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SOCW 6351: Social Policy, Welfare, and Change Week 9

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Discussion: Stakeholders in Health Care Policy

There are many stakeholders involved in health care policy issues, and they represent a wide variety of interests and perspectives. The health care industry employs many people. Though all stakeholders may share the goal of optimum individual and societal health and well-being, it is important to note that stakeholders’ financial interests may influence decision-making.

For this Discussion, review this week’s resources. Consider the impact of health care policy’s evolution on Medicaid and Medicare programs. Then, think about a specific Medicaid policy in your state (Florida), that should be amended, and reflect on how you would amend it and why. Finally, research the stakeholders involved in Medicaid and Medicare health care policy in your state and consider the role of these stakeholders in policy development for this issue.

Post by Day 3 an explanation of how the evolution of health care policy has influenced programs such as Medicaid and Medicare. Then, describe a specific Medicaid policy in your state that should be amended, and explain how you would amend it and why. Finally, describe the stakeholders involved in the Medicaid and Medicare health care policy in your state (Florida), and explain the role of these stakeholders in policy development for this issue.

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Learning Resources

Week 9: Health Care Policy

The requirements, services, and benefits associated with federal programs vary from one geographic area to another. Such variation may result in consumer confusion and difficulties in understanding and accessing needed health care services.

This week, you examine the impact of health care policy’s evolution on Medicaid and Medicare programs, analyze your state’s Medicaid policies, and determine the stakeholders in health care policy development for your state. You also identify individuals who represent “at-risk,” marginalized, or oppressed populations and investigate the impact of these policies from the perspective of select populations.

Required Readings

Acker, Gila M. (2010). How social workers cope with managed care. Administration in Social Work, 34(5), 405–422.

U.S. Department of Health and Human Services. (n.d.). Agency for Healthcare Research and Quality. Retrieved November 14, 2013, from http://www.ahrq.gov

Concannon, L. (2009). Developing inclusive health and social care policies for older LGBT citizens. British Journal of Social Work, 39(3), 403–417.

Responsiveness to Directions

8.1 (27%) – 9 (30%)

Discussion posting fully addresses all instruction prompts, including responding to the required number of peer posts.

Discussion Posting Content

8.1 (27%) – 9 (30%)

Discussion posting demonstrates an excellent understanding of all of the concepts and key points presented in the text(s) and Learning Resources. Posting provides significant detail including multiple relevant examples, evidence from the readings and other scholarly sources, and discerning ideas.

Peer Feedback and Interaction

6.75 (22.5%) – 7.5 (25%)

The feedback postings and responses to questions are excellent and fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, additional resources, and stimulating thoughts and/or probes.

Writing

4.05 (13.5%) – 4.5 (15%)

Postings are well organized, use scholarly tone, contain original writing and proper paraphrasing, follow APA style, contain very few or no writing and/or spelling errors, and are fully consistent with graduate level writing style.

Developing Inclusive Health and Social Care Policies for Older LGBT Citizens

Liam Concannon

Liam Concannon: taught Social Policy and Social Work at Royal Holloway, London,

Brunel University and Goldsmiths College, London, before becoming an independent

researcher and writer. He has a particular interest in citizenship and anti-oppressive prac-

tice. His previous research has investigated citizenship and the social exclusion of LGBT

elders and also people with learning disabilities. His publications include: Planning for

Life: Involving Adults with Learning Disabilities in Service Planning (2005, London

and New York, Routledge) and ‘Inclusion or control? Commissioning and contracting ser-

vices for people with learning disabilities’ (2006, British Journal of Learning Disabilities,

34(4), pp. 200 – 5).

Correspondence to Liam Concannon. E-mail: [email protected]

Summary

Creating anti-oppressive practices in service provision that successfully remove barriers to

the social inclusion of older lesbians, gay men, bisexuals and transgendered (LGBT) citi-

zens has proven thus far tremendously difficult. The White Paper, Better Care, Higher

Standards: A Charter for Long Term Care, (Department of Health, 1999) addresses the

development of non-discriminatory services that treat users with dignity and respect,

taking account of sexual orientation (Department of Health, 1999, p. 3). Such government

social policy holds out the hope that services will be designed to support senior LGBT

people. This paper examines the unique oppression and marginalization faced by older

lesbian, gay men, bisexual and transgendered citizens in homophobic and ageist

societies, which often fail to acknowledge their existence. The research findings highlight

strategies being created through social policy that aim to successfully achieve the

inclusion of this group in the planning and delivery of their services.

Keywords: LGBT elders, inclusive service planning, social work education

Introduction

It is nearly forty years since the rioting at the Stonewall Tavern in New York, and the founding of the gay liberation movement in Britain,

# The Author 2007. Published by Oxford University Press on behalf of

The British Association of Social Workers. All rights reserved.

British Journal of Social Work (2009) 39, 403–417 doi:10.1093/bjsw/bcm131 Advance Access publication December 20, 2007

marked the beginning of the modern gay equality movement. This is the first time in history that a generation of lesbians, gay men, bisexuals and transgendered (LGBT) people who came out during that period are moving into old age and, as time passes, the numbers are set to rise. Individ- uals, who were in their twenties during the Stonewall era, are now approaching their mid-sixties. They came out because of strong political convictions and personal experiences which compelled them to challenge ignorance, prejudice and homophobia. These women and men have lived through some of the most significant years in terms of gay history and social change, including the declassification of homosexuality as a mental illness, the decriminalization of homosexuality and the appearance of AIDS. In significant ways, Britain has followed the lead set by the USA, placing the lesbian and gay agenda within the realms of human and civil rights (Manthorpe and Price, 2005). Nevertheless, difficulties remain because many older lesbians and gay men, who chose not to come out, con- tinue to be invisible, making it a problem for an accurate assessment of their well-being (Jacobson, 1995; Wilton, 1995; Herdt and de Vries, 2004). The modern welfare state, in the UK, was developed around the heterosexual white British family (Williams, 1992) and it was this approach to health and social care that has ultimately led to the current inequalities and dis- crimination against LGBT service users. Yet, social policy and social work practice, based on a traditional family model, is no longer relevant for many in society today, regardless of their sexual identity. It is for this reason that this paper explores the health and social care needs of lesbian, gay men, bisexual and transgendered elders.

While a significant amount of literature exists on the health and social care needs of senior citizens, it comes as no surprise that little is to be found in conventional texts in terms of lesbians, gay men, bisexuals and transgendered people. This paper raises a number of fundamental yet important questions relevant to social policy and social work practice, and considers the implications of non-heterosexual ageing. In exploring this topic, the research method includes a literature search and review of government legislation, and also policy documents from organizations involved in the social care of older LGBT citizens, including Age Concern in Britain, and SAGE (Senior Action in a Gay Environment) in the USA. The key themes investigated throughout include: residential care; promoting the health and well-being of LGBT elders; the active par- ticipation of older LGBT service users; and social work education and train- ing. The discussion takes account of previous research seeking to give ‘voice’ to LGBT services users and social care professionals, illustrating their experiences through their personal narratives. These narratives are of interest to us, because they reveal the complexities about the ways in which social policy acts to re-enforce and support social exclusion. They demonstrate how heteronormative assumptions have hitherto informed policy, resulting in a limited increase in effective policies for the

404 Liam Concannon

development of inclusive services to LGBT elders. In many cases, the participants who recount their exclusion from service provision or discrimi- natory treatment by colleagues highlight how policy reinforces strong feel- ings of isolation and powerlessness, and a sense of being a ‘second class’ citizen. Yet, these narratives also help to illuminate the positive ways in which they can be used to influence and transform policy, such as with the 2005 Civil Partnership Act. The discussion presents the opportunity to consider fresh ways for social care agencies and professionals to develop policies, practices and training that actively seek to support the consultation and participation of LGBT elders, and the research findings draw attention to evolving modules of good practice, offering them a greater degree of choice.

Empowering LGBT elders

Legislation introduced by New Labour has sought to bring about equality and establish anti-discriminatory practices in health and social care services. Nevertheless, the invisibility of older LGBT citizens within social policy research in the UK means that their specific well-being and care needs, and how they may differ from the wider older population, remain largely unknown (Pugh, 2005). This lack of involvement has consequences in terms of policy initiatives and progress; for example, the 2004 Carers (Equal Opportunities) Act does not specify that information will be tai- lored to help understand or meet the concerns of lesbians, gay men and their carers. However, in order to effectively empower senior LGBT service users, and for anti-oppressive practices to be effective in social work departments, the culture must be one that demonstrates a commit- ment to challenge homophobia, while also developing locally inclusive pol- icies. A lack of participation previously has contributed to a lack of involvement in consultation forums and new initiatives designed to support them, ranging from person-centred care to the broader aims of stra- tegic planning and commissioning. Thus, it remains the case that examples of poor practice can be found in the referral, assessment and review pro- cesses which continue to discriminate against LGBT individuals. This can be seen, for example, through the use of inappropriate language, such as questions concerning marital status. A residential home care manager high- lights this problem, saying: ‘By putting a tick in the “single” box under “marital status” on Bill’s admission form, it was like I had dismissed his entire romantic and sexual history with one strike of my pen’ (Knocker, 2006, p. 18).

