Interagency collaboration: reinforcing professional bridges to serve aging populations with multiple service needs. (Interagency Collaboration).

The United States is no longer a nation in which children and youth are the largest population group. Currently, one in five Americans is over age 55 and 13% of the total population is now over age 65 (Herr, 1999; Seibyl, Rosenheck, Coewel, & Medak, 2000). Although most of those age 65 and over are active and functioning well, chronological age can be considered a risk factor, whether or not any other risk factors are present in their lives (e.g., disability, minority group membership). The prevalence of psychological distress among aging populations increases with age. Gerontological research of mental morbidity indicates increased rates and various types of psychological distress, including depression, substance abuse, psychiatric problems, suicidal ideation, and generalized vulnerability to stresses of aging (Lands, 1997). According to Palmore (1999), most rehabilitation programs for persons with disabilities tend to discriminate against elders. One reasonable explanation for this bias is that rehabilitation services are tied to employment outcomes, and most aging and elderly persons are assumed to be retired or approaching retirement and therefore ineligible for services (Atchley, 1997). Moreover, physicians, social workers, and professionals who serve persons with disabilities do not usually refer aging and elderly persons with disabilities for rehabilitation and occupational training programs (Palmore, 1999). Palmore referred to the lack of referral of aging and elderly persons for rehabilitation services as ageism. This form of discrimination against elderly persons results in their having less access to American society than do younger persons with disabilities.

Growing older in a changing, mobile, and technological society imposes heavy demands for adaptation which many older individuals are ill prepared to meet. Because of the growing number of people who are at or beyond conventionally defined retirement ages, and because of the growing understanding of the effects of ageism and other risk factors for these populations, rehabilitation counselors, mental health practitioners, and social workers are recognizing the need to provide counseling and related services, as well as to develop new therapeutic techniques to work with this population.

This article addresses implications of collaboration between rehabilitation counselors, mental health practitioners, and social workers in assisting aging populations with disabilities. In addition to an overview for collaboration between rehabilitation counseling, mental health, and social work, information is presented on casework as a common denominator, the basis for integrative and collaborative policy, and strategies and implications for functional integration in rehabilitation counseling. Collaboration between vocational rehabilitation, social work, and mental health for aging populations may defend against organizational barriers in service provision, and significantly contribute to the goals of employment, mental health stability, and social well being.

Overview for Collaboration

Human service professionals such as vocational rehabilitation counselors, mental health practitioners, and social workers provide specific services to aging populations with disabilities, dysfunctions, and/or interruptions in daily life activities. Each of these providers plays an integral role in the psychosocial adjustment of aging persons with disabilities who receive multiple services, experience family dysfunction, or require therapeutic services. For example, social work is centered on the identification of individual and environmental strength, and based on the belief that services should focus on promoting individual capacities and enhancing the environment in which these can best be mobilized and applied (Loewenberg, Dolgoff, & Harrington, 2000). Chachkes (1999) indicated that "social work values fit easily with the goals of rehabilitation, which are to facilitate maximum functioning and quality of life, encouraging independence and patient involvement" (p. 616). Given the number of social concerns (e.g., financial, loss of marriage/life partner, lack of access to affordable health care, employment concerns) confronting individuals as they age, there is a compelling need for collaboration between vocational rehabilitation counselors, social workers, and mental health practitioners. Moreover, these social concerns may exert primary influence on individuals' ability and desire to access services, their willingness to participate in services, and their resources for maintaining an active role with human service delivery systems.

The various human service agencies with whom aging populations with disabilities interact must build collaborative structures of support to deliver comprehensive services. According to Hanson and Carta (1995), human service providers must be willing to cross regularly traditional professional boundaries to allow this to occur. Moreover, agencies must realize that aging populations with dysfunction, interruption, or multiple challenges may require assistance in numerous areas (e.g., emotional support, housing, food, income, employment) before they can make use of other interventions that address specific needs. Rehabilitation counseling can foster the development of comprehensive services and integrated care and provide a mechanism through which collaborative input and effort of multidisciplinary teams can be developed (Porter, Epp, & Bryant, 2000). Collaboration between vocational rehabilitation counselors, social workers, and mental health practitioners may be regarded as a requirement in which these parties end professional isolation and become necessary professional allies (Bemak, 2000). In essence, collaboration increases the opportunity to augment and expand the quality and quantity of services needed by many individuals.

