid.

19. Cognition—Rate your memory? Difficulty expressing oneself/finding the right word or difficulty understanding what other people are trying to say, following instructions.

20. Mood—Feeling down, depressed, or hopeless. Feeling nervous, anxious, or agitated? Any past trauma in life?

1. The need to take a biopsychosocial approach

The existing form heavily emphasized clinical information, whereas it is the social impact on health outcomes and status that is central to social work practice. Exploring with the older person what is most important for them is central to a holistic assessment. This approach enables a better understanding and prioritization of what is most important to the. community member, leading to the most effective support provision. There appears to be a disconnect between the clinical care of nurses and the psycho-social approach of social workers, with the value of a holistic, biopsychosocial approach underestimated.

2. Need for guidance of less experienced staff

Sensitivity to the emotional and mental health needs of the person seeking support is complex. Beginning practitioners and students new to this field of practice will require education and guidance to effectively undertake this work. Prompts and guides would enable students and less experienced social workers to sensitively draw out information from community members. This would enable them to develop their skills, and better identify the needs of older community members.

Literature review and synthesis

The articles identified in the literature search provided some information on assessment tools that could be used by social workers. These included generalized assessment tools (Craig et al., 2015), a screening tool to assess safety of independent living (Mills et al., 2014), integrated care assessment tools (Taylor, 2012; Warburton et al., 2015), a spiritual assessment tool (Harrington, 2016), and comprehensive assessments of older people with complex needs (Australian Government, 2018; Lambert et al., 2009; Sansoni et al., 2012), shown in Table 1. There was limited access to the tools referred to in the publications, and included questions or domains were generally not provided. No validated social work assessment tool was identified that could be used when working with people living in the community.

The synthesis of the research and tools in the literature review identified the following 10 key domains for inclusion in a comprehensive Social Work assessment tool for older people: (1) Identifying the reason for the contact; (2) Physical health; (3) Cognition/Decision making; (4) Mental health/emotional wellbeing; (5) Functional profile; (6) Mobility; (7) Religion (culture)/Spirituality; (8) Finances/Work/Living Arrangements; (9) Relationships/Sexuality; and (10) Friendships/Social Connections/Supports. These are described in Supplemental Appendix 1.

Focus groups with social workers

The 10 domains identified in the literature review synthesis were discussed with the working group. This group also reviewed existing social work/complex care assessment forms used by local services (n = 4). The group identified that a reworking and addition of four domains would better address psychosocial concerns (1. Functional profile; 2. Communication and sensory function; 3. Physical Health; 4. Pain; 5. Sleep; 6. Nutrition; 7. Continence; 8. Mobility; 9. Mental Health; 10. Social; 11. Cognition; 12. Living Arrangements and Finances; 13. Carer profile; and 14. Hoarding and Squalor), and a draft form was developed with 14 domains. Further, to guide correct assessment the draft also included the addition of guiding questions for social workers.

Researchers presented the assessment form to five social workers, with an average 20 years working as social workers and have worked at an average of 10 years in the current organization. The feedback was used to adapt the form, and a second version was sent for feedback. The final version included the 11 domains shown in Table 2, and the full tool is shown in Supplemental Appendix 2.

Table 2.

Social Work Assessment Tool Final Domains for Inclusion, With Sub Domains.

Domain	Sub domains
Physical health	Age, diagnosis of medical conditions, number of medications, hospitalizations in last 6 months
Pain	Presence of pain, location, rating
Cognition	Diagnosis of cognitive impairment, change in memory, difficulty remembering
Mental health	Diagnosis of mental health condition, Screening for depression and anxiety, history of major life traumas
Social isolation	Screening for social isolation, how often going outside home, community, and family connections
Continence	Bladder or bowel accidents, how individual experiences and manages problems
Nutrition	Screening—weight loss, change in diet, alcohol intake, swallow, dental care, access to adequate nutrition
Functional	Capacity to clean the house, prepare a meal, transport to places, help to shower, dress, or go to toilet
Mobility	Number of falls and observing steadiness of gait
Sleep	Ability to fall asleep, and falling back asleep when woken up, and if anything taken to help fall asleep, sleep patterns including daytime naps
Hoarding and Squalor	Ask about clutter and its impact on daily living activities and mental health, assess home environment using Hoarding and Squalor Clutter Scale, and Environmental Cleanliness Scale where appropriate

The recommendations for guidance involved two components: (1) Supervision: It was considered highly beneficial for new staff and those less experienced to have supervision by a more experienced social worker to discuss clients and how they can engage with their client, evaluate, or continue to progress through the assessment depending on time and capacity of the client; (2) Prompts within the tool: The tool can also be used as a prompt for conversations and engagement. Not every aspect of the tool needs to be filled in and it should be used with flexibility depending on client’s circumstances and needs.

