EXPANDING THE BOUNDARIES OF PRIMARY CARE FOR ELDERLY PEOPLE.

EXPANDING THE BOUNDARIES OF PRIMARY CARE FOR ELDERLY PEOPLE. This article reports the results of a qualitative evaluation of theGeneralist gen��er��al��istn.A physician whose practice is not oriented in a specific medical specialty but instead covers a variety of medical problems.generalistPhysician Initiative, designed to enhance the care of olderpeople provided by primary care physicians in nine demonstrationprojects around the country. A theme entitled "Pushing the ComfortZone" examines activities in which physicians engage beforecollaboration: selecting elderly patients, "opening cans ofworms," recognizing patient and family expectations, and goingoutside the comfort zone. A second theme called "Linking withCollaborators" reveals activities in which physicians engage asthey collaborate: teaming, using intervention agents as eyes and ears,communicating, and tracking patients. Findings indicate that socialworkers are logical collaborators with primary care physicians ascontemporary practice is expanding to be more holistic. Keywords aging care coordination case management interdisciplinary practice physicians Recently primary care has been the subject of much attention asattempts have been made to rethink health care in light of managed caresystems (Strom-Gottfried, 1997). Of particular concern is how primarycare physicians address the needs of increasing numbers of older peoplewith chronic conditions (Christianson, Taylor, & Knutson, 1998;Institute of Medicine, 1996; Mark, Gottlieb, Zellner, Chetty, &Midtling, 1996; Radecki, Kane, Solomon, Mendenhall, & Beck, 1988;Weiss & Blustein, 1996). Social workers have roles to play in helping physicians and theirstaff assess, plan, and intervene with older patients (Berkman, 1996;Berkman, Damron-Rodriquez, Dobrof, & Harry, 1995; Browne, Smith,Ewalt, & Walker, 1996; Ell, 1996; Netting & Williams, 1996,1998; Zayas & Dyche, 1992). For example, Azzarto (1993) examinedfive practices consisting of 34 family physicians in New Jersey in whichthe specialist--therapist role was played by social workers inintervening with older patients who frustrated frus��trate?tr.v. frus��trat��ed, frus��trat��ing, frus��trates1. a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: physicians because theyrequired extensive "reassurance, time, and attention" (p. 46).Berkman (1996) identified a list of tasks that social workers perform asclinical specialists and also identified the case manager role forsocial workers. Many writers have explored the role of geriatric geriatric/ger��i��at��ric/ (jer?e-at��rik)1. pertaining to elderly persons or to the aging process.2. pertaining to geriatrics.ger��i��at��ricadj.1. casemanager (Applebaum & Austin, 1990; Capitman, Haskins, &Bernstein, 1986; Gerber, 1994; Geron & Chassler, 1994; Kane, Penrod,& Kivnick, 1994; Netting & Williams, 1995, 1996, 1998). In 1992 the John A. Hartford Foundation Hartford Foundation,fund established (1929) by retail food merchants John A. Hartford (1872–1951) and George L. Hartford (1864–1957) of the Great Atlantic and Pacific Tea Company (A&P) as a philanthropic institution with the general purpose of doing organized The GeneralistPhysician Initiative to support development of care management programsin primary care physician practices. Building on what had been learned about challenges in everydaypractice with older people in an earlier demonstration (White, Gundrum,Shearer, & Simmons, 1994), the foundation funded nine projects todevelop care coordination models based in physicians' offices.Staff in each project selected comprehensive geriatric assessment geriatric assessment,n the evaluation of the physical, mental, and emotional health of elderly patients. tools,although methods varied. Each project had multiple sites. Sites variedin type of location (urban, suburban, and rural), patient incomes, andpenetration of managed care. The intent was to create a diversity ofrelevant and feasible models, given local conditions, prior experience,the cultures of the systems in which they would be introduced, theirtraditions, and congruence con��gru��ence?n.1. a. Agreement, harmony, conformity, or correspondence.b. An instance of this: "What an extraordinary congruence of genius and era" with leaders' expectations. (For anoverview of each project, see Netting & Williams, 1999). In 1994 program officers from the John A. Hartford Foundation askedus to travel to each project to identify emerging themes thatcontributed to project development. This article reports the results ofour examination and discusses implications for social workers. METHOD We used a qualitative approach. We (a social worker and a healthcare administrator) visited the sites to interview key players, tookfield notes of informal encounters and observations, participated injoint meetings, read six-month and annual reports, and immersed im��merse?tr.v. im��mersed, im��mers��ing, im��mers��es1. To cover completely in a liquid; submerge.2. To baptize by submerging in water.3. ourselves in getting to know these projects. In addition to semiformalinterviews and reading of reports, learning about the sites was oftenhighly informal as we observed interactions on site and presentations atboth joint project conferences and numerous professional meetings. We developed a semistructured interview schedule to allowflexibility for respondents to elaborate and for us to probe and clarify(Fontana & Frey, 1994). In 1994 we coconducted 105 face-to-face,taped interviews with 40 physicians, 32 intervention agents, and 23office staff in the nine projects. We published an article based onthese interviews that focused on issues of professional identity asintervention agents (often called care