Too often, many agencies and programs designed to facilitate the well being of aging populations with disabilities and dysfunction, as presently configured and operated, do not capitalize on what is known about helping. Despite an accumulating body of evidence-based knowledge, there is reluctance to consider a substantial shift in the way practitioners in human service and health care institutions, including vocational rehabilitation programs, mental health agencies, and social welfare agencies, assist aging populations with multiple problems (Luongo, 2000). In part, lack of change is due to resistance to interdisciplinary collaboration on two levels-personal and institutional. "Personal resistance to collaboration is based on the individual's rejection of the new ideas and the change process," whereas institutional resistance "may emerge as discrepancies between what is publicly espoused by the organization and the 'real' unofficial policy that is opposed to collaboration" (e.g., restrictive funding, lack of administrative support, lack of incentives to support collaboration across systems) (Bemak, 2000, p. 329).

Differential principles and concepts of traditional agency-based vocational rehabilitation programs, mental health, and social work practice may also account for limited collaboration between these service agencies. According to Berkowitz (1979), "people do not regard vocational rehabilitation as a welfare program, and portray rehabilitation as the antithesis of welfare. Whereas welfare fosters dependence, rehabilitation promotes independence. Welfare represents a net cost to society; vocational rehabilitation is an investment in society's future" (p. 164). Nevertheless, rehabilitation agencies must be sensitive to environmental and organizational change in human service. Many rehabilitation agencies are responding to these changes with strategies that foster organization flexibility and creativity (Moxley, Manela, & Finch, 2000). Increased collaboration is one such strategy. Consequently, rehabilitation agencies must undertake modifications in how they engage in the business of rehabilitation in general, how they respond to changing dynamics of aging populations with regard to the market for rehabilitation services, and discard habitual ways of doing business that may no longer fit the new social expectations (Handy, 1995; Moxley et al., 2000).

Casework as a Common Denominator

Casework, a myriad of professional processes for the protracted observation and investigation of the habits, histories, and homes of consumers aimed at producing individualized diagnostic and treatment plans for psychosocial adjustment, has been the predominant template for human service delivery in the twentieth century (Harley, Tice, & Kaplan, 2001). A case management model is usually employed with individuals who have complex multifaceted needs that cannot be met by simple information and referral programs (Poulin, 2000). Therefore, case management requires counselors and social workers to develop high level skills in collaborating with professionals from other disciplines. According to Poulin, professionals need to learn the language of other practitioners if they are to develop the best possible intervention plan, especially since casework has played a significant role in the history of human service agencies.

Historically, medical social work was concerned with issues about the living conditions of the medically ill and the connection between social conditions and the delivery of medical care (Chachkes, 1999). Social work in rehabilitation "focuses on client and family understanding of the nature and level of disability, adjustment to the disability, and assessment of motivation, expectations, and goals for rehabilitation and plan for discharge and community integration" (Chachkes, 1999, p. 613). As a member of the rehabilitation team, the counselors and social workers are links between the rehabilitation setting and community resources. Each member of the team must bring a sense of competence, skills, and knowledge to the casework process to focus on the utilization of resources on behalf of persons with disabilities (National Association of Social Workers, 1996).

Many aging and elderly clients coming to terms with the permanence of disability and the expectations held regarding outcome and future functioning, require counselors and social workers to coordinate activities to provide some continuity of service. However, case management has generally remained separate from counseling because of issues regarding reimbursement, insurance contracts, and the intricacies of capitated benefits (Opper, 1996). Subsequently, case management has largely been defined as an area of expertise that facilitates health-related services for clients. The case management industry, which traditionally relied on social workers to provide case services, has since broadened to include service providers from a variety of settings. This shift in service provision has evolved as a necessity to meet the varied needs of the rapidly growing aging population. Rehabilitation counselors, nurses, social workers and others from varied professional settings now, or consistently, provide case management services (Leahy, Chan, & Shaw, 1997).

