Needs assessment in social work with older people in times of Covid-19: Initial ideas from an empirical study

Elin Nilsson

CESAR — Centre for Social Work

Uppsala University

Anna Olaison

CESAR — Centre for Social Work

Uppsala University

CORRESPONDENCE TO:

Elin Nilsson

e-mail: elin.nilsson@soc.uu.se

Abstract

In Sweden, Covid-19 has affected elder care and the services provided for older people to a great extent. In the needs assessment process care managers, in their role as street level bureaucrats are facing an indefinite closure or limitation of services to offer older people. Also, as older people are encouraged to isolate themselves, care managers are now performing assessment meetings by phone rather than face-to-face. Drawing on an initial analysis of audio-recorded telephone meetings between care managers and older couples, we present two different approaches of assessing services for older couples in this current time. The approaches are referred to as «business on hold» and «exploring new options». In the first approach, the meetings unfold as if all regular services were still possible to offer the older people, only to be utilized once Covid-19 has passed. In the second approach, care managers use professionalism in relation to the discretion embedded in their role as social workers to find solutions outside the regular system. The findings suggest supporting innovative approaches in remote assessments allowing care managers to use their relational competence more in conversations, as well as initiating technical education for managing the challenges embedded in this new digital landscape.

Keywords

Covid-19, Needs assessment meetings, Discretion, Inclusion, Older couples, Self-determination.

Introduction

In Sweden, a key part of the social work with older people is the «needs assessment process». In this process, care managers (the official title of social workers working in this field in Sweden) are expected to assess the needs of older people applying for social services. The debate within needs assessment practice in social work describe care managers as street level bureaucrats (Lipsky, 2010) as they have to balance the sometimes-opposing requirements of increasing demands on social services as well as being gate keepers of resources. These demands can be organizational, legal, or financial in relation to values and ethical aspects of social work, but also expressed by the older person’s relatives and/or spousal partner. The assessment of needs in Sweden is often carried out in the home of the older person applying for welfare services and it is to be influenced by the individual’s own description and wishes (Swedish National Board of Health and Welfare, 2015). In Sweden as well as in other countries in Europe there is also a changing policy environment that advocates a strengthened formal right for older people to participate in decision-making (Ray et al., 2015, Österholm, 2016; Donnelly, Begley, & O’Brien., 2019). This is generating higher demands on care managers to create an inclusive environment in the needs assessment process in order to be able to capture all relevant aspects in the assessment of the needs of older people.

Older people in Sweden have suffered tremendously by the rampage of Covid-19. In Sweden, as in many other countries, the virus found its way into welfare settings such as care homes and residential settings to a great extent, and many people were affected. The political attention and media coverage of the situation for social workers in Sweden working with older people during this pandemic time is scarce (Svensson & Bergman, 2020). Due to the Covid-19 pandemic Swedish care managers have been obliged to cancel most or all home visits to older people who apply for welfare services, and instead must make decisions based on telephone conversations with the client and relatives and/or spousal partner. This may cause challenges for the care managers in terms of making well-founded decisions based on criteria of inclusion and self-determination for the older people. Also, the current situation of a support system being on hold or limited may affect the support available, which leaves the care managers to navigate in new and changing fields. Care managers are facing the challenge of addressing the new situation with limited possibilities for professional discretion and resources to offer the older clients. This highlights the complex and multilayered factors that are imbedded in their role as street level bureaucrats even more than previously as none or little services can be offered to the clients, and sometimes the care manager may even be unaware of the status of the services. Yet the older person’s needs are still there, with potential additional ones related to the pandemic. For care managers, this is an unknown territory which has to be explored by each and every one in their interaction with clients. This requires particular attention to professionalism as it is an important factor for how discretion can be used (Ellis, 2011) in their role as care managers. Therefore, how discretion is interpreted and applied in this remote needs assessment process by care managers in a situation like this varies between individuals but also in regard to the directives given from municipalities and managers.

In a research project that started at the same time as the Covid-19 pandemic outbreak we have audio-recorded telephone calls between care managers and older couples living at home applying for social services from two municipalities in Sweden. The aim of the project was to investigate the approaches care managers adopt in order to conduct digital needs assessment meetings with older couples, and how aspects of inclusion for both parties are dealt with in the phone calls. In the following, we will present an initial analysis of this work, and discuss its potential consequences for this remote assessment process during this time of crisis. The examples are follow-up meetings with couples regarding previously approved services. In some of the conversations, both spouses in the couple were participating at the same time via speakerphone, but in the majority, they spoke to the care manager separately after one another.