At a national level, it is the government’s responsibility, through legis- lation, to confront exclusion and oppression, while, at a local level, social services departments must aim, through participation and consultation, to find inclusive mechanisms that avoid alienating LGBT service users.

Health and Social Care Policies for Older LGBT Citizens 405

One way of achieving this is for organizations to have rigorous training programmes that inform their staff. These programmes should also seek to instil an understanding about how social policy and professional prac- tices have reinforced isolation and the marginalization of senior LGBT citizens. Heaphy and Yip (2006) emphasize the significance of delivering care services by practitioners who are aware, knowledgeable and tolerant of the lifestyles of LGBT individuals. They explain: ‘The development, enactment and practice of anti-discrimination policies are of paramount importance. An example of how this could be achieved is by the adoption of a kite-marking scheme, indicating staff are knowledgeable about the concerns of lesbian and gay clients’ (Heaphy and Yip, 2006, p. 446).

Comprehensive training will also help to ensure that social workers successfully empower their service users by putting them at the centre of their care plan. Needs-led assessments should offer tailored packages of care reflecting individual needs and choices (Concannon, 2005). There is little point, for instance, in a social worker making a referral for a lesbian or gay man to attend a day centre, or residential respite unit, as a means of alleviating loneliness, when they cannot openly discuss their lives. Aspects of their life which are important to them will differ vastly from the heterosexual people attending, and lead to an increased sense of iso- lation (Langley, 2001). The majority of residents are unlikely to have a liberal attitude towards fellow residents who are lesbian or gay, having grown up in less tolerant times. As well as this, a lack of adequate support in day or residential settings can contribute to an increased sense of anxiety for LGBT elders (Tully, 2000). Having awareness on the part of practitioners about reasons that may cause additional distress for lesbians and gay elders is essential.

Life stories are a useful tool in helping to assess a person’s current needs and offer an understanding of their life history (Bayliss, 2000). Their narra- tives provide an appreciation of the era in which they were born, and shed light on how and why they make decisions about their later lives. With new legislation being introduced by the government, such as the 2005 Civil Part- nership Act and the 2002 Adoption and Children Act, which came into force at the end of 2005, changing the eligibility criteria to allow same-sex couples to jointly apply to adopt a child, it is easy to forget that this growing culture of acceptance has occurred during a single lifetime. Men and women over seventy years of age will remember a world in which to be attracted to a person of the same sex was heavily stigmatized and where the only ‘choice’ was the choice of concealment. When these les- bians, gay men, bisexuals and transgendered people were younger, contact with other gay people was extremely difficult. They reached puberty at a time when homosexuality was considered to be a mental illness, outlawed as a criminal offence and with cures that included electric shock aversion therapy (Sim and Gordon, 1968).

406 Liam Concannon

New for old: individual budgets a strategy for inclusion

Against this backdrop, notions about citizenship and social inclusion, with a common respect for diverse cultures and lifestyles, have become one of the primary social and political discourses to emerge. During the past few decades, significant attention has been paid by New Labour to the importance of empowering service users by enabling them to take more control. The 1996 Community Care (Direct Payments) Act, for example, authorized local authorities to make payments directly to the service user so that the service user could purchase the services they wanted. The Act extended choice and control, so that personal needs could be met creatively, and the government has been of the firm opinion that making direct payments enhances the well-being of individ- uals receiving them. Direct payments and individual budgets offer greater efficiency in matching needs, allow more flexible arrangements for carers and cut administration charges related to care packages (Netten, 2005). Along with the single assessment process introduced in the National Service Framework for Older People (Department of Health, 2001), these initiatives seek to empower the service user to direct their assess- ment, care plan and reviews. In general, elders who are in receipt of direct payments have an improved quality of life, with positive impacts on their physical and emotional health. Having a choice about whom they employ and control over what happens in their own home is import- ant. For older LGBT citizens, direct payments offers a new option for recruiting personal assistances through gay organizations and the gay press, enabling them to be supported from within their own community. Transferring the purchasing power directly into the hands of the service user in this way has the potential to revolutionize social care (Concannon, 2006) for gay people. It fits with New Labour’s approach towards promoting independence, enhancing the quality of life, extending social inclusion and preventing a reduced lifestyle. Nevertheless, within social services departments, direct payments have not yet become a regular part of the care management process (Clark et al., 2004). This is to do with the fact that social workers continue to fit individuals into existing mainstream ser- vices, due largely to heavy caseloads and competing pressures on their time. This approach has been criticized as discriminatory, because it does not recognize or respond to the unique needs of older LGBT citizens. The White Paper, Independence, Well-Being and Choice (Department of Health, 2005), appears to agree, suggesting that ‘For too long social work has been perceived as a gatekeeper or rationer of services and has been accused . . . of fostering dependence rather than independence. . . . It is clear that direct payments give people that choice and control, and we think that this is a mechanism that should be extended and encouraged’ (Department of Health, 2005, pp. 10 – 11).

Health and Social Care Policies for Older LGBT Citizens 407

Plugging the gaps: the voluntary sector responds

Advocacy organizations for senior citizens in the UK have, in recent years, begun to recognize the neglect of LBGT elders, and to challenge the lack of inclusive services. Age Concern is an organization in Britain, committed to addressing the hopes and fears of lesbians, gay men, bisexuals and transgen- dered people by raising awareness of their health and social care needs. As part of this undertaking, Age Concern held the first conference in the UK in 2002, to examine social policy issues affecting older lesbian and gays. Gordon Lishman, speaking at the conference, said Age Concern seeks to establish an enabling philosophy that:

. . . recognises the normal processes of ageing; and which asserts the indivi- duality and citizenship of all older people and their right to be heard; their right to services on a basis of equality; and their right to be treated as full citizens (Lishman, 2002, p. 4).

One of the principal aims of Age Concern is to challenge the government, by objecting to the ways in which social policy developments have contin- ued to exclude senior LGBT citizens (Lishman, 2006). They argue that empowering older lesbians, gay men, bisexuals and transgendered individ- uals means giving them a ‘voice’ about issues that are important to them as a community in the latter part of their lives. This includes discussions about suitable care provision, partnership rights, mental health, dying and bereavement and support when dealing with legal matters. Age Concern underlines the importance that government legislation places on assess- ment; person-centred planning and respecting the unique identity of indi- viduals. Yet, policies such as the 2000 National Minimum Standards Care Standards Act fail to acknowledge the needs of lesbians and gay service users, and the National Standards Framework for Older People (Depart- ment of Health, 2001) also lacks comprehensive guidance. It is because of this disregard that Age Concern believes that placing users at the centre of consultation processes is a key policy objective for them in order to suc- cessfully promote the needs of LGBT elders. They achieve this by making opportunities available for individuals to be included in focus groups and on decision-making boards, with the aim of developing procedures that ensure that older LGBT citizens directly influence mainstream policy making. One participant at the 2002 conference offered an insight into the difficulties faced by LGBT individuals trying to access inclusive services, pointing out:

What we find above all is public service provision that pretends we don’t exist. I chair an NHS Trust and I know of no guidance coming through the system that the NHS should provide services for lesbians and gay men. I think the same is very broadly true for social services departments. We become more reliant on public services yet those services are not equipped to deliver what we need to live a full and vigorous old age (Real Lives, 2002, p. 15).

408 Liam Concannon

Advocacy organizations in the USA have a longer history of tackling these issues than the UK. In New York City in 1977, for example, SAGE (Senior Action in a Gay Environment) was founded as a direct response to the lack of services specifically to support senior lesbians, gay men, bisexuals and transgendered people. The founding principles of the organization have been to combat oppression, discrimination and the isolation of LGBT elders, with a firm conviction that the gay community should take care of its own. SAGE developed a philosophy based on two simple values:

(1) empower LGBT elders to access high-quality social services and;

(2) provide a caring and secure environment in which older LGBT citizens

could meet within their community (Kaelber, 2002).

Throughout the subsequent three decades, SAGE has grown to become the largest advocacy and social service association for LGBT elders in the USA. At the time of writing, they enable over 2,000 LGBT citizens to access ser- vices throughout the country. The organization places significant import- ance on education, advocacy and communication, offering training to LGBT elders to become advocates for policy change. They emphasize clear differences between the well-being of LGBT elders and their hetero- sexual counterparts, which are of profound importance if social workers and care providers are to understand and effectively respond to LGBT elders. Research carried out on behalf of SAGE discovered that LGBT individuals are twice as likely to age living alone; four-and-a-half times as likely not to have any children; and five times less likely to access social ser- vices (Kaelber, 2002, p. 22). Terry Kaelber, Executive Director of SAGE, agrees with the position taken by Age Concern, believing that:

Creating community is about giving voice to the community you’re working in, and giving voice allows that community to discover its intrinsic worth and its place in the larger society. This in turn is an extremely effective antidote to the marginalization and isolation that is under pinning of what puts us at risk in our old age (Kaelber, 2002, p. 24).