coordinators) tried to definetheir roles (Netting & Williams, 1996). In the 1995-96 visits wecoconducted 89 interviews of 44 physicians, 24 intervention agents, and21 project staff. Because of staff turnover and last minute emergencies,it was not always possible to reinterview the same individuals. Of theseinterviewees, 56 had been interviewed in the first round, leaving 33 whowere new participants. Coming from different fields (social work and healthadministration) assisted us in probing different areas that one of usmight have missed. Interviews lasted an average of 30 minutes, rangingfrom 20 to 60 minutes. Following each interview, we discussed initialimpressions, talked over emerging themes, and wrote field notes (Fontana& Frey, 1994). Interviews were transcribed verbatim ver��ba��tim?adj.Using exactly the same words; corresponding word for word: a verbatim report of the conversation.adv. , checked foraccuracy, then mailed to respondents to make corrections. Interviewees were assigned codes, and each interview was summarizedon a contact summary page (Miles & Huberman, 1994). Final interviewtranscriptions were subjected to open coding in which phrases,sentences, and paragraphs were "broken down into discrete parts,closely examined, compared for similarities and differences, andquestions [were] asked about the phenomena as reflected in thedata" (Strauss & Corbin, 1990, p. 62). We identified subcodeswhen too many data chunks fell into certain categories. This process ofpattern coding assisted in reducing data chunks into smaller sets ofthemes (Miles & Huberman, 1994). Following each round of interviews, after we had identifiedpotential themes, respondents engaged in a member-checking process(Janesick, 1994) reacting to preliminary results. This process wasfacilitated by cross-site meetings held at least once a year, offeringus opportunities to report emerging themes to key players. Respondentsoften were surprised to hear that themes they felt were site-specificwere relevant across sites. Ongoing engagement with respondents betweenand after interviews and our observations assisted in data analysis andinterpretation. Audit trails were established so that any data chunkcould be traced to a specific page of an interview transcript. RESULTS In interviews, documents, observations, and interactions thereemerged an overriding concern--how to expand the scope of physicianpractice to deal with increasing numbers of older patients with diverseneeds. We identified two project implementation themes related toexpanding the scope of practice (1) "pushing the comfort zone'and (2) "linking with collaborators." Each theme has foursubthemes: pushing the comfort zone includes activities physiciansengage in prior to collaboration--selecting elderly patients,"opening cans of worms," recognizing patient and familyexpectations, and going outside the comfort zone. Linking withcollaborators revealed activities in which physicians engage as theycollaborate: teaming, using intervention agents as eyes and ears,communicating, and tracking patients. These themes reflect activities inwhich physicians worked with intervention agents to serve elderlypatients. Pushing the Comfort Zone Selecting Elderly Patients. Each project had established criteriafor patient selection, such as age, diagnosis, health, and functionalstatus, to focus project resources on the patients most likely tobenefit from the intervention. However, across sites, physicians who hadparticipated in establishing criteria changed their minds as projectsdeveloped, and they referred patients who presented with unanticipateddifficult or complicated problems not within the original selectioncriteria. Respondents had strong opinions about who would benefit more from acase management--type intervention. Asked who would be the ideal groupof patients, given their experience with the project, one physiciansaid, Those [outside the project guidelines] have complex needs. Whetherit be medically, with multiple medications or with a history ofnon-adherence to a plan of action,...it might have been dealing with toomany doctors and having too many prescriptions on the shelf and theywere just throwing their hands up in the air and saying that theydon't know what they are doing. A physician in another project said, anyone homebound. You know, who can't drive themselves and whohave to rely on their family for transportation ... multiple medicalproblems...psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. , really. Whether it is depression, anxiety orfamily dysfunction dysfunction/dys��func��tion/ (dis-funk��shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc��tionalerectile dysfunction? impotence (2). , I have a ton of widowed women and they are alldepressed. Yet another physician answered, "You can just open their chartand count the number of drugs they are on. More than three, theyprobably need to be in the program." Another physician said,"Probably patients that are borderline borderline/bor��der��line/ (-lin) of a phenomenon, straddling the dividing line between two categories. borderlinefunctioning as far asindependent living goes and having trouble with medical non-compliance?And yet another physician indicated, "Well, obviously, people whoare lacking in social support. People who don't have family thatare available to do anything for them." Selecting the patients who would benefit most from having a socialworker, nurse, or other collaborator intervene was not always easy. Evenin projects with well-established criteria for patient selection,physicians often encountered new dilemmas with their elderly patients.And these new, complicated dilemmas were not always welcomed. Opening Cans of Worms. A physician in a project that usedphysician's assistants as collaborators, expressed his feelingsabout older people and their complex problems. "I am continuallyfrustrated because we can't do enough....My deep feeling is thatyou help people one person at a time." A physician at anotherproject that used advanced practice nurses as collaborators explained, There is no end to what you can do, so you basically do what youcan...