Summary
Bryan Godfrey, a clinical social worker specializing in geriatrics, discusses the role of social workers in providing mental health support and case management for seniors. He emphasizes the importance of helping seniors stay in their homes and maintain their independence. Bryan shares his personal journey into social work and his passion for advocating for marginalized populations. He also highlights the challenges faced by seniors, such as difficulties with daily activities and the loss of independence. Brian addresses the conflicts between safety and happiness, as well as the autonomy of seniors and the concerns of family members. He emphasizes the need to support and recognize the invisible second patients, the family caregivers. Bryan explains the criteria for Medicare home health coverage and the challenges in accessing home care services. He calls for systemic changes to improve financing and expand coverage for home care services.
Takeaways
- Clinical social workers provide mental health support and case management for seniors, helping them maintain their independence and stay in their homes.
- Seniors face challenges with daily activities and the loss of independence, requiring support and interventions to address these issues.
- Conflicts arise between safety and happiness, as well as the autonomy of seniors and the concerns of family members.
- Family caregivers, the invisible second patients, play a crucial role in supporting seniors and need recognition and support themselves.
- Accessing Medicare home health coverage and home care services can be complicated, and systemic changes are needed to improve financing and expand coverage.
Chapters
00:00 Introduction and Background
00:34 Role of a Clinical Social Worker
01:44 Specializing in Geriatrics
03:23 Challenges Faced by Seniors
05:26 Balancing Health and Independence
07:27 The Invisible Second Patient
10:23 Supporting Family Caregivers
13:59 Caregiver Burnout
17:45 Medicare Home Health Coverage
21:26 Improving Medicare Home Health
25:11 Flaws in the System
25:23 Conclusion
Transcript
leah (00:01)
i am so excited to introduce our guest bryan godfrey after earning a master's in social work from the university of pensylvania and working for four years as an out patient psychotherapist in northern philadelphia brian continued his social work career at u and c chapel hill here he specializes in jeryatrics where he finds fulfillment and advocating for and empowering his patients we are so excited to learn from brian's knowledge and experts on today's podcast brian thank you for
leah (00:31)
being here
bryan_godfrey (00:32)
oh thank you so much for having me
leah (00:34)
to get us started can you explain what does a clinical social worker do
bryan_godfrey (00:41)
solutely what don't we do might be a better question it kind of depends on the role that we're in i think in general when people hear clinical social worker they're referring to a talk therapist also called psychotherapist so they'll be providing mental health or behavior health support often in the communities often working with lower income people but not necessarily actually the majority of mental health services in this country for all people are provided by social workers and of course there's other roles for social
leah (00:43)
yeh
bryan_godfrey (01:11)
workers as well folks like me work more like case managers so i'm associated with u n c geriatrics and i'm so full time there and my role is to make sure that if there are any resources out there that could be helpful to our patients that i track them down and figure out how to connect them to those resources and if they have trouble and run into barriers then it's my job to help solve those problems we want to help people stay in the community stay in their homes you know whatever they would like to do
to age as gracefully and comfortably as possible
leah (01:44)
that is incredible can you tell me how did you get into social work and then why did you choose to specialize in jeriatrics
bryan_godfrey (01:53)
yeah i had an interesting journey i think like a lot of us i've changed careers a couple of times in my life you know i got my bachelors in english because i liked books that i've figured that would be a cool major and that was a lot of fun and then i thought i should really make some money that would be great and so i thought maybe publishing you know i'm interested in books and and you know i'm good at editing and these detail oriented things so i went to emerson college and got a masters in publishing and writing and then i realized
leah (02:07)
oh
bryan_godfrey (02:23)
that was not for me oh my gosh i took a class on books and they were talking about the weight of paper and i thought you know i just don't care i really know i just want to get the information to people and so i got into teaching through that role and through my teaching i ended up teaching a class called cultural diversity and this got me really interested in marginalized populations people who don't get the support they need basically and there's a lot of you know very complicated social reasons for that
and i wanted to advocate to make things better so i figured hey social work would be a good way to do that ended up going to philadelphia i went to u pen and got my masters of social work and then from there went on to become a talk therapist i really loved that work it's really hard work though i was working in north philadelphia with some under served populations and after about four years i was so burned out i needed to change and so i switched over to case management and i kind of stumbled upon the position that u n c i applied