The fact that most health professionals and social workers automatically assume that their patients or service users are heterosexual is an assumption that SAGE considers leads to the marginalization of older lesbians and gay men, continues to (mis)inform service developments and professional prac- tice, and limits the involvement of LGBT service users in activities such as life reminiscing and discussing openly their relationships (Kaelber, 2002). Kaelber, drawing on the innovatory and multifaceted approach taken by Age Concern, admits that ‘This approach is virtually non-existent in the US and may be one reason why GLBT aging issues still do not attract this kind of attention at the national level in America that it is attracting in the UK’ (Age Concern, 2002, p. 25).

Health and Social Care Policies for Older LGBT Citizens 409

Extending choice: creating new models of care

The 2005 Civil Partnership Act legalized same-sex partnerships in the UK, and many states in the USA have also seen the introduction of civil unions, giving registered civil partners rights and responsibilities similar to a married heterosexual couple (Stonewall, 2005). This is unquestionably a landmark in the legal recognition of same-sex couples, yet experience tells us that such reforms are often slow to filter down to specialist areas of policy and practice. Although this is a new area in terms of research in the UK, some statistical evidence is emerging showing the take-up of civil partnerships among older lesbians and gay men. For example, by the end of September 2006, the total number of recorded civil partnerships which had been formed in the UK was 15,672, with more partnerships between gay men than lesbians. In England, 38 per cent were females and 62 per cent male partnerships. Interestingly, between December 2005 and March 2006, over half the men registering a civil partnership were aged fifty and over (National Office of Statistics, 2007). The number of senior LGBT couples is set to increase significantly during the next few decades, and it is recognized that care providers are not ready for the inevitable growth in the older LGBT population needing services. However, some research evidence already exists about the types of services that LGBT elders say they want. For instance, a study asked whether, given the choice, they would prefer services specifically tailored for them, such as separate accom- modation. The study by Hubbard and Rossington (1995), conducted before the advent of civil partnerships, found that nine out of ten lesbians (91 per cent) and three-quarters of gay men (75 per cent) said that they would welcome the choice of separate accommodation. Earlier research findings by Kehoe (1989) and Lucco (1987) had reached similar conclusions. In light of these studies, and if organizations are going to respond to compar- able expressions of choice, in the future, what will be called for will be new and creative ways of planning, commissioning and delivering services.

Traditional service provision is seen as problematic by LGBT elders, due to a lack of understanding about gay lifestyles on the part of statutory agencies and professionals, and it is often one reason cited as to why being offered the choice of services specifically designed for them is import- ant. An older gay man, who cared for his partner of thirty years, illustrates this by recalling his experience when his partner needed to go into long- term residential care, due to dementia and his deteriorating health. He explains:

Because of his challenging behaviour, my partner David had to go into a residential home fairly soon after he was diagnosed with dementia. All the time people wanted to know why I was looking after David and who I was, so there was always the issue of needing to come out. The whole caring system for older people assumes heterosexuality, which is something I found difficult to deal with (Age Concern, 2002, p. 4).

410 Liam Concannon

A related area which is also difficult for LGBT people involved with traditional residential care is the prejudice which can be experienced from other residents and the relatives of residents. For example, research carried out in 2006 in the UK by Heaphy and Yip uncovered concerns among many in the gay community, about going into long-term care, because of the potential for becoming victims of discrimination and harass- ment by fellow residents and even care workers. This is illustrated by a lesbian who speaks about ageing and describes her fears, saying:

If you do have to go into residential care you are going to be put into a totally heterosexual environment . . . which would not cater for your needs and you would be back in a very unliberated environment . . . you would not have the comfort of people who share the same understanding as you (quoted in Langley, 2001, p. 929).

A manager, also speaking about this problem, admits: ‘We can do some- thing about addressing staff attitudes, but it is hard to know how to respond to other residents or relatives who are prejudiced about gay people’ (Lishman, 2006, p. 19).

While new schemes specifically designed for LGBT elders have yet to be considered in the UK, organizations in other countries are responding to this call for choice and developing models of best practice, offering gay people more choices. They are emerging not only in the USA, but also other parts of the world, such as Canada, Spain and Germany (see www. asaging.org). The L. A. Ries House, for instance, is a foundation which established housing with care support for lesbians and gay seniors in Amsterdam. The foundation built seven apartments for independent living, which are adjacent to a nursing home. Among the services offered to residents in their apartments, if needed, are a rapid assistance and emer- gency call; meals at home when ill; and the use of facilities such as a restau- rant and bar, library and accommodation for their guests (see www.asaging. org/networks/LGAIN/lgainlinks.cfm?category=hsq).

In Los Angeles, Gay & Lesbian Elder Housing (GLEH) was opened in 2001. A not-for-profit organization, it offers high-quality assisted living for LGBT as an alternative to a conventional nursing home, within a safe and nurturing environment, operating in partnership with voluntary and statutory agencies (www.gleh.org). This was partly in response to the growing numbers of LGBT elders in Los Angeles in need of affordable accommodation, where it is estimated that there are between 30,000 and 75,000 LGBT elders, many living in isolation. The residents of GLEH live in apartments fitted out with their own furniture and belongings, and the apartments are fully adapted to cope with physical disabilities, such as accessible bathrooms. GLEH also has an on-site community centre con- taining social services and a referrals service, with other activities ranging from yoga, music, art and performance classes to bereavement counselling. The organization understands that lesbians and gay men are often forced

Health and Social Care Policies for Older LGBT Citizens 411

back into the closet when they move into mainstream residential care. To counter this, the GLEH scheme encourages residents to take control over their lives and for those in partnerships to maintain them by offering the opportunity to share rooms, for example. A worker at the project observes: ‘These are the people who fought so that I can walk down the street holding hands with someone. But nobody’s helping them. They get pushed to the fringe of the community and put out to pasture’ (Lelyveld, 2003).

Implications for social work training and practice

Returning to concerns about staff attitudes, in the UK, towards both LGBT service users and, in some cases, colleagues, it can be argued that the values and belief systems of some professionals are often at odds with the notion of equality and the social inclusion of LGBT elders. It is important to under- stand there are inconsistencies whereby professionals uphold the principles of equal opportunities and anti-discrimination in terms of gender and racism, but sexuality is considered a problem. At the very heart of social work training and professional practice are the core values of equality and anti-discrimination. Nonetheless, recent research by Stonewall UK, in a study called ‘Being the gay one: Experiences of lesbian, gay and bisex- ual people working in the health and social care sector’, revealed that dis- crimination does take place against LGBT employees in the health and social care services. The research argued that managers, and those respon- sible for staff training, failed to see homophobia as a structural inequality, on the same level as sexism, racism and disability. This resulted in poor morale, stress amongst gay employees and high absenteeism (Sale, 2007). These findings are important in terms of senior LGBT service users because many social care and health professionals find themselves in the position of having to advocate on behalf of their LGBT service user. A prin- cipal aim for social work education and training must emphasize the funda- mental importance that all LGBT staff, and service users should be afforded the same respect and dignity as heterosexuals. Yet, homophobia in social services continues; the Stonewall research, for example, uncovered the shocking case of Sienna—a lesbian social work student, who experi- enced homophobia from her line manager while on placement. During the training and development ‘slot’ of the team meeting, Sienna informed them that a conference was taking place in London around sexuality and social work. On the last day of her placement, Sienna’s manager met with her to review her time while in the placement. Sienna recalls:

On my last day, my supervisor and practice teacher, who happens to also be the Senior Practitioner on the team, came to give me some ‘advice’. This advice comprised of the suggestion that I ‘tone down’ my opinions and sexu- ality in my next job. She inferred that there had been discomfort within the team about my ‘out’ lesbian identity. She took ownership of her own

412 Liam Concannon

reaction, describing herself as having felt ‘uncomfortable and having blushed when I mentioned my female partner.’ She said she had felt unable to speak to me for a minute or two. . .. What she tried to make out was that indeed I had been labelled as a trouble maker, as a maverick, as this lesbian militant and that I shoved my views down other people’s throats . . . this idea that she’s got that I need to tone down my opinions and she basically implied that everyone on the team felt the same way. She gave the example of me speaking within the team meeting (in the slot on the agenda about training and development) about the Social Work and Sexuality Conference which was taking place in London. She retorted that ‘For God’s sake, we are all in heterosexual relationships!’ She commented that the rest of the team felt very uncomfortable which was reflected in their silence (Hunt et al., 2007, p. 13).

This is an example of how discrimination and hostility disempower LGBT individuals. It highlights a failure to recognize homophobia as an unaccep- table form of discrimination, inconsistent with the values of the social work professions, and with inadequate procedures in place to challenge such inci- dents. Sienna was shocked by what her manager had said, but felt power- less, and could only respond by suggesting that her manager should read a book on lesbians and gay care in social work. The manager’s attitude towards a lesbian member of the team displays deep-seated ignorance and a lack of understanding about what it means to be LGBT. Yet, it is not confined to social care services alone; when Sienna reported this homo- phobia to her university, she was told to do nothing. She said her tutor was ‘absolutely fantastic when it comes to equal ops, she was just, I don’t know . . . I think perhaps that she suspected that it could affect my placement if we started to make a fuss about it, you know my passing the placement . . . so she didn’t encourage me’ (Hunt et al., 2007, p. 14).