[we] deal with medical issues all the time....but they are issuesthat will also have emotional reverberations. The incredible thing to meis how it is a Pandora's box and all of a sudden a sea of troublescomes out of the box. A nurse intervention agent told us the following: "One of thephysicians ... referred to the can of worms that I opened when I wasfirst here and he was like 'where do you get all this stuff?'I would come to him with Mrs. Smith's stuff and he was dealing withthe knee or the arm and I was saying, 'but there is this and thereis that...'and all these other psychosocial or depression issues oranxiety." Another nurse at the same site continued, "[Before]he would not lift the cover because he couldn't do anything aboutit. I think because he is a very sensitive person, it would make himfeel bad whereas now, he opens the cover and let's me take care ofthe worms? Another respondent indicated that the physicians with whomshe worked would like to deal with "one worm at a time." In a rural project that used paraprofessional paraprofessional1. a person who is specially trained in a particular field or occupation to assist a veterinarian.2. allied animal health professional.3. pertaining to a paraprofessional. geriatric techniciansto visit in the homes of elderly patients, a physician expressed hisfeelings: I think you probably have to open that can of worms if you'regonna gon��na?InformalContraction of going to: We're gonna win today.help your patients. Usually I don't go in with a formalagenda...on any office visit. I kinda go in asking open-ended questionsand I set my priorities by what the patient tells me in the first coupleof minutes and if it's mainly a social problem we go into that andwe talk and counsel. If it's mainly a physical problem I take careof the physical health and we talk at another visit. Cans of worms, seas of troubles, and Pandora's boxes broughtphysicians face to face with patient and family expectations. Recognizing Patient and Family Expectations. Some older patientswho called frequently were described as feeling that their physician was"the only one who can answer questions." One physician saidpatient expectations for doctors and ministers are similar. The need andexpectations of elderly patients for more time with physicians wasoffset by resource limitations. Everyone talked about time constraintsand the economic push to see more patients. Physicians and others practicing in small towns and rural areasindicated that seeing the person in context is expected by patients andfamilies. One physician based in a small Midwestern town explained,"Well, we are intimate with the patients who need us to be. I meanwe don't know the social history of everybody. But most of theolder people who have been our patients for awhile a��while?adv.For a short time.Usage Note: Awhile, an adverb, is never preceded by a preposition such as for, but the two-word form a while may be preceded by a preposition. , we know withthem....Half of what we deal with is social, psychosocial, Ithink." Another physician in another project located in the rural southcommented, Most of the physicians I talk to are so enmeshed en��mesh? also im��meshtr.v. en��meshed, en��mesh��ing, en��mesh��esTo entangle, involve, or catch in or as if in a mesh. See Synonyms at catch. in the traditionalresponsibilities of the office that as long as it is not expected forthem to reach out in this way and as long as there are no resourcesthere, they are going to keep the blinders blind��er?n.1. blinders A pair of leather flaps attached to a horse's bridle to curtail side vision. Also called blinkers.2. Something that serves to obscure clear perception and discernment. on and perform as they alwayshave. ... I am an incredibly holistic person. ... We attend funerals, wehave bought people's medicines, we send flowers to people when wethink they just need a little cheering up. We call ministers and tellthem that they need to get out and visit their parishioners whenwe've felt that was appropriate. We've done this even before[this project]. Similarly, when physicians served other family members, they oftenbecame more aware of contextual issues, particularly when a spouse orson or daughter provided information about an elderly relative. Thisoccurred in both urban and rural areas. For example, respondents whoworked in an inner-city clinic told us how their patients' familieskept in close touch with them and that the community surrounding theclinic had long-established, extended family networks. Identifying family issues was mentioned by many physicians as beingextremely important. Issues were identified through formal assessments,in-home visits, and in conversations with patients. One physicianexplained that "it is important to have a [variety of information]as part of their patient profile ... to sort things out. You have tohave ... what the rest of the family looked like. Most of these people,I have several generations coming in at one time ... this is grandma,but I also take care of her kids and their kids, and you get a feelingfor the whole family ... that is when you can intervene the best." These expectations and the need to broaden one's thinkingabout older patients led another physician to remark, "It takes youout of the comfort zone." Going Outside the Comfort Zone. Respondents expressed deeply heldfeelings about their responsibility to focus on