A Balance of Art and Science: Promoting Collaborative Aging Research

Abstract:

It takes a long time to integrate research evidence into healthcare practice and policy. Older adults with chronic conditions and social needs cannot wait. Interprofessional Collaborative (IPC) research teams encourage examining healthcare problems through multiple lenses. These teams also may build information and community networks that efficiently integrate new and innovative research into clinical practice and policy. In this article, we highlight two healthcare studies conducted by our IPC research teams exploring the health of older adults with chronic conditions. We also discuss the importance of including social workers as experts in social care on IPC clinical and research teams.

Key Words:

Interprofessional Collaborative (IPC) research teams, social work

It takes a long time to integrate research evidence into healthcare practice and policy (Barr et al., 2021; Nystrom et al., 2018; Rubin, 2023). A widely cited estimate is that it takes approximately 17 years to integrate research evidence into clinical practice and that only 1 in 5 evidence-based interventions ever become part of routine practice (Rubin, 2023). During this time, patients bear the burden due to delays in receiving beneficial, evidence-based healthcare services (Barr et al., 2021). Additionally, third-party reimbursement for these services lags due to the time it takes for policy implementation to catch up to the science. As such, patients assume avoidable high-cost premiums and out-of-pocket expenses that might otherwise be covered by insurance and third-party reimbursement (Glied & Zhu, 2020).

Older adults—especially patients with chronic conditions and social needs—are unable to wait for research and policy to catch up. Nearly all older adults have one chronic health condition and 80% have two or more (Administration for Community Living, 2022). These conditions, which affect daily living and negatively impact quality of life, health, and mortality (Mode et al., 2016) are compounded by social needs (McGilton et al., 2018).

Almost 50% of older adults have unmet social needs, which include basics like food and housing (Haff et al., 2022). Older adults, particularly those from marginalized Black communities, are at greater risk for poorer health than the general population (Fulmer et al., 2021). Additionally, in 2020, almost 5 million adults ages 65 and older lived below the poverty level, with another 2.6 million just above (Administration for Community Living, 2022).

Older adults with multiple chronic conditions also may be more likely to become socially isolated than their peers (Abdi et al., 2019; Christiansen et al., 2021), thus increasing their risk of premature mortality (Iovino et al., 2023). Two recent scoping reviews found that older adults living with chronic conditions experience several unmet social challenges, including a lack of care coordination and support (Abdi et al., 2019; McGilton et al., 2018). Older adults also experience challenges with social relationships, mental health, self-care, and mobility (Abdi et al., 2019).

The prevalence of chronic health conditions and unmet social needs experienced by older adults highlights the importance of efficiently translating research to practice and policy. It is imperative to consider the clinical and social care contexts when conducting evidence-based research. In healthcare research, interprofessional collaborative (IPC) teams are key to exploring complex phenomenon, such as how to best support older adults with multiple chronic conditions and social needs (Nystrom et al., 2018).

IPC teams involve researchers from two or more professions (e.g., medicine, nursing, social work, community partners, academia, and others) working together to produce new scientific knowledge (Green & Johnson, 2015). IPC research teams encourage examining healthcare problems through multiple lenses and may serve to build information and community networks. When professionals work collaboratively, they are well positioned to integrate new and innovative research into clinical practice and advocate for policy change.

While there is a dearth of research examining the impact of IPC research teams on the time it takes to influence practice and policy, there is evidence that IPC research teams positively affect health outcomes and enhance healthcare efficiency (Green & Johnson, 2015). In this article, we highlight two studies conducted by our IPC research teams that sought to improve the health of older adults with chronic conditions. We briefly describe each study and share the real or potential impacts of this research on healthcare practice and policy. We also discuss the importance of including clinical and research social workers on IPC teams. Despite being overlooked as valuable members of research teams (Bloeser & Bausman, 2019), social workers are well-prepared to enhance healthcare practice and influence policies that support older adults.

IPC Healthcare Research Studies on Aging

Below, we present two research studies conducted by our IPC research teams exploring the effect of the Ambulatory Integration of Medical and Social (AIMS) model on caring for older adults. The AIMS model of care management was developed by the Center for Health and Social Care Integration (CHaSCI), a training and policy center based at RUSH University Medical Center (RUSH). Initially created to integrate social workers onto interprofessional primary care teams, AIMS is a holistic care management model that addresses patients’ social needs and barriers to care. AIMS is delivered by master’s-prepared social workers in coordination with, and often embedded with, outpatient care teams.

Health Risk and Depression

Rizzo et al. (2022) conducted a 1-year longitudinal, comparison group study that examined differences in outcomes for older patients who received AIMS and those who received usual care. Usual care involved a nurse providing information on health risk and depression. A second goal was to examine the role of social workers in affecting these outcomes.