These are clear examples of a failure to recognize that being LGBT is more than about a person’s sex life. It shapes individual identity and the ways in which LGBT people experience life. Caroline, a participant in research by Age Concern, remarks: ‘I think sometimes people see it as all about sex! What you do in bed I mean. If I didn’t have sex at all with another woman for the rest of my life, I would still be a lesbian. It’s as inte- gral to who I am as my identity as a mother, the job that I do and the beliefs I hold dear. It’s not the whole of me but it is a big part!’ (Lishman, 2006, p. 14).

Little attention is given to questions concerning sexuality and older age during social work education and training, and even less to issues concern- ing LGBT elders. It is important to counteract this during social work train- ing because, left unchecked, it upholds the notion of heterosexuality as the unproblematic norm (Wilton, 2000).

Not surprisingly, responses are coming from LGBT elders themselves, supported by voluntary sector organizations. Providing effective services to LGBT elders has seen LGBT users becoming active citizens in a move- ment for change by, for instance, setting up telephone helplines, self-help

Health and Social Care Policies for Older LGBT Citizens 413

groups and drop-in centres. Evidence from the research argues that knowledge alone is not enough (Wilton, 2000) and such schemes provide practitioners, managers and universities with valuable opportunities to invite planners and users of these services to be directly involved, on a fre- quent and long-term basis, in training programmes, consultation forums and team days. It offers the chance for LGBT elders to become valued sta- keholders, working alongside professionals and educators to develop inclusive health and social services. Some government-led initiatives are beginning to appear, most notably from the Department of Health, who are working with groups to promote equality for LGBT service users to develop new policies promoting integrated services. The Sexual Orien- tation & Gender Identity Advisory Group was started in May 2005, with LGBT service users and staff involved in health and social care charged with the task of ensuring that their experience directly informs service plan- ning. The main aims of the initiative are:

† a commitment to equality, human rights and social justice;

† a respect for diversity;

† a commitment to challenge discrimination and exclusion within the organ- izations and communities on whose behalf [they] are working (Department

of Health, 2007).

Conclusion

Without doubt, transformations are taking place relating to citizenship, sexual identity and social inclusion. This paper has sought to investigate the approaches taken to support the well-being and social care needs of older LGBT citizens. It has explored key themes, including the difficulties of accessing appropriate health and social services, methods of empower- ment and the role of statutory and voluntary organizations, arguing that social policy has a responsibility to challenge links between individual and structural oppression, in order to celebrate diversity and afford per- sonal dignity. These issues are being addressed through anti-oppressive pol- icies for black people, other minority ethnic groups and those with a disability, with varying degrees of success. For lesbians and gay men, the introduction of the 2004 Civil Partnerships Act has provided a platform to influence legislation and policy reforms, by creating legal and public rec- ognition of same-sex unions, with new responsibilities on the part of both the individual and the state. The increased legal and social recognition of lesbian and gay lifestyles is demonstrating that older lesbians, gay men, bisexuals and transgendered people are asserting their rights as full citizens. For many, the Act holds out the hope that this is an age of increasing pos- sibilities, yet the politics of gay rights continues to raise a number of funda- mental demands. On the part of LGBT elders, these demands are for

414 Liam Concannon

equality and inclusion in health and social services, and new social policies that ensure that their needs are met. Policy makers, care professionals and service providers are beginning to encounter a generation of politically motivated older LGBT citizens, who live their lives openly, and whose lifestyles and needs have not hitherto been included in heteronormative policies and strategic planning forums (Heaphy and Yip, 2006).

Research on ageing provides not only an insight into the needs of the present generation of older gay citizens, but, importantly, of the future gen- eration who are now in midlife. In light of this, the paper has identified implications for social policy, service planning and professional practice, and makes a number of recommendations, specifically:

† Managers, practitioners and educators need to learn about the lives and concerns that LGBT people have, and understand areas that may affect

their practice. They should take responsibility to protect the interests of

LGBT service users, and, in line with reflective practice, keep updated on changes to legislation, and the broader issues concerning LGBT seniors.

† Training packages must be available to social care staff, with topics relevant to the needs and choices of LGBT elders. The principles of respect, rights,

fulfilment, independence, privacy and dignity are an essential requirement

of this training.

† In the UK, advocacy is one of the most neglected areas of support for older

LGBT service users. Funders must give greater consideration to supporting advocacy groups for lesbians, gay men, bisexual and transgendered elders.

† Limited social settings for LGBT elders exist, and statutory and voluntary

sector day centres are seen as heterosexist. The gay scene also does not

cater to the social needs of older lesbians, gay men, bisexuals and transgen- dered individuals. Commissioning managers, service planners, voluntary

organizations and outreach workers, in partnership with leaders in the

gay community, must encourage social groups to be established and support them financially.

† Mechanisms for monitoring and evaluation, seeking to ensure that the needs of older LGBT citizens are being met, should be set up in care

homes and by community-based providers. Clear guidance for LGBT

service users on complaints procedures should also be included.

† Equal opportunity policies must make specific reference to sexual orien- tation, and practitioners should ensure that this is carried out on behalf

of their service users and implemented in both sheltered accommodation

and residential care homes.

It is essential for the success of new service developments that consultation forums and networks are developed, with organizations working in partner- ship to pool expertise and experiences, and share information.

Health and Social Care Policies for Older LGBT Citizens 415

Accepted: October 2007

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Bayliss, K. (2000) ‘Social work values, anti-discriminatory practice and working with

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Clark, H., Gouch, H. and Macfarlane, A. (2004) ‘Making direct payments work for older

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Concannon, L. (2005) Planning for Life: Involving Adults with Learning Disabilities in

Service Planning, London and New York, Routledge.

Concannon, L. (2006) ‘Inclusion or control? Commissioning and contracting services

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Department of Health (1999) Better Care, Higher Standards: A Charter for Long Term

Care, London, HMSO.

Department of Health (2001) National Standards Framework for Older People, London,

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Department of Health (2005) Independence, Well-Being and Choice: Our Vision for the

Future of Social Care for Adults in England, London, HMSO.

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Equalityandhjmanrights/Sexualorientaionandgenderidentity/DH_4136008 (accessed

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Heaphy, B. and Yip, A. K. T. (2006) ‘Policy implications of ageing sexualities’, Social

Policy and Society, 5(4), pp. 443 – 51.

Herdt, G. and de Vries, B. (eds) (2004) Gay and Lesbian Aging Research and Future

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Hubbard, R. and Rossington, J. (1995) As We Grow Older. A Study of the Housing and

Support Needs of Older Lesbians and Gay Men, London, Polari Housing Association.

Hunt, R., Cowan, K. and Chamberlain, B. (2007) Being the Gay One: Experiences of

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Jacobson, S. (1995) ‘Methodological issues in research on older lesbians’, Journal of Gay

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Langley, J. (2001) ‘Developing anti-oppressive empowering social work practice with

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Acknowledgements

I would like to thank the following individuals for their help and advice on aspects of LGBT ageing and service provision: Antony Smith, National Development and Policy Officer: Older LGB; Age Concern, Astral House, 1268 London Road, London SW16 4ER, Tel: 0800 00 99 66, www.ace.org.uk; Jonathan Finney, Parliamentary Officer; Stonewall UK, Tower Building, York Road, London SE1 7NX, Tel: 020 7593 1850, www.stonewall.org.uk

Health and Social Care Policies for Older LGBT Citizens 417

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permission. However, users may print, download, or email articles for individual use.

SOCW 6351: Social Policy, Welfare, and Change Week 9

Top of Form

Top of Form

Discussion: Stakeholders in Health Care Policy

There are many stakeholders involved in health care policy issues, and they represent a wide variety of interests and perspectives. The health care industry employs many people. Though all stakeholders may share the goal of optimum individual and societal health and well-being, it is important to note that stakeholders’ financial interests may influence decision making.

For this Discussion, review this week’s resources. Consider the impact of health care policy’s evolution on Medicaid and Medicare programs. Then, think about a specific Medicaid policy in your state (Florida), that should be amended, and reflect on how you would amend it and why. Finally, research the stakeholders involved in Medicaid and Medicare health care policy in your state and consider the role of these stakeholders in policy development for this issue.

Post by Day 3 an explanation of how the evolution of health care policy has influenced programs such as Medicaid and Medicare. Then, describe a specific Medicaid policy in your state that should be amended, and explain how you would amend it and why. Finally, describe the stakeholders involved in the Medicaid and Medicare health care policy in your state (Florida), and explain the role of these stakeholders in policy development for this issue.

Bottom of Form

Bottom of Form

Learning Resources

Week 9: Health Care Policy

The requirements, services, and benefits associated with federal programs vary from one geographic area to another. Such variation may result in consumer confusion and difficulties in understanding and accessing needed health care services.