more than medicalissues, the implications of seeing people holistically. Time limitationswere on everyone's mind. For example, one physician said, "Idon't know that we could go as far as we should because of timeconstraints ... I feel more comfortable dealing with medical issues Iknow how to solve or at least know if they are solvable or not, versusthese somewhat more nebulous issues ... that I don't know if Ireally want to get into because if they tell me about them, I feelobliged ... to do something about them." Obligation was a frequently used term by multiple respondents. Aslong as issues were not known, physicians were not obligated to seekthem out. Once identified, however, most physicians felt that theseissues needed to be addressed. Physicians who were predisposed pre��dis��pose?v. pre��dis��posed, pre��dis��pos��ing, pre��dis��pos��esv.tr.1. a. To make (someone) inclined to something in advance: towardexpanded practice boundaries provided case examples of how they wereaware of these issues: I would be disconcerted dis��con��cert?tr.v. dis��con��cert��ed, dis��con��cert��ing, dis��con��certs1. To upset the self-possession of; ruffle. See Synonyms at embarrass.2. ... if a doctor really says that he'soverwhelmed o��ver��whelm?tr.v. o��ver��whelmed, o��ver��whelm��ing, o��ver��whelms1. To surge over and submerge; engulf: waves overwhelming the rocky shoreline.2. a. by dealing with these other issues. It's illogicalsince the patient deals with those issues every day. ... I had a patientthis morning, a man who is 89, is vibrant. And yet he has a wife who isso depressing to him and who just is so demanding and whining...that itactually is destroying him....His major problem in life is not hishealth, he's got heart trouble, diabetes and things like that, hecan lick lick1. a stroke with the tongue, normally used in cleaning the coat or ingesting a substance from a flat surface. See also licking.2. a mixture of salt plus other macro-elements, especially phosphorus, trace elements, vitamins and other feed additives, fed loosely in a box in a moment. It's what to do for him and with thiswife.... What's going on What's Going On is a record by American soul singer Marvin Gaye. Released on May 21, 1971 (see 1971 in music), What's Going On reflected the beginning of a new trend in soul music. outside our medical interaction is farmore important than what I prescribe for him. Physicians predisposed to an expanded practice were sometimeschagrined to relate stories in which they tried to be advocates andended up feeling like they had not performed well. One physician told ofhow he attempted to assist a patient who was upset over a dispute with alandlord. He indicated that these type of interventions take a lot ofpatience: "There are always two points of view. [In sending aletter to a landlord] if you pick the point of the patient and arecompletely wrong, you have egg on your face because you have listened tothem ... [it's better to] have the nurse assessing the situation orsomeone else, then you have a better assessment. If the landlord isindeed being unfair to the tenant, then you can intervene." Another physician at the same site who had joined his colleagueduring the interview chimed in: "I have done that with like gettinga bus. The patient may be handicapped and in a wheel chair and the busroute wouldn't accommodate them. So I sent this long letter and Igot a letter back explaining five different options that the patientreally has but the patient has chosen not to take advantage of and Ifelt kind of fooled... like I was completely off base." Examples of failed efforts to perform nonmedical tasks were common.This led physicians to examine the importance of handing these tasks toa team member. Linking with Collaborators Teaming. The importance of teaming with other professionals was arecurring re��cur?intr.v. re��curred, re��cur��ring, re��curs1. To happen, come up, or show up again or repeatedly.2. To return to one's attention or memory.3. To return in thought or discourse. theme. A physician explained how the project's teammeetings had allowed him to educate residents to know the importance ofother professionals being involved in patient care: "Showing howthe social worker can impact your patient's health to a resident, Ithink is more important... [They] can enlighten en��light��en?tr.v. en��light��ened, en��light��en��ing, en��light��ens1. To give spiritual or intellectual insight to: your understanding of apatient and their problems like why the patient is in and out of thehospital every month. You'll get a better understanding ofwhat's going on or not going on at home." Family physicians commented that their socialization socialization/so��cial��iza��tion/ (so?shal-i-za��shun) the process by which society integrates the individual and the individual learns to behave in socially acceptable ways. so��cial��i��za��tionn. to medicinemandated they have more permeable permeable/per��me��a��ble/ (per��me-ah-b'l) not impassable; pervious; permitting passage of a substance. per��me��a��bleadj.That can be permeated or penetrated, especially by liquids or gases. boundaries than internists orspecialists. One physician stated how working with a nurse/social workerteam in this project reminded him of how he had been socialized so��cial��ize?v. so��cial��ized, so��cial��iz��ing, so��cial��iz��esv.tr.1. To place under government or group ownership or control.2. To make fit for companionship with others; make sociable. :"This reinforced my training, when I first began, I did these typeof things before. This kind of reawakened some of my desires to be therenaissance man Renaissance mann.A man who has broad intellectual interests and is accomplished in areas of both the arts and the sciences.Noun 1. , now