Jonathan Riley, MSW'18

Outpatient Case Manager

Steven A. Cohen Military Family Clinic

I am working in Philadelphia as an outpatient case manager at the Steven A. Cohen Military Family Clinic at the University of Pennsylvania. The Cohen Clinic is a national network aimed at serving current and retired National Guard soldiers, Reservists, and their families/caretakers. As the outpatient case manager I see a range of needs arise, and using a clinical approach to case management, assess the need the client may have and assist them in accessing resources. This often results in a number of different tasks including connecting clients to long term mental health providers, working with them to enroll in health insurance, assisting to mitigate housing crises, finding resources to assist with utility arrears and shut offs, as well as addressing a host of another needs as they arise. In order to accomplish this task, I use a brief biopsychosocial assessment to identify areas the client may need assistance, discuss what the client would like to work on and ways that case management may be helpful to them, and create a plan with the client to address their need(s). My main duty is to ensure clients are able to address needs, while working with the client to eliminate barriers that are preventing attainment of their goals.

The PAC program has been a tremendous blessing for me in my current role as I am able to rely on the many skills and experiences offered through this program. I find myself using the skills and knowledge from classes and field experiences from this program in my current work often. One of the main issues that arise is the need to assist older adults with a new, unexpected care taker role, often stemming from their adult child suffering a traumatic injury. I also appreciate the neurocognitive therapeutic skills developed through PAC as they have been instrumental in my work with soldiers suffering from Traumatic Brian Injuries who often have severe memory and cognitive issues. Having the PAC certificate was a huge advantage when applying for this position as it allowed me to confidently discuss how I would be able to address the need for a Gerontological Social Worker at this organization. This is a similar need across many agencies and fields due to our aging population, and I encourage students to take advantage of this program. PAC provides many valuable experiences and opportunities for growth, both personal and professional, and allows you to be confidently prepared for your social work career.

Ricardo Santos, MSW'13

Social Worker

Mount Sinai Hospital's Martha Stewart Center for Living Geriatrics Outpatient Practice

As a Social Worker at Mount Sinai Hospital’s Martha Stewart Center for Living Geriatrics Outpatient Practice, I am a member of the interdisciplinary care team and I work closely with high-risk older patients and conduct care coordination to assist in the achievement of the Accountable Care Organization goals. I conduct biopsychosocial assessments, provide brief Cognitive Behavioral Therapy and Problem Solving Therapy to patients and family caregiver as needed, identify barriers to seeking appropriate medical care and work with the team and patient/family caregiver to develop educational care plans to overcome these barriers and increase treatment compliance. I analyze population management reports in Epic and review CMS claims data to identify preventive care/screening and disease management care gaps, high emergency department, inpatient and specialty utilization and share this information with the care team to develop interventions.

I found an amazing opportunity to grow as a Social Worker at Mount Sinai hospital and the Penn Aging Certificate (PAC) made it a reality. My training in Problem Solving Therapy, Cognitive Behavioral Therapy, interdisciplinary patient treatment, biopsychosocial assessments, mental health and cognitive screenings as well as my internship at the Penn Memory Center had a very positive impact in the interview process. Without the Penn Aging Certificate I would not be growing in one of the best and most innovative geriatric centers in the country.

Sarah Windt, MSW'13

Genesis Healthcare’s Rehabilitation

I have been working at Genesis Healthcare’s PowerBack Rehabilitation Center City facility since graduating from the University of Pennsylvania’s MSW program in May of 2013. As a social worker who specialized in geriatrics with the Penn Aging Concentration (PAC), I am constantly utilizing my clinical skills in working with older adults that I developed and studied in the PAC program, everyday in my position. PowerBack works with primarily older adults who are determined to return home after receiving hours of physical and occupational therapy. My position assists them in returning home and gaining their independence back. I conduct psycho- social assessments upon admission and plan their discharge along with the patient, and their families. The PAC program gave me the experience and education that I needed to excel in my first social work position. These areas include: working with an interdisciplinary team, knowledge of the mental and physical challenges older adults face, and the ways in which I can positively impact their lives as a geriatric social worker. The Penn Aging Certificate provided me with the confidence and professionalism necessary to succeed in the field of aging.

Catherine Kane, MSW'12

Intensive Care Unit Social Worker

Hahnemann University Hospital

I work with patients and families at HUH’s medical intensive care unit and progressive care unit. The patients are medically complicated, and many are geriatric I work closely with the Palliative Care team to address the goals of care for patients and their families. For patients requiring additional care after discharge, I facilitate referrals to a variety of facilities, including long-term acute care hospitals, acute rehabilitation units, skilled nursing facilities, long-term ventilator facilities, and inpatient hospice units.

My PAC experience helped prepare me for my position as an ICU social worker. Many of my patients are geriatric, and I use my knowledge about issues affecting older adults everyday. The experience of the simulated patient training, in particular, has proven to be extremely useful as I am involved in having discussions about goals of care, including palliative and hospice care, each week.