The vocational concerns for the aging population and the disincentives for returning to work place this population in a particularly peculiar situation. Recent literature suggests that participation in vocational rehabilitation has a different meaning for the aging population (Drebring et al., 2002). While typically at a stage in life where employment is no longer a major focus, the aging population is displaced in a system where employment and its role in society is a primary focus. Nonetheless, rehabilitation counselors are becoming more engaged through the practice of case management. With rehabilitation counselors moving into more diverse service settings, the opportunity to intersect the values of the aging with the values of rehabilitation has increased. Leahy, Chan, and Shaw (1997) assert that the evolution of health care management and reform has substantially impacted the work of rehabilitation counselors providing case management in health care or related programs. For rehabilitation counselors specifically, this will call for increased efforts during educational preparation to focus on cost analysis and cost attainment, treatment patterns, disease management, coordination and service delivery. The enhanced educational preparation will then place rehabilitation counseling in concert with the "programmatic efforts needed to adequately address the differing needs of aging populations" (Drebring et al., 2002, p.24).]

Similarly, the dramatic growth spurt of the aging population has also presented itself as a challenge to the fields of social work and mental health (Scharlach, Damron-Rodriguez, & Robinson, 2000). The more general characteristics of case management, which include determining service eligibility and monitoring eligibility, are no longer adequate practices. Social workers are now being called to design and implement individualized plans, facilitate work and training opportunities and assist clients in locating and securing community resources (Anderson, 2001) all of which are typical case management duties for rehabilitation counselors. Scharlach et al. (2000) emphasize the shortage of social workers with specialized knowledge needed to effectively serve the aging population and purport that in order to maintain efficiency, major curricula enhancements will need to incur. Additionally, mental health practitioners have expressed concerns regarding case management methodology, including "gaps in service needs in specific areas of the community and breakdowns and inadequacies in working with other systems" that serve their clients (McClelland, 1998).

Clearly, across disciplines, case management is a relevant and necessary process in order to provide the most comprehensive service to clients. Conversely, within each field there also exists an apparent lack of specialized knowledge of the case management process. The specialized function of each organization further hinders efficient service to the aging population (Jenkins & Laditka, 2000). The fragmentation and disorganization of service typically dissolved through case management, still exists. The unique challenges of the aging population and the need to enhance competencies in case management present the opportunity for interagency collaboration. In fact, Boult, Rassen, and Rassen (2000) state that most individuals who have experienced the fragmentation of services believe that coordination would improve outcomes and possibly lower the overall costs of health care. The test now involves discerning how to best promote interagency collaboration without impinging on the unique qualities and services that define the various fields.

Basis for Integrative and Collaborative Policy

Luongo (2000) provides a poignant example of how various professions subsequently do less than a best effort to help individuals in service delivery. The example states that no one would seriously consider publishing a book entitled Ineffective Therapy: A Guide to Mediocrity in Helping. Yet, the way in which service delivery is set up, "it is still too easy for practitioners to define the scope of practice to the confines of a single social institution and consequently 'define-out' the other social institutions and necessary helpers" (Luongo, 2000, p. 311). For example, as practitioners working with aging populations, vocational rehabilitation counselors do not intervene directly in issues related to neglect and abuse, social workers do not perform job placement activities, and mental health practitioners do not provide elder care services. Clearly, each professional is likely to work to improve casework practice within specific areas and not to improve outcomes for those who are involved in multiple social institutions. Thus, each service agency can rationalize and justify why they do not provide certain types of services. The result is an almost circular reasoning that unnecessarily limits the scope of vocational rehabilitation, mental health, and social work practice (Luongo, 2000). However, current trends illustrate that as case management processes improve, the focus will shift away from individual disciplinary practices (Burgess, 1996 cited in Leahy et al., 1997) as multiple issues and concerns for aging populations drive practice and policy.

The basis for integrative and collaborative helping in human service agencies resides in the momentum to reengineer government to have an outcome-focused approach (Linden, 1994). Increasingly, funding sources (e.g., government agencies and foundations) are demanding collaborative components because they recognize that single-focus programming is not as effective in bringing about change as are multi-focus partnerships (Bailey & Koney, 1997). Human services programs must demonstrate the intended outcome that is expected from service delivery. That is, for aging populations, vocational rehabilitation, mental health, and social work must center on consumer-appropriate outcomes through collaboration and cooperation, not on sequential or parallel intervention processes that satisfy administrative requirements. According to Luongo (2000), organizational boundaries can no longer be considered "the limit of influence" (p. 311). Because helping no longer is bound by the limits prescribed in job descriptions or by strategically worded mission statements, the integrative and collaborative model is the only practical option for vocational rehabilitation counselors, mental health practitioners, and social workers.