The focus of the analysis was to investigate the challenges and approaches when communicating and making decisions in a crucial time of Covid-19, where none or little physical interaction was possible, and most formal services were limited or completely put on hold. The data for the project consists of 20 audio-recorded telephone conversation with couples. In this initial analysis, 10 conversations were subject for analysis. Approximately half of the included couples were applying for social services due to dementia. In the couples in the two examples below, the husbands have support due to needs for care. Although the husbands are the clients, the wives receive hours of relief (avlösningstimmar in Swedish) from their informal caring duties, during which staff from elder care services attend to the husbands. This situation in which only one of the spouses is the client is an issue that the care managers must balance in the assessment conversations. In accordance with the Swedish legislation, the Social Services Act (SFS 2001:453), care managers are namely obliged to take into account the needs of relatives although they are not in a formal sense clients.

In this paper, we illustrate two different approaches of assessing services for older couples in this current time, found in our ongoing analysis. These are referred to as «business on hold» and «exploring new options». In the first approach, the meetings unfold in a similar manner as if all regular services were still possible to offer the older people, only to be utilized once Covid-19 has blown over. In the second approach, care managers use the discretion embedded in their role as street level bureaucrats to find solutions outside the regular systems and manuals. The two different approaches are in the following described in relation to two examples employed by different care managers.

Business on hold

This example is drawn from the very beginning of a telephone meeting with an older couple. The extract starts when the care manager has summarized the services they have, which the husband already has been granted from social services. Worth mentioning is that in this particular part of the call the care manager speaks only to the wife of a man with dementia. In the end of the call, the care manager asks the wife to put her husband on the phone.

Care manager: Am I correct in this? Those are the services you (collective) have?

Wife: Yes, that is pre, that is precisely what we need and have had. And now it is all put on hold (laughs).

Care manager: Yes, now nothing of that is active, say.

Wife: No.

Care manager: No. But do you think that the help you’ve had previously then, are you (collective) pleased with how it has worked?

After the care manager has summarized the services they have, she asks for the wife’s confirmation that the information is correct (line 1). The wife confirms that it is, but adds that the services that they normally get from elder care are at present all put on hold (line 2-3). She says this with a laughing tone, which may imply that she initiates further discussion on this current situation. The care manager however continues the conversation with a follow-up of assessments of the services (line 6-7), rather than exploring how they cope with the present time which could have been an option for the care manager to pursue.

The approach «business on hold» which is illustrated in this example was recurring in the data, and employed by different care managers. The approach can be seen as a way of checking in on the client’s welfare but without being able to offer any solutions to the changed situation. It can also entail the execution of existing services due to them being closed or due to the wishes from the clients to isolate themselves. The care managers who used this approach did not make any deviations or adaptions to the current situation from the existing standardized template for assessments. Instead, they referred to the organizational and administrative guidelines that are normally used in the assessment process-a system currently and indefinitely put on hold. In our data, we can also see that sometimes when care managers are sticking to strict manuals when speaking on the phone, it becomes problematic for the older people due to cognitive disabilities as well as hearing loss. These remote assessment meetings are therefore lacking some quality in regards to social rapport and relational connection between the care manager and the older people. It also becomes evident how visual clues like gestures and body posture are important when conducting needs assessment meetings with older people. This get ethical consequences in terms of assuring transferences of information and inclusion of all parties’ voices.

Exploring new options

At other occasions, the care managers were more creative and approached the current situation as more permanent. They proposed alternatives to the ordinary services, which were individually designed and unfolded in the interaction. In these interactions, the problem-solving process was tentative and sometimes even a shared project between the interactants, where possibilities were raised, weighed and evaluated in a more equal manner.

This example is drawn from a follow-up meeting between a care manager and a couple in which the husband has several different types of granted services for his needs. In this conversation the discussion is about his granted hours of relief, which enable for his wife to get some hours off from her informal caring duty. All interactants here jointly assess these services and discuss the current limitations due to Covid-19. In contrast to the previous example, this phone-call was conducted via speakerphone with both spouses at the same time. In this specific episode, they are discussing the husband’s lack of possibilities to perform his exercise program due to closed day care facilities.

Care manager: I’m just thinking also, in case corona is here longer than…what we hope for. So that you won, so that you won’t lose your abilities, when you’ve been used to exercise…at [name of day-care facility]… eh, [name of day-care facility].

Husband: Yes, that is sort of what I am also afraid of.

Lines omitted

Care manager: Either way, [husband’s name] I’m thinking that it is actually nothing that stops, eh, during these hours of relief or something, when the staff is there, you from taking the opportunity to perform this training program.

Husband: Right, right.

Wife: One can ask them to do this, you mean?

Care manager: Yes, I thought it might… It is an activity which actually…

Wife: Yes.

Care manager: Like going out or so. Or kind of, yes, to read aloud.

Wife: Yes, right, that is very good that. Because they are simple things, this that you have received, but it ought to be done either way.

Care manager: Yes, and it depends on, if you just need some encouragement, some reminder of it.

Husband: Yes, right.