Daniela O'Keefe, MSW'12

Social Worker - General Medicine Service

Hospital of the University of Pennsylvania

My work responsibilities:

  • I provide support and counseling to patients and families in the area of loss and adjustment to illness
  • I coordinate discharge to alternate levels of care by securing authorization and facilitating transfer to skilled and sub-acute nursing facilities, nursing homes, boarding homes, shelters, psychiatric facilities, and addiction treatment programs
  • I advocate for highest and optimum level of care with payers and facilities
  • I provide referrals to community resources to support patients return to home including home care, hospice, transportation programs, home delivered meals, adult day-care, senior centers, and disease/diagnosis specific agencies
  • I educate patients and families on financial assistance programs and disability benefits to assure ongoing income and health care benefits for disable individuals
  • I participate in daily rounds with medical staff to review the plan of care for hospital stay and discuss movement to the next level of care

Utilizing PAC geriatric training: I’ve found that the PAC motto definitely has truth to it, working with older adults is working with everyone! While many of my patients are older adults, often times patients are also caretakers of older family members as well. Completing the PAC geriatric training has enabled me to understand the needs of these patients and their families and utilize the skills learned in providing support and resources within the community.

Min Shin, MSW'12

Medical Social Worker

Community Based Adults Service

I am working in California as a medical social worker at Community Based Adults Service (ADHC), an adult day care service and short-stay nursing home setting. My main duties are assessments (cognitive, mental health, and home environment), intake and discharge, individual counseling, monthly group therapy, care planning and family counseling, advocacy for community resources, and outreach.

I feel so grateful about the Penn Aging Concentration (PAC) program because both the courses and field internship provided me with the clinical skills needed for my position at ADHC. I hope potential students understand the advantages and benefits of the Penn Aging Certificate program if they want to be skilled in a specialization. During my interview for my current position, I was informed that I was the only candidate who had knowledge about all the necessary geriatric scales and measures for bio-psychosocial-spiritual assessments. The job interviewer was very pleased about my internship experience in the medical field especially with seniors. Beyond clinical skills, the policies and knowledge about the health care system from the Penn school also helped me to assist my older patients.

I would like to encourage potential PAC students to be cognizant of the assessment tools and scales that are provided in the PAC course because they are used in real-world practice in the field. I never thought that I would review and need the class materials/slides to prepare for this new position, and it was really helpful that I did. The Penn Aging Certificate will prepare you as a geriatric specialist professional with clinical and macro skills, and you can start anywhere you want if you have the passion for working in this growing field!

Breanne Sullivan, MSW'12

Hospice Social Worker

Keystone Care

My duties include:

  1. performing psychosocial assessments for all new hospice and palliative care patients, educating patients and families about implications and goals of hospice and signing consents.
  2. Following a caseload of about 20-25 patients (primarily hospice, but also some palliative) and providing support to individuals and families.
  3. Providing case management to obtain resources such as: meals on wheels, legal assistance and documentation such as living wills and POA, utility and/or rent assistance.
  4. HIV/AIDS case management, funeral planning, transportation, caregiver support, services through PCA, finding and utilizing available grants through American Cancer Society, and assessing bereavement depression risk.

A great deal of what I learned from being in the PAC program has certainly been very helpful in my new role as a hospice social worker. I am much more knowledgeable about services and resources that are available to older adults in the community, and I think I am much more aware of the needs that older adults have especially at end of life.  I also learned a lot about discussing issues around death and loss, which is something that I now do on a daily basis at my job. I found the simulated patient training through PAC program to be an excellent experience because it provided me with a great deal of insight about my one-on-one interactions with patients, particularly when discussing very difficult issues such as illness and death.

Abby Rix Degge, MSW'11

Medical Social Worker

University of Maryland Medical Center

For the past two years, I have worked in several roles as a Licensed Graduate Social Worker for the University of Maryland Medical Center (UMMC). Because of my background with the Penn Aging Concentration (PAC), I was offered a position as an HIV/AIDS social worker, which included an opportunity to create programs for individuals aging with HIV/AIDS. In this initial position, I created resource files tailored to the needs of geriatric patients living with HIV/AIDS, and I pooled information pertaining to local transportation, insurance programs, pharmacy voucher programs, senior citizen housing and advocacy programs for the elderly. In addition, I was able to create and manage my own caseload of geriatric patients that involved assisting my clients in obtaining the necessary insurance to obtain their anti-retroviral medications thereby enabling them to have a higher quality of life. I worked closely with an interdisciplinary medical team to coordinate crisis intervention and counseling for HIV patients in acute medical and emotional distress. I also worked closely with a housing outreach worker to research and connect vulnerable older adults with affordable and safe housing options.