that I have help, I don't have to try and doit all. There is a real delight in having this [project] here. Physicians were knowledgeable about the role of hospital socialworkers and recognized that they often functioned as discharge planners.Physicians revealed how they depended on hospital social workers tofollow through whenever they could. Otherwise, it became thephysician's "obligation" as the patient was discharged.One physician explained, "In the office I feel some obligation todo that but in the hospital no, I will let the social worker take careof that. Otherwise, it would be a never-ending problem. You know, talkto her daughter, talk to the nursing home, talk to the insurance[company],and what have you... It just is impossible." It was as ifhe used a patient's hospitalization hospitalization/hos��pi��tal��iza��tion/ (hos?pi-t'l-i-za��shun)1. the placing of a patient in a hospital for treatment.2. the term of confinement in a hospital. , and access to a collaborator,as a bit of a respite RESPITE, contracts, civil law. An act by which a debtor who is unable to satisfy his debts at the moment, transacts (i. e. compromises) with his creditors, and obtains from them time or delay for the payment of the sums which he owes to them. Louis. Code, 3051. from the emerging daily issues. The same physicianindicated that another strategy he used to maintain some order was totriage: "If you have a triaging system so that persons say it isreally important that you do that, rather than the nurse or the socialworker do it, then I am willing to do that. But, to do that all the timeyou simply can not [take on everything]." Using Intervention Agents as Eyes and Ears. The intervention agentsat various sites became people to whom physicians could refer theirhardest, most complicated older patients who needed much more thanmedical care. Physicians often used body metaphors, callingcollaborators their eyes and ears, and even their brains, that go intothe community. Seven of the nine projects used intervention agents to dohome visiting. Physicians repeatedly told us that they learned thingsabout their older patients not previously known and usually were pleasedto have this contextual information. Although two projects used social workers in case management-typeroles as part of their intervention, and another project used a socialwork consultant with nurse practitioners, the remaining six projects didnot use social workers. Three used nurses, one used physicianassistants, one used paraprofessionals, and one used physicians as theirown care coordinators. However, when asked about practice boundaries interms of broader community needs, physicians often would make commentslike "maybe the solution is a social worker working much moreclosely than we have ever worked with those patients." Thisphysician was at a site that used advanced practice nurses ascollaborators. Another physician in a project that used physician assistants hadthis to say, I try to know as much as I can about my patients. ... Occasionallyyou will see a patient that you have seen over the last year who seemslike something is just wrong and you ask them and you get to the bottomof it--someone new is living in the house (a nephew, a friend, adaughter on drugs). Something has changed in their perspective. I wouldnote that. I wouldn't go see what that person was doing at thehouse, I didn't have time. [I would make] social work referrals. And yet another physician who was part of a project that used nursepractitioners had this to say about social workers with whom he hadworked: We've had some really frustrating frus��trate?tr.v. frus��trat��ed, frus��trat��ing, frus��trates1. a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: situations where peoplearen't getting what they need, are mentally impaired but notincompetent incompetentadj. 1) referring to a person who is not able to manage his/her affairs due to mental deficiency (lack of I.Q., deterioration, illness or psychosis) or sometimes physical disability. and sometimes there isn't a safety net and this personis kind of in the middle. We've had a social worker be thesurrogate surrogaten. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. family for some of our patients, make arrangements to havethem moved into safer housing, call the moving company....We had [aconsultant here one day] and a theme emerged. They were all single womenwith no family. The consultant he mentioned was a social work educator, and thesocial worker to whom he referred was not part of the project. The nursepractitioner nurse practitionern. Abbr. NPA registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician. at this same project added in a subsequent interview,"I don't think it's necessary for [physicians] to try tobe the social worker, but to know when to be aware that maybe some ofthese other people can help in taking care of patients." Communicating. Care coordinators collected a great deal of clientdata, much of which were used for evaluative purposes. However,physicians often felt overwhelmed with so much information. Depending onthe project, various methods were used to streamline what was placed inmedical charts to give physicians only what they considered useful andcritical. Intervention agents came up with quick and easy ways tofacilitate written communication with physicians. Different projectsused color-coded sheets that stood out in medical charts to alertphysicians to issues faced by patients, whereas others used sticky notesto make notations of important concerns. Physicians and office staffwould refer to the "purple sheets" or the"stickies." Verbal communication was as important as written communication interms of routine office decision making. Terms such as "rapidresponse," "immediate