This week, you examine the impact of health care policy’s evolution on Medicaid and Medicare programs, analyze your state’s Medicaid policies, and determine the stakeholders in health care policy development for your state. You also identify individuals who represent “at-risk,” marginalized, or oppressed populations and investigate the impact of these policies from the perspective of select populations.

Required Readings

Acker, Gila M. (2010). How social workers cope with managed care. Administration in Social Work, 34(5), 405–422.

U.S. Department of Health and Human Services. (n.d.). Agency for Healthcare Research and Quality. Retrieved November 14, 2013, from http://www.ahrq.gov

Concannon, L. (2009). Developing inclusive health and social care policies for older LGBT citizens. British Journal of Social Work, 39(3), 403–417.

Responsiveness to Directions

8.1 (27%) – 9 (30%)

Discussion posting fully addresses all instruction prompts, including responding to the required number of peer posts.

Discussion Posting Content

8.1 (27%) – 9 (30%)

Discussion posting demonstrates an excellent understanding of all of the concepts and key points presented in the text(s) and Learning Resources. Posting provides significant detail including multiple relevant examples, evidence from the readings and other scholarly sources, and discerning ideas.

Peer Feedback and Interaction

6.75 (22.5%) – 7.5 (25%)

The feedback postings and responses to questions are excellent and fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, additional resources, and stimulating thoughts and/or probes.

Writing

4.05 (13.5%) – 4.5 (15%)

Postings are well organized, use scholarly tone, contain original writing and proper paraphrasing, follow APA style, contain very few or no writing and/or spelling errors, and are fully consistent with graduate level writing style.

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Administration in Social Work

ISSN: 0364-3107 (Print) 1544-4376 (Online) Journal homepage: https://www.tandfonline.com/loi/wasw20

How Social Workers Cope with Managed Care

Gila M. Acker

To cite this article: Gila M. Acker (2010) How Social Workers Cope with Managed Care, Administration in Social Work, 34:5, 405-422, DOI: 10.1080/03643107.2010.518125

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Administration in Social Work, 34:405–422, 2010 Copyright © Taylor & Francis Group, LLC ISSN: 0364-3107 print/1544-4376 online DOI: 10.1080/03643107.2010.518125

How Social Workers Cope with Managed Care

GILA M. ACKER Department of Social Sciences, York College of The City University of New York,

Jamaica, New York, USA

The study reported in this paper examined the relationships between social workers’ experiences when interfacing with man- aged care organizations, coping strategies, burnout, and somatic symptoms associated with stress. A sample of 591 social work- ers completed questionnaires that included demographic questions and measures of perceived competence in the context of man- aged care, coping strategies, burnout, and somatic symptoms. Multiple regression analyses revealed that coping had statistically significant correlations with several burnout dimensions and with workers’ perceived competence in the context of managed care. As coping provided the most comprehensive influence on workers’ psychological and somatic reactions associated with burnout, the author suggests that agencies provide social workers with adequate training to promote workers’ use of effective coping styles that are appropriate when interfacing with managed care organizations.

KEYWORDS managed care, emotional exhaustion, depersonal- ization, personal accomplishment, somatic symptoms, perceived competence in the context of managed care, coping strategies

INTRODUCTION

Social workers, along with other human service workers, have shown to be vulnerable to work stresses characteristic of those occupations that involve ongoing contacts with people. External and internal pressures includ- ing role conflict, overload, economic problems of the health and mental health systems, and increased accountability to managed care organizations,

Address correspondence to Gila M. Acker, Department of Social Sciences, York College of The City University of New York, Jamaica, NY 11451, USA. E-mail: [email protected]

405

406 G. M. Acker

have created new pressures for service providers, including social work- ers (Cohen, 2003; Daniels, 2001; Hall & Keefe, 2000; Keefe & Hall, 1998). Job stress is thought to be largely a function of conflicts within the work envi- ronment, such as when workers feel that they cannot master organizational and work demands, and that their job activities are inappropriate and incon- gruent with their training and expertise (Acker, 2004; Al-Garni, 2003; Arches, 1997; Cohen, 2003; Hall & Keefe, 2000; Lambert, Pasupuleti, Cluse-Tolar, Jennings & Baker, 2006; Lloyd, King & Chenoweth, 2002). Prolonged stress is associated with chronic anxiety, psychosomatic illness, emotional fatigue, frustration, irritability, and a variety of other emotional problems (Lloyd, King & Chenoweth, 2002). Burnout is a syndrome composed of three dimensions including emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach, Jackson & Leiter, 1996). Burnout has serious implications for both the worker and the organization including poor job performance, absenteeism, psychosomatic illnesses, and turnover (Montes- Berges & Augusto, 2007; Thoresen, Kaplan, Barsky, Warren & Chermont, 2003).

Addressing burnout can increase employees’ efficiency and effective- ness in today’s increasingly cost-prohibitive world of care. Although the empirical literature has emphasized that the ways that workers cope with job stressors may be more important than the amount of stress itself (Gellis, 2002; Latack, 1992), insufficient attention has been paid to how social work- ers cope with the new culture of mental health care (Cohen, 2003; Feldman, 2001; Gellis, 2002; Hall & Keefe, 2000). In this study, the negative out- comes of job stress, including the psychological and the psychosomatic disturbances of social workers, were explored in relation to workers’ coping strategies.

BURNOUT

Burnout is defined as a negative psychological experience that is a reac- tion of workers to job-related stress such as challenging organizational demands, lack of autonomy, unsupportive work environment, and large caseload size (Acker, 2003, 2004; Arches, 1997; Gellis, 2002; Maslach, Jackson & Leiter, 1996; Pines, 1983; Rosenbaum, 1992). Burnout refers to a cluster of physical and emotional symptoms, including emotional exhaustion, a lacking sense of personal accomplishment, and deperson- alization of clients. Burnout symptoms can also include common colds, flu-like symptoms, gastroenteritis, headaches, fatigue, poor self-esteem, dif- ficulty in interpersonal relationships, and substance abuse (Maslach, 1982; Maslach, Jackson & Leiter, 1996; Mohren, Swaen, Kant, Van Schayck & Galama, 2005). It is critical to recognize that social workers confronted by the complex needs of clients and the organizational demands of cost

How Social Workers Cope with Managed Care 407

containment are at risk to experience the negative symptoms associated with burnout.

Job resources like supervision and other supportive mechanisms directed toward workers have been diminishing with the lack of funding associated with social services (Acker, 2003, 2004; Adams, 2001; Pumariega, Winters, & Huffine, 2003). Lack of social support is known to be another stressor associated with burnout, as workers who feel professionally unsup- ported are more likely to develop negative attitudes toward their job (Acker, 2003; Pines, 1983; Um & Harrison, 1998; Winnbust, 1993).

MANAGED CARE

During the past two decades, managed care has become the new approach and organizing theme for the delivery of mental health care services in the United States. It strives to provide efficient quality care at a lower cost than that offered in the fee-for-service professional community. The emer- gence of managed care has created a new source of stress for social workers and other helping professionals. Managed care’s cost containment approach, which includes limited access to necessary services, strict practice guidelines, reduced autonomy, and increased accountability, has created new challenges for social workers, who used to enjoy much more profes- sional freedom and opportunities for decision making (Cohen, 2003; Egan & Kadushin, 2007; Feldman, 2001; Keefe & Hall, 1998; Lu, Miller & Chen, 2002; Mechanic, 2007).

The increased involvement of managed care has had vast implications for the role of social workers in the mental health care field. Social work- ers who perform the largest portion of mental health work in the United States have been required to alter their role from serving as clients’ advo- cates to balancing clients’ needs against the need for cost control. In their new roles as gatekeepers and treatment providers, social workers must learn new strategies and skills to reduce considerable cost-savings expenditures when providing services to clients (Cohen, 2003). Skills that social workers need in the managed care environment involve computers and technology, documentation and paperwork, empirical validation of treatment methods, knowledge of brief treatment methods, and a business orientation in man- aging services in a profitable way (Bolen & Hall, 2007; Feldman, 2001; Lu, Miller & Chen, 2002). Building on the concept of competence, which describes feelings of confidence about one’s abilities to master organiza- tional and work demands (Hall & Keefe, 2000; Wagner & Morse, 1975; White, 1967), several theorists argue that a person’s belief that he or she can- not perform well professionally increases their risk of becoming burned out (Bandura, 1989; Cherniss, 1993; Harrison, 1980). Participating in managed care is complicated, and those who are not apprised about the managed

408 G. M. Acker

care world are likely to suffer stress and anxiety concerning their ability to provide effective services in the context of managed care (Hall and Keefe, 2000; Spevack, 2009).