After six months of employment, the head of Social Work at the hospital offered me an internal transfer to work as a Pre-Kidney/Pancreas Social Worker in the Division of Transplantation, one of the largest departments in the medical center. In this role, I evaluated adults 18+ by conducting in-depth psychosocial assessments. My responsibilities included screening patients for substance abuse problems, assessing them for any support barriers, potential medical compliance concerns, and mental health problems. I assigned each patient a psychosocial risk level (Low, Moderate or High), and presented my findings along with a psychosocial treatment plan to the transplant listing committee.  Together with committee of transplant surgeons and interdisciplinary medical professionals, we decided whether or not a patient was an appropriate candidate for transplantation. These interdisciplinary efforts allowed me to pull from my geriatric knowledge base and identify psychosocial issues or barriers that an older adult may face obtaining a transplant later in life.

After about a year of employment in the Division of Transplantation, the hospital needed to fill the inpatient Infectious Disease Social Work position. UMMC has been seeking new ways to increase HIV testing and education programs in Baltimore City, and they sought me out for the position. In this role I continue my efforts to advocate and educate those living and aging with HIV/AIDS. I assess each patient on the service and screen for medication adherence, substance abuse issues, mental health problems, as well as housing and transportation barriers. I work closely alongside the interdisciplinary team to help patients overcome barriers that prevent them from receiving treatment to maintain a high quality of life. I provide counseling, support and crisis intervention to newly diagnosed HIV patients and also link them to follow-up care and community supports. I also assist families dealing with end-of-life decisions by providing access to palliative care and referrals to hospice.

Every day I draw on my experience gained from the PAC program. The program opened the door for me to have these life-changing opportunities early on in my career at UMMC. Penn’s outstanding reputation coupled with a specific skill set gained through the PAC program made me highly desirable in a competitive job market and at an institution as large as UMMC. While not every medical specialty requires a social worker with a geriatric knowledge base, every specialty across the healthcare spectrum will be faced with the need for one as the aging population continues to grow. While the positions I’ve held have not included an exclusively geriatric population, I’ve been able to enrich the programs with my background in aging. My graduate internship with Journey’s Way Geriatric Counseling Service increased the breadth of my clinical knowledge and provided me with hands-on opportunities to build strong therapeutic relationships with a diverse population of adults facing complex psychosocial issues related to aging. Furthermore, my PAC coursework provided me with diagnostic tools and evaluative measurements I use in everyday practice to assess patients and provide them with evidence-based interventions. My time at Penn and my decision to complete the PAC program is one of the smartest decisions I have ever made; it has equipped me to be a well-rounded social worker and an effective social change agent.

Other SP2 Alumni in Aging

Katie McDonough Arner, MSW'09

Director of Community & Social Services

Capitol Hill Village

I made my decision to become a social worker based on my experiences with older adults in my life, both personally and professionally. Through these experiences, I realized that my culture viewed aging negatively and many of my clients’ beliefs about themselves, were reflective of this view of aging. I decided to become a gerontological social worker because I wanted my clients to value themselves, and my culture to value older adults as much as I do.

As the Director of Community & Social Services for Capitol Hill Village, I am able to affect such change. In this role, I meet older adults and their families at critical moments in their lives and provide care coordination, case management, and counseling to help clients realize their full potential and lead fulfilling lives as they age. Since it is the mission of our organization to help people age in the communities that they love, it is my goal to work with my clients to arrange for services and supports that help them remain in their homes during the aging process as long as they can.

In addition to my individual work with clients, I affect change at the macro level as well. One important lesson I learned at SP2 is that work at the individual and policy level must go hand and hand to create lasting change. For this reason, my role at CHV also includes building partnerships with other community organizations and advocacy for local and national policy changes on issues that affect my clients. Through these partnerships and various policy initiatives, I am able to serve the mission of my organization more effectively.

Whether you are committed to a career in aging or are just exploring professional possibilities, I encourage you to take advantage of this opportunity. As a graduate of SP2, I find this program invaluable not only to students but to the aging profession as a whole. As we face a dramatic demographic change with the aging baby boomer generation, our country is in desperate need of highly-trained and passionate social workers in aging. There is incredible room for growth and creativity in the field, which I encourage you to explore.

Rachel Lipman, MSW'09

Geriatric Care Manager

Aging Network Services

I am currently working as a Geriatric Care Manager for Aging Network Services, a for-profit social work company based in the Metro DC area that specializes in helping adult children handle the issues that arise with their aging parents. As a Geriatric Care Manager, I provide assessments, counseling, home visits, and referrals. I carry a small caseload of 16 on-going older adults which allows me to work with my clients and families, as well as provide effective social work interventions.

If not for my education at Penn, I would not have obtained such a position. The generalist program at Penn provided me with the breadth of knowledge I needed to deal with the many situations I have encountered thus far in practicing social work. The faculty prepared me to handle the ethical dilemmas that I encounter while working in geriatrics as well as provided an understanding of the greater social and political context of aging in the United States.

When I first started at Penn, I tailored my classes to specialize in children and youth, but after my first year practice class, I decided to give gero-social work a try and I LOVED the field! I recommend to any student who has the slightest interest in this population to consider the new gero-social work concentration!

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