In-Home Care Allows Seniors to ‘Age in Place’ with Social Work Intervention: A case example

I am a very bright and resourceful woman. I am 80 years old and I live at home where I manage my COPD with the help of a visiting nurse. My independence means everything to me. I have arranged a comprehensive in-home care program to meet my needs because I want to age in place. I have a homemaker who comes twice a week, meals delivered weekly, a housing case manager, and numerous neighbors and volunteers in my community who visit with me a few times a month. Right now I am in the hospital being treated for an acute breathing problem. The hospital social worker just told me that my physician wants me to move to a nursing home. The social worker shared this information with my housing case manager before speaking with me, prompting my case manager to threaten me with eviction if I do not go to a nursing home. I am beside myself with anger, disbelief, and fear. I call one of my volunteers and tell her that I don’t have a reason to live anymore, that I simply can’t go on living if it means moving to a nursing home. Fortunately, my volunteer is a social worker too, and she jumps to action by advocating on my behalf with the discharge planning team. Together, we develop a successful discharge plan enabling me to go home. Without her and my in-home care services, I don’t know where I would be right now.

In-Home Care Valuable Resource for Seniors ‘Aging in Place

Despite the barriers facing seniors who want to age in place, many seniors prefer not to give up the independence and privacy of their own homes. According to AARP, 82% of people want to remain in the comfort and familiarity of their own homes as opposed to an institutional setting. For seniors dealing with chronic health conditions who want to age in place, in-home care serves as a valuable resource.

Types of Home Care Services for Seniors

Home care services provide seniors help with household chores, health care, relief for caregivers, and linkage to community resources. Two different types of agencies can provide in-home care: home care agencies and home health agencies. Home care agencies typically assist seniors in meeting their day-to-day needs such as grocery shopping, laundry, and cleaning. Home health agencies provide a wide range of services such as nursing care, home health aides, physical therapy, or medical social work services. Most importantly, in-home care provides personalized support to seniors in the least restrictive environment, while allowing seniors to maintain their dignity and independence in a setting of their choice.

Social Workers Help Seniors Transition from Hospital to In-Home Care

In-home care enables seniors with chronic health conditions to transition back home after hospital discharge, in hopes of preventing readmission and nursing home placement. Social workers play an integral role in helping seniors develop an in-home care program during the discharge planning process. Robyn Golden, LCSW, director of the older adult programs at Rush University Medical Center, explains how effective social work intervention can determine the success of the discharge plan:
Social workers possess extensive knowledge of community resources, expertise in navigating complex social systems, experience using a framework of practice that focuses on the person in the environment, and training in case management and care coordination. Social workers are also able to use psychosocial assessment skills to explore family dynamics or resources that may affect the success of the discharge plan.

Utilizing Person-In-Environment Framework to Develop a Successful Discharge Plan

Within the person-in-environment framework, social workers can coordinate a discharge plan that takes into consideration the unique relationship between a senior and their environment. In creating a successful discharge plan, it is imperative that hospital social workers include seniors as part of the discharge planning team from the onset of the discharge planning process. When social workers fail to include the senior on the discharge planning team, they may feel helpless, isolated, and stripped of their dignity and independence as illustrated in the case example above. Completing an accurate psychosocial assessment is also fundamental to the discharge planning process. Utilizing the person-in-environment framework, a social worker can assess how a senior interacts with their environment to determine if adequate supports are in place to ensure safety at home upon discharge. Once an assessment has been completed, the social worker can coordinate an in-home care plan by linking the senior to the appropriate services and community-based resources. Furthermore, this case example calls aging professionals and social workers alike to use their expertise in navigating complex social systems to ensure seniors can return home with adequate support while maintaining their independence and quality of life. Photo courtesy of tweng on


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