Discussion

Instigated by social workers and using both evidence and practice-based experience of practitioners working in aged and community care with older people and those living with compromised health and wellbeing, a social work assessment tool was developed. The proposed tool includes 11 domains which social workers can use in practice to identify comprehensively and sensitively what is important to older community members, as a basis for developing an intervention plan to address their wellbeing needs. The additional guidance recommendations include supporting less experienced social workers and students through supervision to enable them to undertake these assessments comprehensively and effectively, developing key skills to support care plan development. Further, the tool includes questions that can be used as prompts for guidance. This work provides the foundation for further validation of the tool and its implementation in clinical practice with a larger sample of social workers from other age and community care organizations to confirm face and content validity and perform construct and criterion validity and reliability testing.

Research regarding specific social work assessment tools to be used with community dwelling older people is limited. Peer reviewed literature describes a range of holistic tools, including a general geriatric assessment (Craig et al., 2015), integrated care (Taylor, 2012; Warburton et al., 2015), and comprehensive assessments of older people with complex needs (Australian Government, 2018; Lambert et al., 2009; Sansoni et al., 2012). However, a discipline specific tool to guide social work assessment when working with older people in the community is currently not published, and access to the tools described in existing publications is limited. To ensure accessibility of the work done in this paper, we have included the full version of the tool in Supplemental Appendix 2.

To support optimal wellbeing among older people, a comprehensive community-based assessment is crucial, incorporating assessment of an individual’s needs, development and implementation of a care plan, provision of monitoring and referrals as needed, and supporting informal caregivers (Thiyagarajan et al., 2019). There are substantial limitations in the existing Australian health and aged care system regarding the provision of comprehensive assessments, and coordination and delivery of services, that is, person-centered, integrated care (Royal Commission into Aged Care Quality and Safety, 2021; WHO, 2015a). Across the globe, governments increasingly recognize that prevention and early intervention are key (WHO, 2020). This is in line with Australian Government reform (Department of Health, 2021; Primary Health Reform Steering Group, 2021); striving for a system that focuses on timely assessment rather than crisis management (Primary Health Reform Steering Group, 2021). There is momentum to consolidate and integrate existing primary care services, where the majority of Australian healthcare is provided, with a “supporting maintenance of wellbeing” approach rather than a “responding to illness” focus (Primary Health Reform Steering Group, 2021). Social workers are well placed to co-ordinate the holistic care needs of individuals, including planning for current and future need (McGilton et al., 2018). The existing reactive approach will require change (Primary Health Reform Steering Group, 2021) at the individual, healthcare provider, and system level (WHO, 2020). A structured assessment tool, with its focus on holistic care needs that also pre-empts wellbeing concerns, is a step toward this goal.

A co-design approach underpinned this work, driven by the need and desire of social workers within an aged care organization to improve their practice. Engaging the users of the tool in the development ensured that it included relevant components and was fit for purpose (Greenhalgh et al., 2016). Further co-design work with older people and a broader network of social workers is needed to ensure it adequately meets the needs of all stakeholders. A further strength of this work is that the tool is geared to assessments being done in the homes of older people where, in the main, older people seek to remain as they age (Commissioner for Senior Victorians, 2020). Remaining at home may require health and aged care support, with this assessment tool providing the necessary person-centered review of their home and social context.

A limitation of this tool is the lack of a mechanism of integrating social work assessment with other multi-disciplinary assessments for comprehensive care delivery to service users. Social Workers have a focus on psychosocial needs to promote wellbeing, and on justice in society (AASW, 2015). Given the significant impact of social determinants of health on the wellbeing of community members service users will often require assessments with a number of health and community workers (WHO, 2020). The need to integrate social work assessments with other assessments is an area that requires further investigation (Kangasniemi et al., 2021).

Conclusion

Social workers are key members of multi-disciplinary teams that work with older people in the community. This paper describes how an assessment tool was codesigned with and for social workers working in the field of aged care. This assessment tool aims to enable holistic assessment of older community members through incorporating 11 domains identified and includes questions to guide novice or student social workers; identified as important by social workers engaged in providing care for older community members. The assessment tool supports social workers to be more proactive in building partnerships with older people to focus on early identification of issues, proactive planning, and engaging people to make informed and educated choices to shape later life and mitigate against the risks that can occur and have been identified in the literature. The next step would be to pilot test the tool in practice with service users to further validate the tool, its implementation, and assess its efficacy in clinical practice with a larger sample of social workers from other age and community care organizations.

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Supplemental material, sj-docx-1-ggm-10.1177_23337214221119322 for Assessing Older Community Members Using a Social Work Tool: Developing an Organizational Response by Rajna Ogrin, Claudia Meyer, Aliki Karantzoulis, Isabel Jane Santana and Ralph Hampson in Gerontology and Geriatric Medicine

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Supplemental material, sj-docx-2-ggm-10.1177_23337214221119322 for Assessing Older Community Members Using a Social Work Tool: Developing an Organizational Response by Rajna Ogrin, Claudia Meyer, Aliki Karantzoulis, Isabel Jane Santana and Ralph Hampson in Gerontology and Geriatric Medicine