An important first step in conducting this research was getting buy-in from all stakeholders, such as hospital administrators and healthcare providers. This was achieved by working with physician champions who recognized the importance of social care in healthcare. The physician champions brokered conversations with administrators and other healthcare providers and educated them on the importance of advancing IPC clinical research. Equally important was identifying professionals for the IPC clinical research team. This was guided by study methods dictating that we identify which professionals were needed to execute the project. After a series of conversations with the AIMS social worker and physician champions, it became evident that the team needed to include a range of professionals and assistants to carry out the project.

The IPC research team included: 1) doctors responsible for identifying patients with social needs; 2) nurses who referred patients to the AIMS group or usual care group and documented steps in usual care; 3) social workers who delivered AIMS and documented the steps and activities completed in patient electronic health records; 4) research assistants who conducted follow-up interviews with patients to collect longitudinal outcome data; 5) hospital administrators who addressed internal barriers; and 6) academic researchers who developed the methodology, identified or created the measurement tools, oversaw data collection, analyzed and interpreted the data, and reviewed patient electronic health records.

With the IPC members in place, the project was undertaken. Factors that contributed to successfully carrying out the clinical research were communication among team members, trust and respect for one another’s roles, and shared understanding of how each professional’s role contributed to the goal of the research and patient outcomes. According to Green and Johnson (2015), these are essential ingredients for conducting IPC research.

The study included 340 patients ages 50 and older who had two or more chronic health conditions and received primary healthcare at one of six RUSH clinics. Although the findings revealed no significant effects between AIMS and usual care on the outcomes, AIMS patients (n = 170) showed significantly lower levels of health risk and depression at 6 months (Rizzo et al., 2022). These findings were used to advance wider integration of the AIMS training within the RUSH healthcare system [Rowe et al., 2016) and other healthcare environments (Rowe et al., 2021). Additionally, these findings reified CHaSCI's commitment to advocating for reimbursement for social care, including needs assessments and ongoing care provision.

As part of this study, Rowe, Rizzo, Kang, et al. (2019) also examined the effect of time as part of care management (i.e., AIMS and usual care) on participants’ depression levels. The social workers documented the amount of time they spent delivering AIMS to intervention group patients in the electronic health records. Documenting time spent providing usual care was not part of their clinical practice; however, the nurses completed a brief survey in which they estimated the time spent providing usual care to the comparison group. Time data extracted from the electronic health record for AIMS patients and from the survey for usual care patients were compared.

Findings revealed that social workers spent significantly more time with patients providing care management compared to nurses. The findings further suggest that the more time spent with patients was linked to lower levels of depression. These findings directly impacted practice at RUSH by altering the way AIMS social workers document their work in the electronic health record (Rowe, Rizzo, Guthrie, et al., 2019). This research also provided greater evidence regarding the value and importance of social workers as part of IPC healthcare and research teams (Fraser et al., 2018; Ross et al., 2024).

It is important to note that to our knowledge there is no research comparing social workers to other professionals in delivering care management (Rowe, Rizzo, Kang, et al., 2019). As such, we are unable to say whether these outcomes might be observed elsewhere. Regardless, the findings document positive outcomes for patients and enhanced procedures in the clinical environment.

Importance of Community Partnerships

Moro and colleagues are conducting a retrospective analysis examining the value of adding community health worker services to existing social work care management teams at a large, national primary and specialty care community group that serves older adults. In this community group, all of their social work care managers and community health workers were trained by the CHaSCI team. The social workers received training on the AIMS model.

This study uses the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework (Glasgow et al., 2019) to evaluate program outcomes, including cost and utilization, for in-patient, emergency department and primary care visits, patient health status, and model fidelity and adherence. Retrospective data were collected for all patients referred for care management services during a 3-month time period.

The research team consists of an academic healthcare researcher (Moro), a statistician, a healthcare economist, and a community partner. The healthcare researcher worked closely with the healthcare economist to design the study and determine how to best collect and analyze cost and utilization data. Both collaborated with the community partner to translate what data we were hoping to obtain and what information they were able to provide. The statistician is in the process of cleaning the cost and utilization data. Patient demographics and healthcare status are also being cleaned and analyzed.

Because the study is ongoing, its direct impact on practice and policy is unclear. According to the first systematized review exploring collaboration between social workers and community health workers, Noel et al. (2022) found that this collaboration may increase patients’ access to care and address health inequities; but more research is needed. The team at RUSH anticipates that this work will contribute to the scholarship exploring these essential professional partnerships in improving health and healthcare delivery for older adults. Given RUSH’s strong commitment to this partnership, the findings will be presented to both teams and serve as a springboard for future collaborative research.

Social Workers on IPC Healthcare and Research Teams

Including social workers on IPC practice and research teams is important because they help teams effectively address social needs (U.S. Department of Health Human Services, 2023) and move research into practice and policies that support older adults. In healthcare, social workers perform several roles including care coordination, transitional care, case management, behavioral interventions, and completing intake assessments (Milano et al., 2022; Petruzzi et al., 2023).