you know i was a good match for him i speak some spanish and they were looking for that as well so that was a nice in yes so i had no experience in geriatrics prior to that but you know i love learning i love researching and so i was a good fit for the position that was about a little over five years ago and so since then we moved from pensylvania to north carolina for this position so it was a huge change for me and my family and i didn't know anything down here i didn't know any of the resource
sis i've spent years you know researching things that can help seniors and putting those into guides for them that are easily digestible and meeting with them and their care givers one on one to explain what's out there and help them connect with these really valuable resources and i don't know i kind of just lucked into it i love working with seniors it's absolutely fantastic we pay a lot of live service to respecting our elders in this culture but i don't know if we actually do it and so i want to help hold this accountable for that i think
people are deserved some respect when they hit a certain age
leah (04:27)
yeah that is an incredible journey and i'm so glad to hear that you have found work that you find incredibly meaningful and you are passionate about and it is incredibly important so to give our listeners some context as to why your work is so important and becoming increasingly so i went to share a few statistics so of the ten million people living in north carolina seventeen percent belong to the senior demographic which is a really large proportion
bryan_godfrey (04:39)
oh yeah
oh ah yes
leah (04:56)
and this on a society level will mean putting a strain on the welfare system and a strain on the sandwich generation which is the people who are responsible for caring for both children and aging parents on an individual level aging can be incredibly joyful and reaching an old age is what so many of us aspire for it means a lifetime of lived experiences and valuable memories however it also means increased health concern
bryan_godfrey (05:06)
oh ah
m
oh
leah (05:26)
and sometimes a loss of independence so would you mind explaining what are some of the more common challenges you see your patients dealing with and what sort of interventions do you typically offer
bryan_godfrey (05:40)
definitely yeah you summarized it very well our population is aging like populations all over the world and people are needing more and more support there was a time when we just didn't live as long as we do now and you know now we need more supports in order to stay there's also this a greater push to stay in your home i think the vast majority of people want to stay in their home as long as possible and there are ways to do that but that can be quite challenging
so one of the first things that seniors will often find themselves having some difficulty with is what they call i a d ls the instrumental activities of daily living and these are the things like you know managing bills and making appointments and filling out forms and sometimes other things as well like the cooking and the cleaning and the laundry you know all of these can become more challenging as you get older you're not as physically
able to get down on your hands and knees and scrub the toilet the way that you once did and you know now that everything is on line the systems can be so confusing to use for banking in this sort of thing so people may start to notice some challenges there and you know there's some simple things you can do like putting bills on auto pay instead of writing checks and then there's you know more more involved interventions that might be needed to like even bringing someone into the home to help with some of these tasks so that's commonly where we'll get
started is just exploring with seniors you know what are some of the challenges you're starting to run into like what's harder for you than it should be and let's see if we can solve those problems because you know let's face it once you hit your retirement you don't want to be scrubbing toilets anymore and maybe you shouldn't be you know let's let's get someone to help you with that i think that would be great
leah (07:23)
right
yeah that is awesome i cannot emphasize enough the importance of your work and from your description it sounds both incredibly fulfilling and emotionally charged so i would like to know when you're working with a patient what are some of your biggest goals is it insuring their health and safety is it helping them maintain otonomy and dependence and dignity i like i can imagine sometimes it's a combination of all of the above but these can sometimes be conflicting
objective so how do you help your patients navigate the dichotomy that can arise between simply living and living a life that they find meaningful
bryan_godfrey (07:57)
oh
absolutely yeah i think there's two big conflicts that i see the most in the work that i do the one i refer back to one of our physicians dr margaret drickemer who likes to talk about the balance between safety and happiness this is a crucial balance to strike sometimes seniors would rather someone not come into their home i mean i understand that you're worried about privacy maybe you're even worried about them stealing who knows
but there's also perhaps a safety concern and so we have to balance these two if it's not safe to shower alone or at least you need someone in the house in case something happens but you also value your privacy how can we strike a balance between the two of these and so that's a lot of what i'll do in conjunction with the doctor the patient may be even a family member or a care giver to have that dialogue to say you know how can we really balance these two the safety but also happiness and to realize as well that's really important