Delivering comprehensive, coordinated services to aging populations who have a "continuum of risks" requires a "continuum of service options" (Hanson & Carta, 1995, p. 209). In programs that have been successful in improving outcomes, several common themes emerge among service providers. These themes include (a) individualized interventions (Dupper, 2000), (b) flexibility (Patton & Browder, 1988), (c) creativity in reducing obstacles, and (d) going beyond the jurisdiction of their own agency (Hanson & Carta, 1995). Developing coalitions may expand resources, better integrate existing services, and increase the likelihood of achieving identified goals (Poulin, 2000).

In spite of the economic and client-centered benefits to interagency collaboration, there remain several obstacles that should be considered. Resource allocation and networking policies are two areas relevant to any discussion on agency coalitions. Jenkins and Laditka (2000) highlight the resource dependency theory, which asserts that organizations are more likely to collaborate and coordinate services when resources are reduced. The current trend in health care funding has been uncertain and this produces a fertile atmosphere for interagency collaboration. Conversely, this theory promotes an environment that could give way to competition for scarce resources. Given the specificity that exists amongst service organizations and disciplines which make them unique, it is conceivable that each entity would initiate a hierarchy of service; those which their particular agency would provide most effectively. Resultant from the application of the resource reduction theory is the concept of "exclusivity networking." Jenkins and Laditka assert that this form of collaboration fosters exclusivity in coordinating services between organizations with smaller values and threatens to undercut the potential for "true" integrated attempts at service delivery.

While a basis for collaborative case management practice does not exist, it is most relevant for service organizations to formally address the collaborative process. Addressing the intricacies of shared service provision will not only highlight ideological strengths of agencies involved, but will also facilitate discussion regarding strategies for successful partnerships.

Strategies and Implications for Functional Integration and Collaboration

Crossing professional borders to work with aging populations is frequently easier said than done. The question becomes, "how can an interactive, multilevel, coordinated approach be developed and implemented to address the complex needs of aging populations'?" Several critical components must be given immediate priority. First, mobilization of a broad range of resources and services that counteract the effects of a continuum of risks for aging populations must be put into place (Hanson & Carta, 1995). Second, a reorientation of policy, practice, and value-adding activities to outcomes is necessary (Luongo, 2000). Finally, a transformation of the roles of vocational rehabilitation counselors, mental health practitioners, and social workers to provide leadership in policy reform through collaboration must be advanced.

In order to make use of specific collaboration strategies in daily interactions, vocational rehabilitation counselors, mental health practitioners, and social workers must embrace some prerequisite, basic relationship values and attitudes (Walker & Singer, 1993). This essential set of values includes equality, cooperation, partnership (Walker & Singer, 1993), and the incorporation of a holistic-centered focus in collaborative relationships. The remainder of this section will address specific strategies for integration of services and implications for policy development and implementation.

Strategies for Integration of Services

Understanding how to cross traditional professional borders may help counselors and social workers predict potential barriers to successfully integrating services for aging clients. Given the ease of availability and the reliance on technology as a means of communication, technologies could allow collaborative groups in rehabilitation, mental health, and social work agencies to interact without leaving their respective workplace or domains. Technologies such as laptop computers, web sites, and the Internet have given professionals the means to disseminate information among themselves and to receive almost instant reaction. Aging persons with disabilities who use online technology are able to avoid physical obstacles, to be personally mobile with greater safety, and to convert in real-time text or animation sign language (Jones, 2000). However, the application of technologies may also produce substantial barriers to aging persons with disabilities who do not have access or skills to use these technologies to facilitate effective and efficient interaction with service providers. The digital divide that exists for persons with disabilities, particularly the elderly, is significant (Kaplan, 1997).

Given the inherent challenges both for clients and service providers in regard to integrating services, it may be necessary to move away from the proverbial "box" and consider more innovative approaches to collaboration. "Often barriers appear to service coordination that are rooted in turf issues, competition for clients and concern for confidentiality" (Woodside & McClam, 2003, p.223). Considering these concepts of turfism and exclusive networking, as well as, varied professional philosophies, financial constraints, and reduced resources, it perhaps would be more conducive and productive to develop an umbrella organization comprised of staff from various agencies. The umbrella agency structure would remove typical restraints produced by parent company organizational structures and would allow representatives from various agencies to collaborate using a team approach to case management. In other words, the umbrella agency structure can be structured to resemble the current one-stop programs in rehabilitation agencies. Jenkins and Laditka (2000) stress that this initiative is necessary in order to effectively strengthen interagency collaboration.

