Abstract
The present study explores how social workers can collaborate with older adults and their family caregivers in transitional care facilities to increase older adults’ ability to live independently in the community versus receive institutionalized care. The data was gathered through five interview sessions with licensed social workers in transitional care units serving geriatric populations. Findings suggest that involved family caregivers who demonstrate knowledge of an older adult’s medical condition play an integral role in the older adult’s treatment plan and continued success in the community by facilitating communication with the treatment team and providing necessary supportive cares in the community. Findings conversely suggest that family caregivers who lack adequate knowledge of the older adults’ medical conditions or struggle with acceptance of their decline in functioning often resist the treatment team’s recommendations and impede the older adult’s care plan in the facility. Study implications include the need for increased education and support from social workers and health care providers in transitional care that include programming on building knowledge and skills to help family caregivers cope with their challenging role both in the facility and in the community. Additional implications for social work practice include education provision related to financial planning and benefit programs available to older adults, as many have a minimal understanding of Medicare coverage and other community programs or resources that are available.