and kind of going along with happiness the other piece of this is sort of what the patient wants versus what family members want which can be the same but are often not the same a lot of times i hear from concerned family members that they're worried about their loved one they're afraid that they're unsafe in their home or they need more support they're worried there could be a fall that they could break a hip and end up in the hospital and rehab and and we know there can be some negative health outcomes for
ings like that these are serious and valid concerns at the same time a person's autonomy is also incredibly important we live in an individualistic society that believes that in general we all have the right to make our own choices even bad choices and that's really important to remember we have the right to make mistakes we have the right to choose things that are not in our own best interest just because we want them and as long as the doctor says we have capacity we have to respec
that choice and so some of what i'll do will also be negotiating with family members and patients and loved ones and care givers to figure out how can we respect this adults autonomy while still helping to promote some safety and that can be complicated for sure
leah (10:23)
yeah and i'm so glad you brought up family units because in addition to working with seniors themselves you also worked closely in supporting and interacting with family units as a whole i recently came across the term the invisible second patient that professionals within jeryatrics used to refer to family care givers can you explain to our listeners the meaning behind this term
bryan_godfrey (10:33)
yeah yeah
absolutely sometimes they're not even so invisible you know ye so the idea is yes the patient is our patient right they're coming to our doctor for medical support and they're seeing me the social worker for their psycho social support and resources but at the same time as you mentioned there's a family unit here and none of us exist alone
leah (10:52)
oh
bryan_godfrey (11:12)
even though we are an independent culture no man is an island right we're all connected to other people and we need other people for support whether we like it or not in some cases and so i think that it's just important to remember that in any senior's life there is probably a care giver as well uh sure some people may have someone who's remote or relatively uninvolved but there's probably someone else involved very often in any case there is oftentimes they're local sometimes
live with the person and they're often providing a great deal of support there's all sorts of challenges associated with this the patient may not realize their own impairment may be they have a cognitive impairment and the brain likes to protect us against things that could hurt us so it will tell us we have nothing wrong and then we won't be upset however that can be pretty upsetting for a care giver who sees the impairment and knows you need help and you know wants to get it for you but but can't and so there is a stress in it
leah (11:59)
uh huh
bryan_godfrey (12:11)
tension that's kind of inherent to the care giver relationship in that way but at the same time it can also be really rewarding to connect with your loved one in a way that may be you never had before and to be able to be that meaningful care giver some people see it as their duty some people see it as their pleasure but it's important to know that some people also find it exhausting it's often not a role we signed up for and we're often not prepared for it there's no manual for this just like there's no manual to raise a child for instance
and with seniors with dementia or other cognitive impairment it can sometimes feel like that very similar so we need to pay attention not just to the patient but to the people that surround them and in particular their close family members who we often call care givers who are providing care to make sure that they're not left to be invisible and we do attend to their needs so when a patient comes in our doctor is sure will ask about the patients medical problems but they'll also ask about who's helping you in the home and hopefully we can talk
them and see how they're feeling if they're feeling burned out there's ways to get some support we call it respite to give care givers a break and that can come in many forms from some additional home care to a day program even something like assisted living or there's lots of other options so we would talk about all of those and you know help everyone understand that we're all human here right we all have limits and all the time i see care givers these invisible patients try to push past their
it's and they mean well and sometimes they can do it and other times they crash and sometimes they will snap at their loved one and get impatient and even cause harm unintentionally and that's what i'm here to help identify and hopefully avoid but problem solve if we need to
leah (13:59)
yeah absolutely one of the best explanations i've heard recently as to why care giving can be so psychologically draining is because it requires such a high on those constant level of vigilance so being constantly on an attentive would be draining for anyone regardless of how much you love or care for your relative it is training and these burdens are often not talked about in society and so i really want to encourage an open dialogue about
bryan_godfrey (14:01)
oh yeah
oh h h
oh
m h
leah (14:29)