The facilitation of interagency collaboration is also more likely to end in successful partnerships in which collaborative links formed. Here again, the lack of a formal process leaves partnerships vulnerable to the effects of exclusive networking and competition for resources. While in some instances it may not be feasible to establish an umbrella organization, the opportunity for clearly articulated, shared goals will always exist. Woodside and McClam (2003) emphasize communication as being key to coordinating service activities during the case management process. They assert that each service should "enhance and support all other efforts" (p.23). This can only be achieved when all interested parties are aware of each other's service philosophy, general practice guidelines and links to community resources. Uncoordinated efforts can adversely impact the aging client in need of mental health services. Avoiding this through communication significantly reduces the potential risk for clients in the human service system (Jenkins & Laditka, 2000).

Policy Implications

It is becoming increasingly evident that the population of the United States is aging. By the year 2030, Americans 65 and older will comprise 20% of the population (Scharlach et al., 2000). As the population of the United States begins to reshape and redefine itself, social policy must also adjust itself to meet the needs of this growing group. This fact has not gone unnoticed. Many federal agencies, as well as human service agencies with long-standing commitments to the aging population are rallying to push forth social policy to better assist America's fastest growing group of citizens. The drastic increase in the aging population is also allowing these agencies to intensify their focus by pooling resources, practices, efforts and policies.

Uncertain long-term health care provisions and policies are currently plaguing the aging population. Fragmented services and complex care systems are adversely impacting the physical and mental health of older Americans. Wallack, Sciegaj, and Long (2002) identified several current trends and policy issues affecting the aging population. Non-institutional/community-based care, private financing for long-term care, and expansion of cash benefit and consumer directed options are trends that currently impact policy. One commonality among these three trends involves the role of government and the effect Medicaid policy has on the direction of services. Another commonality includes the potential for increased, more personalized and client-centered community based services. This has direct impact on services provided by rehabilitation counselors, social workers and mental health practitioners. Not only does it further illustrate the necessity for collaboration across these various disciplines, it also provides additional support for enhanced case management training, which would allow effective assessment of client needs, cost benefit analysis and health care funding issues.

Doty (2000) also highlights consumer directed trends supported by the Office of Aging and U.S. Department of Health and Human Services. Most relevant to interagency collaboration is the emphasis on networking and collaboration needed to make such trends feasible and viable for the aging population. Doty assets that policy changes such as these, "require a considerable investment not only of finances, but in team building and teamwork" (p.23).

One of the major limitations of human services for older Americans is the lack of networking amongst service organizations (Jenkins & Laditka, 2000). Policy shifts and trends for the aging population can pose challenges for service providers. Alternatively, they can act as a much-needed catalyst for change because tighter budgets and capitated environments necessitate interagency collaboration and networking.

Conclusion

Professional border crossings between rehabilitation counseling, mental health, and social work are not new ventures. However, the issues and concerns facing aging populations with disabilities are changing continuously. Given both the divergent and overlapping roles and functions of professionals in rehabilitation, mental health, and social work in addressing the needs of aging persons with disabilities, collaboration can lead to higher quality service experiences.

Continued collaboration between rehabilitation counseling, mental health, and social work offers both optimism and naivete in light of economic shifts, public policy changes, and organizational structures. Demonstrating cooperative behavior and teamwork are becoming increasingly important in human service agencies. Collectively, human service practitioners can embark on a path toward embracing shared casework, integrative policy, and utilization of technology as part of collaboration.

In conclusion, collaboration is a viable solution to addressing complex challenges confronting aging persons with disabilities and to helping human service personnel meet the needs of these individuals. Creating a future vision of sustained multi-agency collaboration and linkages with service providers from early intervention through secondary programs can promote involvement of rehabilitation counselors, mental health practitioners, and social workers in planning and providing individuals uninterrupted services. Overall, professional border crossings for purposes of facilitating quality service delivery by rehabilitation counselors with other human service providers working with aging persons with disabilities is a noteworthy endeavor. Collaboration is deserving of attention and support from each respective discipline.

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Debra A. Harley, Ph.D., 219 Taylor Education Building, Department of Special Education and Rehabilitation Counseling, University of Kentucky, Laxington, KY 40506-0001. Email: [e-mail]

Debra A. Harley
University of Kentucky

Chandra Donnell
University of Memphis

Jo Anne Rainey
Kentucky State University