COPING STRATEGIES

Coping strategies are defined as the cognitive and behavioral efforts that people use to manage external and/or internal demands appraised as tax- ing or exceeding the person’s resources (Lazarus, 1993; Lazarus & Folkman, 1984; Sears, Urizar & Evans, 2000; Shikai, et al., 2007). Lazarus and Folkman (1984) describe two major strategies for coping with stress: problem-focused coping and emotion-focused coping. Problem-focused coping consists of active behaviors and deliberate efforts to solve the situation, and the use of social support, including collaborative efforts to educate and support each other at the workplace (Brooks & Riley, 1996; Jenaro, Flores & Arias, 2007). Emotion-focused coping, on the other hand, is directed at regulating emotional responses to a problem, such as using alcohol, drugs, exces- sive sleep, and denial and disengagement behaviors (Lazarus & Folkman, 1984; Jenaro, Flores & Arias, 2007; Shikai, et al., 2007). Previous studies have found problem-focused coping to be effective for reducing stress in the workplace (Gellis, 2002; Jenaro, Flores & Arias, 2007; Koeske, Kirk & Koeske, 1993; Riolli, 2003). On the other hand, previous studies have found emotion-focused coping to be related to negative psychological outcomes such as higher levels of occupational stress (Gellis, 2002; Jenaro, Flores & Arias, 2007; Thornton, 1992; Koeske, Kirk & Koeske, 1993).

A growing body of literature is stressing that personal resources (cop- ing strategies) may help workers adjust to job demands, and diminish the stress associated with a difficult and demanding job environment (Gellis, 2002; Jenaro, Flores & Arias, 2007; Latack, 1992). With the impact of man- aged care on the professional lives of social workers, such as increased demands for new management activities and paperwork, cost containment, and ongoing demonstration that continued treatment is needed (Rupert & Baird, 2004), it is important to understand how workers cope with these job situations. Types of coping strategies that workers use when interfac- ing with managed care are important to explore as they are likely to affect work outcomes of social workers (i.e., burnout). Although managed care has not suffered from any lack of attention from both the public and the professional media, there is limited data to support the notion that social workers feel that they are not competent and/or able to master the orga- nizational demands associated with managed care (Feldman, 2001; Cohen, 2003; Hall & Keefe, 2000; Keefe & Hall, 1998; Shera, 1996; Stone, 1995). There is also scarce data about how social workers cope when interfac- ing with managed care, and the impact of managed care on negative job

How Social Workers Cope with Managed Care 409

outcomes such as burnout (Feldman, 2001; Cohen, 2003; Rupert & Baird, 2004).

The aim of the present study was to explore in more depth the pro- fessional lives of social workers heavily involved in managed care, and to identify the coping strategies they find most useful in helping them to deal more effectively with the job demands associated with managed care and in reducing negative work outcomes. This study will add to the knowl- edge of how managed care impacts social workers, and how social workers respond to the new demands and challenges associated with managed care. The hypotheses of the study include:

1. Social workers who use problem-focused coping are more likely to feel more competent in the context of managed care.

2. Social workers who use emotion-focused coping strategies are less likely to feel competent in the context of managed care.

3. Social workers who use problem-focused coping strategies are less likely to suffer from burnout, including emotional exhaustion, depersonaliza- tion, reduced personal accomplishment, and somatic symptoms.

4. Social workers who use emotion-focused coping strategies are more likely to suffer from burnout, including emotional exhaustion, depersonaliza- tion, reduced personal accomplishment, and somatic symptoms.

MATERIALS AND METHODS

Procedure

The sample of this study, which was obtained from a professional list of social workers practicing in New York State, consisted of 591 social work- ers. Self-administered and anonymous questionnaire packets were mailed to 1,000 randomly selected individuals from this list. The overall response rate was 58%. The institutional review board of the university where the author is employed approved the study.

Sample

Educational levels of respondents included 89% with master degrees in social work, and 5% with doctoral degrees. The respondents were primarily females (80%). The mean age was 51, ranging from 21 to 80. Seventy-one percent were married or involved in long-term relationship with a partner; 28% were not married. The respondents were predominantly White (86%); 5% were African American or Black, 7% were Latino, and 1% were Asian. The mean for years of experience in social work was 22 years, ranging from 2 to 50 years of employment. The median for client contact hour per week was 25. Forty-three percent were employed in outpatient mental health

410 G. M. Acker

settings, 13% in community support systems, 23 % in private practice, 7% in substance abuse rehabilitation settings, 8% in inpatient psychiatric settings, and 6% in schools.

Measures

PERCEIVED COMPETENCE IN THE CONTEXT OF MANAGED CARE (CMC)

In this study, perceived competence in the context of managed care was defined as workers’ feelings of confidence about their abilities in mas- tering organizational and work demands associated with managed care. The CMC developed by Hall and Keefe (2000) included 16 items ranging from “1 = strongly disagree” to “4 = strongly agree.” Higher scores indi- cated a perception of greater competence in the context of managed care. Example of items included: “Managed care allows me enough direction to be effective in treating clients”; “Coordinating care under managed care con- ditions is easy once you understand the various managed care company requirements”; and, “Managed care allows me enough freedom to be effec- tive in treating clients.” Hall and Keefe (2000) demonstrated that the CMC had adequate validity and reliability. In this study, the Cronbach’s alpha for the CMC was .86.

PROBLEM-FOCUSED COPING STRATEGIES (PFCS)

Problem-focused coping strategies described assertive efforts of the indi- vidual to alter stressful situations. PFCS were measured by a 10-item scale developed by Folkman and Lazarus (1988). Examples of items are: “Stood my ground and fought for what I wanted”; “I expressed anger to the per- son(s) who caused the problem”; and, “Talked to someone who could do something concrete about the problem.” Respondents were asked to rate each item on a 4-point Likert-type scale for the extent to which they used each strategy during stressful job encounters in the past (0 = did not use; 1 = used somewhat; 2 = used quite a bit; 3 = used a great deal). PFCS are known to have both good reliability and validity (Carver, Scheier & Weintraub, 1989; Folkman, Lazarus, Dunkel-Schetter, DeLongis & Gruen, 1986). Cronbach’s alpha for this study sample was .84.

EMOTION-FOCUSED COPING STRATEGIES (EFCS)

This 9-item scale (Folkman & Lazarus, 1988) described wishful thinking and efforts to escape or avoid stressful job related situations. Examples of items were: “wished that the situation would go away or somehow be over with,” “didn’t let it get to me; refused to think about it too much,” and “tried to make myself feel better by eating, drinking, smoking, using drugs,

How Social Workers Cope with Managed Care 411

or medications.” Respondents were asked to rate each item on a 4-point Likert-type scale as described before. EFCS are known to have both good reliability and validity (Carver, Scheier & Weintraub, 1989; Folkman et al., 1986). Cronbach’s alpha for this study sample was .76.

SOCIAL SUPPORT AT THE WORKPLACE

This scale was adapted from the social support from supervisor and social support from co-workers scales (Caplan, Cobb, French, van Harrison, & Pinneau, 1980). The new scale comprised eight questions about the extent to which people around the worker (the worker’s supervisor and co-workers) provided support by listening and by being persons that the worker can rely on for help. Examples of questions are: “How much does your super- visor go out of the way to do things to make your life easier?” and “How much are other people at work willing to listen to your personal problems?” Cronbach’s alpha for this study sample was .88.

BURNOUT

Emotional exhaustion (EE), depersonalization (DP), and personal accom- plishment (PA) were measured by a slightly modified version of the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996). The EE subscale com- prised nine items reflecting feelings of being emotionally overextended, exhausted, physical exhaustion, and emptiness. Examples of items included: “Working with people all day is really a strain for me” and “I feel frus- trated by my job.” The four items of the DP subscale described an unfeeling and impersonal response toward clients of one’s service. It included such items as “I feel I treat some as if they were impersonal objects” and “I don’t really care what happens to some clients.” The PA subscale consisted of six items that describe feelings of competence and successful achieve- ment in one’s work. Examples of items included: “accomplishing worthwhile things at work” and “positively influencing my clients’ lives through work.” Respondents were asked to rate each statement on a 7-point Likert-type scale for frequency of agreement (0 = never, 1 = a few times a year or less; 2 = once a month or less; 3 = a few times a month; 4 = once a week; 5 = a few times a week; 6 = every day). Cronbach’s alpha coef- ficient for this study’s sample included .92 for EE, .78 for DP, and .77 for PA.

SOMATIC SYMPTOMS

This measure included two scales based on previous research done by Mohren and colleagues (2005) and Nakao, Tamiya and Yano (2005). The first scale (12 items) measured flu-like symptoms (e.g., colds, sore throat, cough,

412 G. M. Acker

and fever). The second scale (3 items) measured symptoms of gastroenteritis (GA). Respondents were asked to rate each item on a 7-point Likert-type scale in terms of how often they have been experiencing each of those symptoms for the past six months (0 = never, 1 = rarely; 2 = sometimes; 3 = fairly often; 4 = often; 5 = very often; and, 6 = all or most of the time). Cronbach’s alpha coefficient for this study’s sample included .85 for common colds and flu-like symptoms, and .75 for symptoms of gastroenteritis.

DATA ANALYSIS

Pearson product-moment correlation coefficient was used to investigate the research hypotheses and other relationships among the study’s variables. A correlation matrix was computed for all the study’s variables. To fur- ther explore how coping strategies contributed to the burnout measures above and beyond work-related variables (i.e., competence in the context of managed care, social support, caseload size, satisfaction with the salary, and years of experience practicing social work), as well as workers’ socio- demographic variables (i.e., age, race, and gender), hierarchical regression analyses were used. Data analyses utilized SPSS computer software.