that um so you you mentioned the need for respite care and getting a break for care givers which is incredibly important and you also brought up burn out which is unfortunately something that we see a lot so can you speak to what sort of socital or structural changes you would like to see so that we can help alleviate some of this burn out that's happening
bryan_godfrey (14:35)
yeah
oh
oh
absolutely i think some of it comes from a smatch of expectations a lot of care givers will assume that medic care will pay for home care they've heard that medic care covers home health and so they figure if the person needs more support well we'll just get the doctor to order some home care and medic care will pay for it and in theory that can be true sometimes but the reality of our culture is the
medic care is pretty strict about this sort of thing they generally do not cover home care they'll only cover things like skilled care like nursing or physical therapy but not someone to help you with daily tasks and it's partly because of budget and partly because of culture and it's also partly because frankly we don't have enough aids there's simply not enough care givers uh able and willing to do this work especially for the rates that we pay them which are often
far lower than they should be so yeah it can be a situation where care givers do feel burned out because a lot of the support that they kind of assumed would be there just isn't there the other time i often see it is when people assume that a family member will step in oh i'll help for now and then my brother will take them for the weekend and then it will be okay or maybe they'll stay with my cousin for a month or something and then that person doesn't want to do that or
maybe you assume that they should chip in and they just don't a thousand situations can come up but they can all lead to frustration and burn out and especially if you feel like the person is in danger or in risk and you want to help them you want to protect them and they don't want to help it can be very frustrating i think the the hyper vigilance that you mention you know this always being on can certainly contribute and going along with that is often a care giver belief that they have to do ever
things themselves and they're the only ones who can do it right even if that's true that can be the road to burn out pretty quickly right so a lot of my work is talking with care givers how can we delegate some of this work how can we give it to someone else that will be good enough even though it's not perfect how can we keep them safe enough that they're happy and not in the hospital but you know we're also not completely burning out care givers
leah (16:56)
all right
right absolutely that is very difficult task and you mentioned medic are home health coverage i would love to learn more about that it's my understanding that the overall objective of medic are home health coverage is to improve health outcomes for medic are beneficiaries by subsidizing access to both skilled and unskilled home health services and just from my preliminary research it seems like there are a number of criteria that one has to meet in order to qual
i for this can you walk us through what those criteria are and i know that is a very long question but can you go to break it down for us
bryan_godfrey (17:55)
i will do my best i'll tell you whenever insurance gets involved things get complicated doesn't it so
leah (18:01)
uh
bryan_godfrey (18:02)
yeah so and in general i like to distinguish between home care and home health so home care is the one that's covered by medic care home health is the one that's not home care will typically involved skilled care like physical therapy and home care will typically involved what they call unskilled care which could be i a d l support with cooking and cleaning or activities of daily living a d l support with things like bathing and dressing so so just focus on home
care for a moment and i'll focus on the medi cure criteria which many other people and the companies will also use and i will say when in doubt ask your doctor because they are the the experts in doing these referrals and they should be able to tell you if you meet these guidelines are not but number one the person has to be home bound that doesn't mean they can't leave the home but it does mean it's very difficult to leave the home so if someone's driving they're generally not considered home bound the other thing
is the patient has to need skilled care that can be provided intermittently in the home and so typically this would be like a physical therapist coming two or three times a week you can get a nurse to come out as well but it's often not the nurse that people are thinking about it's more about disease education showing you how to fill a pill box correctly may be managing some wound dressings and things like that and of course you can get other services as well and you can attach and aid to these serve
this is if the doctor includes it in the order but it just depends on if the company can provide it or not and even though in theory medici says that it will pay for in rare cases up to thirty five hours a week of home aid care and nursing combined the reality is it's very hard to justify that as being medically necessary and so because of fear of audit and the fact that none of this is pre authorized it's all sort of
a reimbursement based system a lot of companies won't offer that that aid or they can't because they don't have the staff so yeah a long story short if you're feeling like home health or home care could be necessary or helpful ask your doctor and they can tell you for sure you do need to have seen your doctor typically within the last ninety days in what they call a face to face visit in order to qualify that can be in person or it can be a two way video