Research has documented the valuable contributions social workers make to IPC teams serving older adults. For example, in their scoping review exploring the value of social work on IPC healthcare teams, Ross et al. (2024) found 75% of the studies reviewed described social work–led interventions focused on the care of older adults and that health and cost outcomes were generally positive. Similarly, in their review of 42 studies examining the impact of social work interventions in aging on quality of life and cost, Rizzo and Rowe (2016) found that 71% reported significant quality-of-life outcomes. Significant cost savings also were documented in 71.4% of the 21 studies that included cost outcomes. Other studies also have found that including social workers on IPC teams improves patient care, behavioral health (Fraser et al., 2018), and other quality metrics (Lombardi et al., 2024).

A 2019 National Academies of Sciences, Engineering, and Medicine (NASEM) report titled Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health recognized social workers as experts in social care and essential members of healthcare teams. The report outlined five essential tasks necessary to address social care needs, including: 1) Awareness of activities that identify the social risks, needs, and assets of populations served; 2) Adjustment of clinical care to accommodate identified social barriers; 3) Assistance or engaging in activities to reduce social risk by connecting patients with social care resources; 4) Alignment of activities undertaken by healthcare systems to understand and utilize existing social care assets; and 5) Advocacy efforts in which healthcare organizations work with partner social care organizations to impact policy.

Social workers in healthcare are already engaged in all five of these activities. Specifically, they are aware of the needs and strengths of the communities they serve because they work closely with, and are integrated into, community spaces. Social workers meet patients, families, and communities where they are and provide invaluable insight into necessary clinical adjustments that enable the healthcare team to accommodate and address social barriers. In addition, social workers partner with patients and families to assist them in locating and obtaining essential resources by addressing both internal and external healthcare system barriers. As bridge builders, social workers help align teams across sectors to attend to the needs of patients and families, community-based organizations, and the healthcare team.

For example, Craig et al. (2020) found that social workers described their roles as empowering collaboration by actively communicating and proactively educating both other members of the healthcare team and patients. Finally, social workers are advocates who work with healthcare and research teams as well as community social care organizations to develop effective and culturally aware interventions.

Despite the importance of their roles and important contributions in healthcare and research, social workers often are overlooked as members of IPC teams (Bloeser & Bausman, 2019). This is due in large part to the lack of a standardized definition of what social workers do, limited research on their unique contributions, and research that includes social workers but fails to describe how they are involved. Additionally, the limited research on the value of social work often lacks scientific rigor (Rizzo & Rowe, 2016; Rowe, Rizzo, Kang, et al., 2019; Ross et al., 2024). Finally, a lack of standardized payments from Medicare, Medicaid, and private insurance may inhibit the inclusion of social workers on IPC teams due to limited billing options for the services social workers provide (NASEM, 2019; National Association of Social Workers, 2023).

Conclusion

Evidence-based clinical research is critical to the health of older adults. However, the challenge of moving the evidence to practice and influencing policy in a timely manner persists (Barr et al., 2021; Nystrom et al., 2018; Rubin, 2023). This situation, coupled with the reality that nearly all older adults have a chronic condition (Administration for Community Living, 2022) and almost half have unmet social needs (Haff et al., 2022), points to the importance of IPC research teams that examine aging through multiple lenses. Social workers are an important profession central to addressing social care needs for patients and communities, yet they have been historically underrepresented on IPC research teams (Bloeser & Bausman, 2019).

While we argue that IPC teams are important in conducting high-quality health research with older adults, more research is needed. In the era of cost containment, it is essential to understand the role and contribution of each discipline on IPC teams. Identifying the unique contributions of each discipline will ensure the right combination of skills to maximize older adults’ health outcomes, appropriate use of services, and cost containment by eliminating unnecessary, costly care. Understanding the roles and contributions of each discipline also may lead to faster adoption of evidence-based practices into healthcare and community-based settings as well as Medicare and Medicaid billing policies and practices that encourage the adoption of evidence-based IPC team research and practice.

Acknowledgement: We’d like to acknowledge Yanjun Dong for helping with this article.

Teresa Moro, PhD, AM, LSW, is an assistant professor in the Department of Social Work in the College of Health Sciences and a health services researcher with the Center for Health and Social Care Integration at RUSH University Medical Center in Chicago. She may be contacted at Teresa_Moro@rush.edu. Jeannine M. Rowe, PhD, MSW, is a professor of social work and gerontology at the University of Wisconsin–Whitewater. She may be contacted at rowej@uww.edu. Victoria M. Rizzo, PhD, LCSW-R, is a professor and interim dean at the School of Social Welfare, University at Albany, SUNY. She may be contacted at vmrizzo@albany.edu.

Photo credit: PeopleImages.com - Yuri A

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