Nominal variables such as gender and race (people of color or Whites) were included in the regression analysis by coding them as dummy variables.

RESULTS

The analysis began with the investigation of the relationships among the variables included in the study’s hypotheses and the other variables of the study. As shown in Table 1, problem-focused coping was found to have statistically significant low positive correlations with emotional exhaustion (EE), depersonalization (DP), flu-like symptoms, and symptoms of gastroen- teritis (GA); and low negative correlations with perceived competence in the context of managed care (CMC) and age. Emotion-focused coping was found to have statistically significant low to medium positive correlations with CMC, EE, DP, reduced personal accomplishment (PA), flu-like symp- toms and GA; and low negative correlations with age and work experience. EE had low negative correlations with CMC, satisfaction with the salary, and social support, and positive low correlation with size of caseload. DP was found to have statistically significant medium positive correlation with emotion-focused coping, and statistically significant low negative correla- tions with age and work experience. PA had statistically significant low negative correlation with emotion-focused coping and low positive cor- relations with age and work experience. CMC had statistically significant

T A

B L E

1 In

te rc

o rr

e la

ti o n s

A m

o n g

St u d y

V ar

ia b le

s (N

= 5 9 1 )

E E

D P

PA F LS

G A

P F C S

E F C S

SS P

R ac

e C as

e lo

ad Sa

la ry

E X

P. A

g e

G e n d e r

V ar

ia b le

2 3

4 5

6 7

8 9

1 0

1 1

1 2

1 3

1 4

1 5

1 . C M

C −.

1 7

∗∗ −.

0 7

.0 2

−. 1 4

∗∗ −.

0 5

−1 9

∗∗ .1

4 ∗∗

.1 2

∗∗ −.

1 3

∗∗ .0

1 −.

1 1

∗ −.

0 9

−. 0 7

−. 0 1

2 . E E

.5 0

∗∗ −.

2 9

∗∗ .3

2 ∗∗

.2 9

∗∗ .2

6 ∗∗

.4 1

∗∗ −.

1 4

∗∗ .0

9 ∗

.1 4

∗∗ −.

1 8

∗∗ −.

0 9

∗ −.

1 0

∗ .0

1 3 . D

P −.

3 7

∗∗ .2

6 ∗∗

.2 2

∗∗ .2

0 ∗∗

.4 4

∗∗ −.

0 2

.1 1

∗∗ .0

2 −.

0 5

−. 1 4

∗∗ −.

1 5

∗∗ −.

1 0

4 . PA

−. 1 3

∗∗ −.

1 3

∗∗ −.

0 5

−. 1 9

∗ .0

3 −.

0 0

.0 3

.0 8

∗ .1

2 ∗∗

.1 7

∗∗ .0

4 5 . F lu

-l ik

e sy

m p to

m s

.4 0

∗∗ .1

5 ∗∗

.2 5

∗∗ −.

1 0

∗ 0 7

−. 0 3

−. 0 6

−. 0 6

−. 0 8

−. 0 8

6 . G

as tr o –

e n te

ri ti s

.1 6

∗∗ .2

8 ∗∗

−. 0 7

.1 4

∗∗ −.

0 1

−. 0 7

−. 0 4

−. 0 6

.0 4

7 . P ro

b le

m –

F o cu

se d

.5 3

∗∗ −.

0 1

−. 0 5

.0 8

.0 3

−. 0 8

−. 1 6

∗∗ .0

6

8 . E m

o ti o n –

fo cu

se d

.0 2

.1 0

∗ −.

0 3

−. 0 3

−. 1 7

∗∗ −.

2 8

∗∗ .0

0

9 . So

ci al

su p p o rt

−. 0 1

.0 2

.0 6

−. 0 1

−. 0 5

−. 0 6

1 0 . R ac

e .0

1 .0

6 −.

0 3

−. 0 3

−. 0 4

1 1 . C as

e lo

ad si

ze .0

7 .0

7 .0

1 −.

0 3

1 2 . Sa

la ry

.0 7

−. 0 4

−. 0 5

1 3 . W

o rk

e x p e ri e n ce

.5 8

∗∗ −.

1 8

∗∗

1 4 . A

g e

−. 9

∗∗

∗ p <

.0 5 ,

∗∗ p

< .0

1 .

413

414 G. M. Acker

low positive correlation with social support, and statistically significant low negative correlation with flu-like symptoms. Both coping styles had low pos- itive correlations with flu-like symptoms and GA. Positive correlation means that the two variables move in the same direction, and negative correla- tion means that the two variables move in opposite directions—that is, as one increases, the other one decreases. White workers reported higher lev- els of DP and GA than non-White workers and also felt less competent in the context of managed care than the non-White workers. The results also indicate that the power of the correlations between the primary variables including EE, DP, PA, flu-like symptoms, and gastroenteritis are sufficiently independent to be examined separately.

Multiple regression analyses provided information on the influence of the different coping mechanisms on burnout symptoms including EE, DP, PA, flu-like symptoms, and gastroenteritis above and beyond the work-related variables (i.e., CMC, social support, caseload size, satisfaction with the salary, and work experience), and workers’ socio-demographic variables includ- ing age, gender, and race. Problem-focused coping was entered first into the regression equation. The second step included the variable emotion- focused coping. Then, in the third step, the work variables were added to the regression to examine whether there was an increase in predictabil- ity above and beyond the information provided by the coping strategies variables. The fourth step included workers’ socio-demographic variables to examine if those variables also contributed significantly to the outcome variables (Table 2). To reduce the problem of finding significance that’s actually produced by chance when multiple correlations are made with mul- tiple regression analysis, the Bonferroni procedure calls for the researcher to divide the .05 probability level by the number of statistical tests to be con- ducted, which in this case included 10 tests. This resulted in a new p value, p = .005 (.05/10)(Montcalm & Royse, 2002).

The first analysis for predicting EE, which included the variable problem- focused coping in the first step, resulted in significant relationship: R2 = .05, F (1, 378) = 20.86, p < .001. Step two, which included the variable emotion- focused coping, was also significant: R2 change = .12, F (1, 377) = 53.07, p < .001. The third step, which included work variables (social support, CMC, caseload size, satisfaction with salary, and years of experience practicing social work), was not significant: R2 change = .03, F (5, 372) = 3.02, p < .011. The fourth step with the socio-demographic variables (age, race, and gender) was not significant, R2 change = .00, F (3, 369) =.537, p < .657. The first step of the second analysis with problem-focused coping as the predictor of DP was significant: R2 = .03, F (1, 378) = 11.36, p < .001. The second equation, which included emotion-focused coping, was also significant: R2

change = .16, F (1, 377) = 76.70, p < .001. The third step, which included the work variables, was not significant: R2 change = .02, F (5, 372) = 2.10,

T A

B L E

2 R e su

lt s

fr o m

H ie

ra rc

h ic

al R e g re

ss io

n A

n al

y se

s P re

d ic

ti n g

O u tc

o m

e V ar

ia b le

s (E

E , D

P, PA

, fl u -l ik

e sy

m p to

m s

an d

G A

)

E E

D P

PA F lu

– li k e

sy m

p to

m s

G A

V ar

ia b le

β t

p β

t p

β t

p β

t p

β t

p

S te

p 1

: P ro

b le

m -F

o cu

se d

.2 3

4 .5

6 8

∗∗ .1

7 3 .3

7 6

∗∗ −.

0 4

−. 8 4 6

∗∗ .1

6 −3

.1 3 0

∗∗ .1

7 3 .4

3 4

∗∗

R 2

.0 5

∗∗ .0

3 ∗∗

.0 0

.0 3

∗∗ .0

3 ∗∗

F 2 0 .8

6 1 1 .4

0 .7

2 9 .8

0 1 1 .8

0

S te

p 2

: E m

o ti o n -F

o cu

se d

.5 4

7 .2

8 5

∗∗ .4

7 8 .7

5 8

∗∗ −.

2 3

−3 .8

9 8

∗∗ .2

0 3 .5

0 8

.2 6

4 .5

0 5

∗∗

R 2

.1 7

∗∗ .1

9 ∗∗

.0 4

∗∗ .0

6 ∗∗

.0 8

∗∗

F 5 3 .0

7 7 6 .7

0 1 5 .1

9 1 2 .3

1 2 0 .2

9

S te

p 3

: C M

C .1

3 2 .8

6 7

∗ .1

3 2 .9

4 2

∗ −.

0 1

−. 1 9 0 4

.0 6

1 .2

2 5

.0 1

.1 2 4

So ci

al su

p p o rt

−. 0 6

−1 .1

4 1

.0 2

.3 6 7

−. 0 2

−. 3 0 8

−. 1 1

−2 .2

2 5

−. 0 5

−. 8 9 5

C as

e lo

ad −.

0 2

.5 2 0

.0 1

.1 3 6

−. 0 6

−1 .1

6 8

.0 2

.3 3 1

.0 3

.6 3 8

Sa la

ry −.