but it cannot be a phone visit so yeah make an appointment with your doctor ask them what you might qualify for and if they're not sure see if there's a social worker around if for some reason the office doesn't have a social worker you can also call your insurance like medic care for example one hundred mediccare you can also check with your local department of social services they often have some senior supports that can help provide some guidance
leah (20:56)
yeah this sounds like it can be a complicated process and so i'm very glad we have people like you to help us navigate it and it also sounds like even once you go through the steps of qualifying for medic are home health or medic are home care you're not necessarily guaranteed to be matched with a care provide to right away since you mentioned the care giver shortage in north carolina and around the country so in your opinion what is the best way to impro
bryan_godfrey (21:04)
oh yeah
yeah yeah
leah (21:26)
medic are home health moving forward should we be expanding the qualifying criteria to include more people should we increase the available home health services that are offered through medic are home health what do you see as the path we need to take
bryan_godfrey (21:44)
it's like if i had a magic wand and i could wave it and change medic care policy what would i do oh my gosh um i will i will say that things are like this by design and a lot of it is based on money and a lot of it's based on availability it's not just home aids that we have troubles sometimes we don't have enough physical therapist or enough nurses and so we're really looking at sy some systemic issues here than a lot of it's driven by by pay
leah (21:46)
yeah
bryan_godfrey (22:14)
frankly and financing so i would love to see if i could waive my magic wand i would say medic care now covers home care as well as home health and if a doctor orders it and says you know this person needs assistance with uh cooking and cleaning and they need someone to run to the grocery store and grab their groceries for them and they need someone to come to their house and fill their pill box and they need someone there to remind them to take their pills like if the doctor can
if i what's needed i would love to have that covered by better care currently it's not possible uhmedicare doesn't have near enough money in fact there's there's been concerned pretty much since mediccare was founded that it's like on the verge of bankruptcy like we see it going bankrupt just a few decades in the future and so to this day to this very minute we're trying to figure out how to avert that it doesn't help that the population is leaning towards older adults and in some countries it's approaching a disaster in japan for exam
ple the aging population is so significant they have the oldesttlife expectancy in the world that there's a very low birth rate and there's just not enough people working and paying into the system to take care of their needs we're not that bad in this country but we're getting there and so we would need a huge push to better finance medic care and that would have to come from the top i mean from the congressional budget officer whoever does this stuff it would literally take an active congress to change so write your congress people
leah (23:39)
right
bryan_godfrey (23:44)
tell them that you want medic care to cover home care i think that would be crucially helpful it would help so many seniors stay in their home it would alleviate so much care giver burn out and it's something that people just kind of expect a lot of people assume they're going to do it anyway because it's just common sense they say oh well it's not medically necessary what you don't have to eat i mean like if you have stuff all over your house you're going to trip over like so it's not medically necessary but there's other medic care policies that would have to be looked at as well
leah (24:05)
m m
bryan_godfrey (24:14)
medic care does not cover anything long term full stop that would have to change men care does not cover most preventative things that has to change too you know what it shocks me to learn about this did you know medicare doesn't cover anything for the bathroom nothing at all no raised toilet seat no grab bars no shower chair nothing for the bathroom why why not that's obvious
leah (24:33)
i did not know that wow that is really intesting
oh my goodness
bryan_godfrey (24:44)
i mean almost everyone needs that who knows why but they won't cover it and so we need to look at fundamental policies like this and financing and it's got to come from the very top i don't think you know we've done our best to fill in the gaps there are community agencies that will step in and help provide medical equipment to people who need it and there's there was some volunteer home care for a while until they went bankrupt in the tryingal area people are attempting to solve these problems but we really need it to come from the top so right your congress person
leah (25:11)
yeah these sound like some pretty big flaws with the system and i hope that we are able to see significant changes soon because there are so many people out there who would benefit from these improvements brian thank you so much for being on our podcast and sharing your expert t s i have learned so much from speaking with you and i am sure that our listeners will as well i really admire and appreciate the work that you do and again thank you so much for sharing with us
bryan_godfrey (25:23)
it's been such a pleasure thank you so much for having me