Care manager: Yes.

The care manager introduces the important aspect of enabling for the husband to maintain his previous abilities despite the pandemic (line 1-3). In line 5 the care manager is returning to the topic in a tentative manner by proposing that there is nothing that stops him from using the existing services of relief in another way than it was intended. As they all speak interchangeably via speakerphone, the care manager is inviting both the client and his spouse to participate and co-create the current situation in a collaborative manner. This discussion goes on for some time (line 10-17). In the end they all agree that it is a good idea to ask the visiting elder care staff for relief, to aid the husband with his training program which he used to do at his day-care facility. The approach «exploring new options» highlights how the care manager suggests a creative solution for using the already granted home care service of relief in a different way. This was argued to be important in order for the client to receive the training that he needs to cope with everyday life, something that has not been possible due to the situation of the pandemic.

The care managers who used this more innovative approach of exploring new options utilized their professionalism and discretion in relation to how rules and guidelines could be interpreted. As shown also in other studies (e.g. Wallander & Molander, 2014; Olaison, Torres & Forssell, 2018), welfare professionals that have experience and/or feel secure in their professional role have a tendency to use their discretion and push the boundaries of rules and regulations in a more inventive manner. In our material, it was clear that the approach of exploring of new options was a way for the care managers to maneuver the situation at hand in the pandemic. In this management the care manager was able to offer and re-negotiate the content of services in other ways than they existed in the municipality’s catalogue of services for elder care.

Concluding remarks

In this paper, we have highlighted two different approaches care mangers adopt in order to address the current situation; as an interruption from ordinary practice or as a situation which may not be temporary and therefore needs to be explored. The latter relates more to what has originally been characterizing the social work profession, where the social workers use their professional discretion embedded in their role as street level bureaucrats to find suitable solutions in a changeable situation. Researchers have feared a development where social workers rely too much on manuals and paragraphs in their work, and where aspects regarding values and solidarity are at risk of being forgotten (see Ellis, 2011; Taylor & Whittaker, 2020). This development might be a risk in current time, where those care managers who rely on manuals to a great extent will more likely have a harder time making qualified needs assessments in the insecure time of Covid-19.

Although these findings of two approaches of meeting the new situation are demonstrated through an initial analysis of a small data set, different ways of working in time of Covid-19 are worth further discussion. Social workers are used to being dependent on, and restricted by political decisions and economical cut-downs with short notice. However, never have we in modern time experienced the level of insecurity which characterizes our current time, with specific effect on gerontological social work as older people are more vulnerable to Covid-19. Meetings with older people cannot be held in a regular way and the premises for their work are in constant change as services may or may not be paused, something which care managers have to adapt to in their conversations with clients. The only directives we know were given from the managers on a higher level in these specific workplaces, were that meetings with the clients should be performed via phone or digitally. To our knowledge, there were no specific guidelines in terms of how to perform these remote assessments in practice concerning «interaction style» or how to cope with the insecurity.

The current situation with Covid-19 is different from political or organizational challenges that care managers have faced previously, as there is no known time frame for when the crisis is over and things are back to normal. Many people, young and old, have suffered and are still suffering isolated in their homes during this time of pandemic, left to care for their own and each other’s needs. Also, both care managers and the older clients face the reality of balancing the risk of older people’s social isolation and that of catching the Covid-19 virus. These new challenges ought to be reflected in the directives for care managers. For instance, in regard to Covid-19, Berg-Weger and Morley (2020) proposes that assessments of social isolation and loneliness ought to be included in gerontological social work. By mainly sticking to the ordinary manual for assessments there is a great risk of missing important signs of a severe situation for older people due to social isolation. Also, the current situation differs from previous crises within social work, as the entire population is part of the problem as well as the solution. This means that the care managers included for this paper may be in a similar situation of social isolation as the older client, perhaps belonging to a risk-category or having a family member who is. This new landscape can therefore also provide a more «symmetric relationship» in interaction in terms of understanding between the care manager and the client, where the exploring of finding solutions to the current situation regarding needs can be done on more equal terms.

The insecure situation does not only regard the services, it is also connected to the practical matter of conducting the meetings with clients. All care managers in our material navigate in a new terrain in terms of talking on the phone rather than meeting in person when making remote assessments of needs. This poses challenges when assessing a person’s ability to practice self-determination in decision-making, as well as assuring the inclusion of both parties’ voices in spousal relationships. The care managers have to make well-founded decisions of which s/he ought to be certain that both parties agree on. This aspect may be at risk when they do not have visual access to the spouses’ faces and expressions. In turn, it may increase the risk that the voice of one of the older persons receives more weight than the other, causing a negative balance in terms of inclusion. One way to counterbalance this, which we saw in the latter example above, was that both spouses were simultaneously included through a speaker-phone. This, at least, gave the care manager access to the couple’s shared discussions on the topic and thereby also increased transparency regarding aspects of self-determination.