0 8

−1 .7

7 4

.0 0

−. 0 0 5

.0 8

1 .4

8 6

−. 0 8

−1 .6

1 6

−. 0 5

−1 .0

1 8

e x p e ri e n ce

.0 2

.4 2 2

−. 0 7

−1 .4

3 1

.0 9

1 .6

4 4

−. 0 2

−. 4 3 9

.0 2

.3 1 6

R 2

.2 0

.2 2

.0 7

.0 8

.0 9

F 3 .0

3 2 .1

0 2 .1

0 2 .0

.4 7

S te

p 4

: A

g e

.0 7

1 .1

2 4

−. 0 7

−1 .4

3 1

.1 5

2 .3

2 0

.0 5

.7 8 7

.0 4

.5 8 5

G e n d e r

.0 3

.5 4 9

−. 0 8

−1 .6

7 4

.0 9

1 .8

2 0

.0 3

.6 3 0

.0 6

1 .1

6 1

R ac

e .0

2 .3

6 3

.0 4

.9 2 5

.0 9

1 .8

1 9

−. 0 2

−. 3 0 7

.0 1

.2 4 0

R 2

.2 1

.2 3

.1 0

.0 8

.0 9

F .5

4 1 .5

7 3 .7

6 −.

3 5

.5 4

∗ p <

.0 0 5 ,

∗∗ p

< .0

0 1 .

415

416 G. M. Acker

p < .064. The fourth step with the socio-demographic variables was not significant: R2 change = .01, F (3, 369) = 1.20, p < .197.

The first step of the third analysis for predicting PA was not significant: R2 = .00, F (1, 378) = .716, p < .398). The second equation, which included emotion-focused coping, was significant: R2 change = .04, F (1, 377) = 15.19, p < .001. The third step which included the work variables, was not sig- nificant: R2 change = .03, F (5, 372) = 2.10, p < .065. The fourth step with the socio-demographic variables was not significant: R2 change = .03, F (3, 369) = 3.76, p < .011.

The analysis for predicting flu-like symptoms resulted in significant rela- tionship for the first step: R2 = .03, F (1, 377) = 9.80, p < .002. The second equation was also significant: R2 change = .03, F (5, 376) = 12.31, p < .001. The third step, which included the work variables, was not significant R2

change = .03, F (5, 371) = 2.00, p < .077. The fourth step with the socio- demographic variables was not significant: R2 change = .00, F (3, 368) = .35, p < .790. The last analysis for predicting gastroenteritis resulted in a signif- icant relationship for the first step: R2 = .03, F (1, 377) = 11.80, p < .001. The second equation was also significant: R2 change = .05, F (1, 376) = 20.29, p < .001. The third step including the work variables was not significant: R2 change = .01, F (5, 371= .47, p < .800). The fourth step with the socio- demographic variables was not significant: R2 change = .00, F (3, 368) = .54, p < .653.

Based on the results of the multiple regression analyses, EE, DP, and the somatic symptoms were predicted by problem-focused coping and emotion- focused coping when controlling for the work and the socio-demographic variables. PA was predicted only by emotion-focused coping when con- trolling for the work and the socio-demographic variables. The sets of the work variables and the socio-demographic variables offered little additional predictive power beyond that contributed by problem-focused coping and emotion-focused coping.

DISCUSSION

The results of this study suggest significant relationships between compe- tence in the context of managed care, coping, emotional exhaustion, somatic symptoms, social support, and several demographic variables such as race, age, and work experience. The data suggested that social workers that felt competent in working with managed care organizations did not rely on problem-focused coping. It is possible that, because of their good relation- ship and comfort working with managed care organizations, they did not need to assert themselves with managed care staff and/or direct their energy and efforts toward actions and activities that would eliminate problems. This confirms previous research, which suggests that stressful work situations

How Social Workers Cope with Managed Care 417

elicit those behaviors directly aimed at altering or managing the problematic situation (Gellis, 2002; Lazarus & Folkman, 1984; Shikai, et al., 2007).

On the other hand, those who did not feel competent in working with managed care organizations relied on emotion-focused coping and used escape-avoidance behaviors. The study also found that competence in the context of managed care did contribute negatively to emotional exhaustion and flu-like symptoms. These findings are consistent with other researchers (Bandura, 1989; Cherniss, 1993; Hall & Keefe, 2000; Harrison, 1980; Wagner & Morse, 1975; White, 1967).

The findings of this study are in accordance with the coping strategies literature, which suggests that the mere existence of stress is less important than how individuals appraise and cope with stress (Aldwin & Revenson, 1987; Antonovski, 1979; Gellis, 2002; Lazarus, 1981). When controlling for all the other variables in the hierarchical regression analyses, coping strate- gies had statistically significant relationships with all the burnout variables, indicating that the internal psychological resources available to people are the key component of how people deal with work stress. Contrary to the burnout literature (Arches, 1997; Maslach, 1978; Maslach, Jackson & Leiter, 1996; Pines, 1983; Rosenbaum, 1992), in this study work-related stressors, such as those associated with lower levels of competence in the context of managed care, social support, and caseload size, were not as important in predicting burnout as the ways that people cope with those stressors.

As some theorists state, the relationship between problem-focused cop- ing and emotion-focused coping is not as simple, as people tend to use both coping styles when dealing with the same source of stress. When dealing with stressful encounters, people do not necessarily use either problem- focused coping or emotion-focused coping. They may wait for a while until they react directly to the stressful encounter by first using emotional-coping style. When people feel that they have not handled the stressful situation well, they will expand the effort to reduce the impact of the stressful event; one possibility is to switch to more effective coping styles such as those that deal directly with the problem and are more likely to reduce the impact of the stressful event (Carver, Scheier & Weintraub, 1989). In this study, both problem-focused coping and emotion-focused coping had statistically significant positive correlations with the burnout dimensions; however, the power of the correlations between emotion-focused coping and the burnout variables were stronger than the power of the correlations between problem- focused coping and the burnout variables. These results suggest that workers probably use both coping styles; however, those that use more emotion- focused coping are more likely to experience burnout. These results support other studies that show that emotion-focused coping has substantial posi- tive association with distress, and that problem-focused is not necessarily effective in lowering it (Ben-Zur, 2005).

418 G. M. Acker

The results of this study also exhibited that several demographic vari- ables such as race, age, and work experience were related to competence in the context of managed care and several burnout variables. These find- ings are consistent with early studies of burnout, which claimed that older workers with more life and job experience are at a lower risk for burnout compared to those who are young and have less job experience. Non-White workers, according to the early theory of burnout, do not burn out as much, as they have a more realistic perspective about life and are thus better prepared to cope with stress (Farber, 1983; Maslach, 1982).

Although competence in the context of managed care had statistically significant correlations with coping and several of the burnout symptoms, those relationships were not evident in the multiple regression analyses. These findings support the empirical coping literature, which has empha- sized that the ways that workers cope with job stressors may be more important than the amount of stress itself (Aldwin & Revenson, 1987; Antonovski, 1979; Gellis, 2002; Latack, 1992; Lazarus, 1981). Thus, it appears that it is more important to focus on how social workers deal with the new challenges and requirements associated with managed mental health care rather than on the stressors themselves.

STUDY LIMITATIONS

The convenience sample of social workers and the voluntary nature of participation limit the generalizability of the study’s findings. Because of the respondents’ advanced age and work experience, as well as their higher level of education, they may be more competent and better pre- pared in dealing effectively with the challenges and demands associated with managed care practices. Younger and less educated workers may be at a disadvantage when negotiating and intervening with managed care organizations in comparison to the more experienced and skilled workers. Another limitation is the response set of subjects when respond- ing to self-report measures, which is inclusive for this type of research design. A similar response set to different scales that measure respon- dents’ feelings and perceptions about their job could be a result of a temporary mood of respondents at the time of responding to those measures, as well as it can be related to a social desirability factor. The non-response bias is another problem, as those who choose not to participate may be different than those who participate. Although the findings included several statistically significant correlations, most of them would not be significant with a Bonferroni correction. Thus, with this type of research design, a cautious interpretation of the findings is suggested.

How Social Workers Cope with Managed Care 419

CONCLUSIONS

The coping strategies provided the most comprehensive influence on work- ers’ both psychological and somatic reactions associated with burnout. Although this study provided a preliminary understanding of how social workers cope in this current mental health care environment, there are still many more unanswered questions. Future research should use more diverse samples with workers who are younger and who represent more diverse ethnic and racial backgrounds. Future studies should also attempt to answer what the most effective strategies are for social workers dealing with the external pressures associated with the current mental health care environment. Coping skills can be improved by providing social workers— especially those just entering the field—with training that can promote the use of effective coping styles appropriate for dealing with challenges such as those associated with managed care organizations.

Agencies may consider workshops and peer group discussions that focus on how to deal with work stressors and work demands not suffi- ciently discussed in professional programs and academic institutions (Bolen & Hall, 2007; Keefe & Hall, 1998). Creating a supportive environment for workers is another consideration that could help reduce the negative impact of potential work stressors and alter workers’ negative perceptions of their work.

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