reaction," and "catch as catchcan" were used to describe how physicians and care coordinatorsliterally caught one another in the hallways to share patientinformation. Physicians explained that it was easier to catch carecoordinators when a patient was in the office, chat for five minutes,and then hand the person off to the care coordinator for follow-up.Communicating information when it was fresh on one's mind ensuredthat referrals were made immediately. One physician referred to "amoving roundtable up and down the hail"; another said that"you hit the door running and you don't stop"; anotherdescribed his practice as "bedlam." None of the projects had fully developed information systems. Theone site that did not use professional or paraprofessional staff wasdeveloping an information system for the extensive amount ofself-reported data that were generated. However, the data were notentered at the practices themselves, and there was lag time beforephysicians actually got printouts on their patients. As the projectcontinued, the intent was to computerize data collected at actualphysician offices, but this phase was just beginning. Projects withoutcomputer systems were still unable to link with hospital databases andwere using computers for billing only, rather than patient informationpurposes. One physician simply felt information systems were unhelpful:"I would much rather hear directly from someone working with a casewith me, their personal impressions and knowledge of the case....Frequently notes are slightly out of step with what is going on, andgood documentation just doesn't help in those day-to-day decisionmakin g processes. Most projects quickly abandoned trying to have set meeting times inwhich to communicate with one another about patients. One projectmanaged to preserve bimonthly bi��month��ly?adj.1. Happening every two months.2. Happening twice a month; semimonthly.adv.1. Once every two months.2. Twice a month; semimonthly.n. pl. meetings of care coordinators, but theydid not meet formally with other team members (for example, physiciansor office staff). In one project, which managed to maintain monthlymeetings of physician and nurse practitioner, teams felt theseopportunities were valuable. Perhaps there was a trade-off between time to meet in teams andhome visiting, as the one site that managed to retain team meetings didnot do home visiting. Projects seemed to benefit greatly from theinformation that was collected during home visits. One physicianexplained, "Occasionally [she finds out things I don't know].I think she discovered one of our patients was a closet alcoholic orsomething that I was kind of flabbergasted about." Tracking Patients. Tracking patients between office visits becameextremely helpful to physicians and office staff. Physicians told usabout patients who entered different hospital systems or nursing homesand how they lost track of how they were doing. As other physiciansintervened with these patients, new medications might be ordered, andthese medications would not be noted in the primary carephysician's charts. One physician described the importance ofknowing when patients were being discharged: "The thing I foundmost useful was (knowing) when the hospitalized patients were coming outand making sure ... what happened while they were in, when the visitingnurse vis��it��ing nursen.A registered nurse employed by a public health agency or hospital to promote community health and especially to visit and administer treatment to sick people in their homes. is coming to see them, they were going to be having blood drawn,the medications they were on when they were coming out, the changes inthe medication from what I had them on, and when they were coming to seeme. The care coordinator became a link between the physician'spractice and patients. Physicians focused on the daily practice routine,responding quickly, and seeing lots of people. Care coordinators linkedthe patient with the physician's office, keeping in mind how thepatient fit within the larger environment beyond the office walls. Anoffice staff person explained how physicians viewed the care coordinatorin this way: I think [hearing from the care coordinator] helps him understandmore of the patient. Why is this woman's blood pressure up or thisdepression that we are seeing, you can put it altogether. It is anotherpiece of the puzzle and, the more information that you have on thepatient the better. It is a better way to serve them if you really doknow what is going on. [The care coordinator] had messages upon messagesbecause they call [her] before they even call us.... They tell hereverything. Sometimes they don't even call for a medical reason,they talk about their granddaughter did this or that... a lot of thesepeople are lonely. DISCUSSION Pushing the Comfort Zone reveals a set of activities in whichphysicians engage. Having specified selection criteria does not alwaysaccount for the unexpected dilemmas that arise for older people. Forexample, having a certain diagnosis (or diagnoses) or being a certainage does not mean that patients do not present with other, potentiallyeven more difficult, problems. Physicians agree that they want to handoff these complex, often nonmedical problems to others. Postfunding,grantees rapidly changed criteria to be much more inclusive, recognizingthat physicians need the flexibility to refer without undue constraints. Selecting elderly patients and the concerns regarding criteria ledphysicians to recognize that once they referred patients collaboratorsinevitably found even more complexity in almost any situation. Ourfindings reinforce Kaufman's (1995) observation that physiciansengage in a constant process of decision making about how to intervenein the everyday