The needs assessment process during the pandemic time of 2020 is messier than ever, and care-managers’ prior experience and knowledge have to be utilized in new ways to meet the changing demands. Also, the conditions shift rapidly and at times the care managers do not even know which services are active or put on hold, something which has to be dealt with in situ in conversations with clients. In this short paper, we wish to emphasize the vulnerable situation care managers have faced and are facing. Their professional discretion in relation to making remote assessment of clients’ needs is greatly complicated as the pandemic poses challenges in relation to the institutional logics, as there are none to relate to. We propose clearer guidance from superiors, and guidelines and manuals on how to perform remote assessment meetings which may continue for an indefinite time. Although the advanced digital technology may be a tool for social engagements in time of Covid-19, Seifert (2020) suggests the digital arena is yet another place for social exclusion which affects the older population as more services rely on digital skills in this time of pandemic. Therefore, there is a need to explore more options to enhance education of digital competence (Wand et al., 2020) and thereby counterbalance the risk of maltreatment and isolation during Covid-19. Both care managers and older people would probably benefit from video-calls, where all participants can have visual contact in order to secure self-determination, inclusion and relational connectedness. However, all participants, as in both the older people and the care managers, may not have the proper equipment or technical skills for this change. In addition to these difficulties, it is also important to emphasize the opportunities of this situation. Care managers are acquiring new skills for meeting clients, which may be useful in proactive ways when developing communication training in the future.

In summary, an important dimension in understanding the needs assessment process in times of Covid-19 seems to be how care managers use professionalism in relation to discretion as street level bureaucrats (Scourfield, 2015) when interpreting the organizational rules in their meetings with clients. Finding new ways forward can include supporting innovative approaches in remote assessments. One way is to allow care managers to use their relational competence more creatively in conversations to explore options in co-construction with clients regarding how to get access to, and use existing as well as new services. New approaches would also require meeting the ethical demands of inclusion by creating solutions that advocates the needs of both individuals and couples in a new digital landscape.

References

Berg-Weger, M., & Morley, J.E. (2020). Editorial: Loneliness and social isolation in older adults during the covid-19 pandemic: Implications for gerontological social work. Journal of Nutrition, Health & Aging, 24(5), 456-458.

Donnelly, S., Begley, E., & O’Brien, M. (2019). How are people with dementia involved in care-planning and decision-making? An Irish social work perspective. Dementia, 18(7-8), 2985-3003.

Ellis, K. (2011). ‘Street-level bureaucracy’ revisited: The changing face of frontline discretion in adult social care in England. Social Policy & Administration, 45(3), 221-244.

Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services. New York, NY: Russell Sage Foundation.

Olaison, A., Torres, S., & Forssell, E. (2018). Professional discretion and length of work experience: what findings from focus groups with care managers in elder care suggest. Journal of Social Work Practice, 32(2), 153-167.

Österholm, J. H. (2016). Assessment meetings between care managers and persons living with dementia: Citizenship as practice (Doctoral dissertation, Linköping University Electronic Press), Linköping University: Sweden.

Ray, M., Milne, A., Beech, C., Phillips, J. E., Richards, S., Sullivan, M. P., … & Lloyd, L. (2015). Gerontological social work: Reflections on its role, purpose and value. British Journal of Social Work, 45(4), 1296-1312.

Scourfield, P. (2015). Even further beyond street-level bureaucracy: The dispersal of discretion exercised in decisions made in older people’s care home reviews. The British Journal of Social Work, 45(3), 914-931.

Seifert, A. (2020). Letter: The Digital Exclusion of Older Adults during the COVID-19 Pandemic. Journal of Gerontological Social Work. Online first. SFS. (2001:453). Socialtjänstlag [Social Services Act].

Svensson, L., & Bergman, A-K. (2020). Sweden. In T. Harrikari, J. Mooney, E. Kennedy Tsunoda, & V. Leskošek (Eds.), Covid-19 and social work: Country reports (pp. 123-127). COVID-19 Social Work Research Forum July 2020.

Swedish National Board of Health and Welfare. (2015). Handläggning och dokumentation inom socialtjänsten. (Case management and documentation within social services). Stockholm: Swedish National Board of Health and Welfare.

Taylor, B., & Whittaker, A. (Eds.). (2020). Professional judgement and decision making in social work: Current issues. New York, NY: Routledge.

Wallander, L., & Molander, A. (2014). Disentangling professional discretion: A conceptual and methodological approach. Professions & Professionalism, 4(3), 1-19.

Wand, A. P. F., Zhong, B-L., Chiu, H. F. K., Draper, B., & De Leo, D. (2020). Commentary: COVID-19: the implications for suicide in older adults. International Psychogeriatrics, open access.

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