dilemmas presented by elderly patients. These are notimmediately life-threatening situations, but are viewed metaphoricallyas cans of worms, seas of troubles, and nebulous issues that canoverwhelm o��ver��whelm?tr.v. o��ver��whelmed, o��ver��whelm��ing, o��ver��whelms1. To surge over and submerge; engulf: waves overwhelming the rocky shoreline.2. a. physicians and staff as they seek to balance time constraintswith patient care. Physicians made emotional comments as they sought togain control over situations that could not be addressed in 15-minuteoffice visits. Physicians repeatedly admitted that they could not deal with thenumbers of psychosocial issues presented, but recognized that patientsand families often expected them to be able to do so. When they did stepoutside their "comfort zone" and attempt to solve socialproblems, they went beyond their expertise and often failed. Physicianswere not hesitant to reveal these failures, and they did not hide theirembarrassment over not being able to resolve these dilemmas. Theirvulnerability in trying to provide holistic care reveals the importanceof the second overriding theme--linking to collaborators. Teaming with collaborators literally means that they becomephysicians' eyes and ears in the community. Learning how tocommunicate in an efficient manner and helping physicians track theirpatients were critically important skills. In fact, anothervulnerability was revealed at this point-that physicians literally losttrack of where their patients were. Without collaborators, patientscould be in life-threatening situations without physician knowledge.They definitely emerge from hospitals with new medications about whichtheir primary care physician has not been consulted. Respondents were somewhat interested in exploring practiceboundaries with elderly patients or they would not have agreed to bepart of these demonstration projects. Therefore, they were open to theseconcerns. Even with openness, we observed that several physicians werevery traditional in their practice styles, somewhat hesitant to fullyembrace collaborative practice interventions. The majority of physiciansare transitional (Mizrahi & Abramson, 1994), recognizingpsychosocial needs and the importance of collaboration with others. Nomatter how collaborative a physician wants to be, however, timeconstraints are ongoing. Intervention agents, whether they were professionals orparaprofessionals, told us that they could not assume anything aboutphysician style. Each practice had its own culture and each physicianhad a distinctive personality. Within practices, physicians variedtremendously in how they practiced and how they viewed collaboration.Intervention agents indicated that it was important to meet each personwhere her or she was--not to assume anything--and their success inestablishing relationships is based on this flexible approach. Physicians often were open to expanding their practice boundaries,but rarely did anyone describe this expansion in positive terms. Fearand trepidation trepidation/trep��i��da��tion/ (trep?i-da��shun)1. tremor.2. nervous anxiety and fear.trep��idanttrep��i��da��tionn.1. An involuntary trembling or quivering. of what might be found, rather than interest andexcitement over what might be, were common. Physicians did not have timeto visit in the home, fully assess the situation, and intervene, nomatter how committed to holistic patient care they were. The intent wasto solve the problem, focus on the medical issue, and refer anythingelse. Even physicians seen as transformational or highly collaborative(Mizrahi & Abramson, 1994) were somewhat overwhelmed in systems thatpushed them to see more patients each day. We observed that it was rare for physicians to provide anydirection for their new collaborators. No matter how specific writtenjob descriptions of the intervention agent's role were (whetherthey were called case managers, care coordinators, geriatricspecialists), those roles evolved as projects matured. This hasimplications for who is hired into case coordination roles. Theseindividuals worked hard to be a part of the practice, to gaincredibility, and to demonstrate teamwork. We also witnessed theincredible amount of work it took to become an interdisciplinary team interdisciplinary team,n a group that consists of specialists from several fields combining skills and resources to present guidance and information. .Few projects were able to get beyond multidisciplinary practice. Most important, the actual intervention (what the project isdesigned to do) was often hard to explain. Certainly visiting in aperson's home and setting up services is fairly concrete, but therewere many activities that intervention agents engaged in that weredifficult to define. Repeatedly, care coordinators told us aboutpatients who were stunned stun?tr.v. stunned, stun��ning, stuns1. To daze or render senseless, by or as if by a blow.2. To overwhelm or daze with a loud noise.3. when someone from their physician'soffice called to check on them, much less make a home visit to assesstheir status. Obviously, putting this type intervention in place requiredadministrative support and had to be financially viable. What we havetried to convey is that it takes work to establish interventions thattruly focus on the whole person and that expanding the boundaries ofprimary care means linking physicians with collaborators. IMPLICATIONS FOR SOCIAL WORK PRACTICE WITH PRIMARY CARE PHYSICIANS Of particular interest here is that physicians often referred tosocial workers even when project-based collaborators were members ofother professions. Asked about their practice role in the largercommunity, social workers came to mind as people who would likely dealwith these type problems. Physicians actually strategized about how touse social workers to avoid having to call a daughter or follow-up afterdischarge or contact an insurance company. Willing to triage, physicianswere more than willing to refer complicated or difficult patients. Permeating per��me��ate?v. per��me��at��ed, per��me��at��ing, per��me��atesv.tr.1. To spread or flow throughout; pervade: "Our thinking is permeated by our historical myths"our interviews was physicians' sense ofdisempowerment. They did not know what to do or how to resolve manyscenarios that developed. When they tried to advocate, they often feltfoolish after learning the entire story. Their interventions in thesesituations were to not call or talk with someone else before going outon a limb and writing a long letter. They frequently were not skilled inmediation, negotiation, community relations 1. The relationship between military and civilian communities.2. Those public affairs programs that address issues of interest to the general public, business, academia, veterans, Service organizations, military-related associations, and other non-news media entities. , and advocacy. It was notthat they claim to be skilled in these areas (or even want to be), butexpanding their practice boundaries cast them squarely in arenas thatrequired someone with these skills. Essentially, they did not have thetime to contextualize con��tex��tu��al��ize?tr.v. con��tex��tu��al��ized, con��tex��tu��al��iz��ing, con��tex��tu��al��iz��esTo place (a word or idea, for example) in a particular context. situations fully and often were disappointed oreven embarrassed when they learned additional information thatdiscounted, minimized, or contradicted the nonmedical interventions theyhad made. What this means for social work is that there are opportunities forcollaboration with physicians in an age when practice boundaries arebeing pushed out, to encompass an understanding of older people incontext. Working as an interface between the community and the practicesetting is something social workers are educated to do as part of theirsocialization. Taking on unsolvable problems that cannot be fixed, butdoing the best that can be done is something social workers are used todoing. It is not a sign of failure to encounter barriers; it is achallenge. Whereas a medical professional may be socialized to describea situation as a "sea of troubles'" social workers maysee the same case as a challenging but worthwhile endeavor. Embedded Inserted into. See embedded system. within our results are specific approaches that socialworkers and physicians might use to work together, whether the socialworker is based in the practice or is collaborating from another base.First, physicians seem to identify with hospital social workers,probably because they encounter them on an ongoing basis, althoughphysicians' offices do not always know when someone is beingdischarged into the community. Connecting with primary carephysicians' offices needs to be part of discharge planningprotocols. Social workers who serve as hospital and long-term carefacility discharge planners in hospitals probably have sympatheticlinkages with physicians' offices if they reach Out to them andreinforce the importance of expanded boundaries. Social workers involved in home and community-based services dohome visits, involve families, and place older clients in context.Again, social workers in these settings may need to take the initiativein connecting with primary care physician practices, so that physiciansare aware of psychosocial issues. Literally going into practices andproviding information on how to make appropriate referrals andsocializing medical staff to what social workers do could contribute tovaluable boundary expansion. We learned that these physicians and their staffs were eager tohave professionals to whom they could refer older clients with complexproblems. Once Pandora's box is open, physicians feel obligated todo what they can. Social workers, as well as other professionals, arelogical collaborators with primary care physicians. Social workers,therefore, should seize these opportunities by demonstrating their valuein dealing with the seas of troubles, nebulous issues, and cans of wormsthat characterize geriatric practice for physicians. To do this, socialworkers will need knowledge and skills in working with older people. ABOUT THE AUTHORS F. Ellen Netting, PhD, is professor, School of Social Work,Virginia Commonwealth University Formed by a merger between the Richmond Professional Institute and the Medical College of Virginia in 1968, VCU has a medical school that is home to the nation's oldest organ transplant program. , 1001 West Franklin Street The following roads are named Franklin Street: Franklin Street (Baltimore) in Maryland, United States Franklin Street (Chapel Hill) in North Carolina, United States Franklin Street (Manhattan) in New York, United States ; Richmond,VA 23284-2027; e-mail: enetting@saturn.vcu.edu. Frank G. Williams, PhD,is professor, School of Health Administration and Policy, College ofBusiness., Arizona State University Arizona State University,at Tempe; coeducational; opened 1886 as a normal school, became 1925 Tempe State Teachers College, renamed 1945 Arizona State College at Tempe. Its present name was adopted in 1958. , Tempe. The authors thank the casemanagers, physicians, office staff and administrators who have sharedtheir insights, and to the John A. Hartford Foundation for support ofthe projects on which this article is based. REFERENCES Applebaum, R., & Austin, C. (1990). Long-term care casemanagement: Design and evaluation. New York New York, state, United StatesNew York,Middle Atlantic state of the United States. 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