University of Southern California Dissertations and Theses

Closing the health gap

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Closing the health gap

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Content Running head: CLOSING THE HEALTH GAP 1

Closing the Health Gap
Nancy Greene
University of Southern California
December 7, 2018

CLOSING THE HEALTH GAP 2
Closing the Health Gap
Executive Summary
The Grand Challenge being addressed is Closing the Health Gap, specifically health
equity. Health inequities are systematic differences in health that can be avoided by reasonable
means, affect social group differences in health, and cause an unfair distribution of health risks
and resources (Arcaya, Arcaya, & Subramanian, 2015). Therefore, health equity is the key to
understanding the disparities minority populations face in the health care system. Minority
populations bear the brunt of social, economic, and racial exclusion when it comes to poor health
outcomes (Fong, Lubben, & Barth, 2018). The cost of health inequalities is shocking. According
to Arcaya, Arcaya, and Subramanian, (2015) between 2003 and 2006, the direct economic cost
of health inequalities based on race or ethnicity in the United States was estimated at $230 billion
and research calculated that medical costs faced by African Americans, Asian Americans, and
Hispanics were in excess by 30 percent due to racial and ethnic health inequalities, including
premature death and preventable illnesses.
Consequently, focusing on race and ethnicity allows for an understanding of current
health inequalities in a historical and cultural context, which then provides insights into how
health differences may have begun. For example, consider the history of slavery and segregation
in the United States and how this history sheds light on the current state of racial and ethnic
health disparities (Arcaya, Arcaya, & Subramanian, 2015).
Programs must be developed that combat inequalities by focusing on populations who are
disenfranchised and include community engagement (Fong, Lubben, & Barth, 2018). The
development of social work education which is culturally competent which will assist minority
CLOSING THE HEALTH GAP 3
populations and help to create equitable group dynamics, promote intermediate and long-term
equity outcomes, and therefore help to improve health equity in the broader community.
According to the Surgeon General (2017), health inequity is preventable differences in
the burden of disease, injury, violence, or opportunities to achieve optimal health that are
experienced by socially disadvantaged populations. In December 2017, the Surgeon General
called for the prevention of health inequities. He said that
A health disparity is a difference in health outcomes across subgroups of the
population. Health disparities are often linked to social, economic, or
environmental disadvantage (e.g., less access to good jobs, unsafe neighborhoods,
lack of affordable transportation options). Health disparities adversely affect
groups of people who have systematically experienced more significant obstacles
to health on the basis of their racial or ethnic group, religion, socioeconomic
status, gender, age, mental health, cognitive, sensory, or physical disability,
sexual orientation or gender identity, geographic location or other characteristics
historically linked to discrimination or exclusion (U.S. Department of Health and
Human Services, 2017).
The Surgeon General recommendations that are pertinent here include ensuring a strategic focus
on communities at highest risk and increasing the capacity of the health workforce to identify
and address disparities. He also called for further training in culturally sound communication
among health care professionals.
Demographic Changes and Dementia
The United States is undergoing dramatic demographic changes that will further affect
the need for family caregiving. By the year 2030, one in five U.S. residents will be 65 years of
CLOSING THE HEALTH GAP 4
age or older. Much of that growth will be among people over 80 years old, who need the most
care (AARP, 2016). While it is underdiagnosed, it is believed that as many as one in seven U.S.
residents over 70 have a form of dementia (Alzheimer’s Association, 2016). The total health care
costs for persons with dementia are enormous and continue to grow rapidly, and there is an
increased financial burden to the United States health care system because of the growth in
seniors with dementia (Prince, et al., 2015). Dementia causes unnecessary emergency room
visits, extended hospitalizations, increased 30-day readmissions, and an increased need for long-
term care (Prince, et al., 2015).
The trends mentioned above in dementia caregiving have resulted in an exponential
growth in the number of informal caregivers which mainly are comprised of families and friends.
This, in turn, has brought about adverse health outcomes for some family caregivers and is
primarily associated with caregiving stress, also known as caregiver burden. A 2011 study
reported that informal family caregivers for a family member with dementia had a 25 percent
increase in the use of health services, costing an averaging $4,766 more per year than non-
caregivers (Schultz & Cook, 2011). However, research has suggested that caregivers who feel
they have more capability in giving care have better health outcomes, calling for social work
interventions to increase family caregiver resilience and self-efficacy (Harmell, Chattillion,
Poepke, & Mausbach, 2011).
The Problem
Approximately 80 percent of the estimated six million individuals with dementia in the
United States are cared for by family caregivers (Boltz, Chippendale, Resnick, & Galvin,
2015). This statistic emphasizes that millions of family caregivers, usually spouses and adult
children, care for someone who has dementia (Alzheimer's Association, 2015). Studies have
CLOSING THE HEALTH GAP 5
determined that the demands of caregiving usually come with an increase in caregiver stress and
more inferior quality of life (Wells, et al., 2017). Caregiver stress which includes anxiety and
depression is more likely for family caregivers of those with dementia than any other disease
(Alzheimer's Association, 2015). Caregiver stress has been shown to cause a decrease in the
quality of the relationship between family caregiver and care recipient, (Boltz et al., 2015). It is
clear from the evidence that addressing the needs of family caregivers is as crucial as addressing
care recipients' needs.
Additionally, there is an underlying assumption that all family caregivers of adults with
dementia have the same needs, challenges, and resources. However, this is incorrect, people in
underserved communities, especially minorities, have different needs and are generally health
equity challenged. Aging minorities with dementia and their informal caregivers face more
challenges than the majority population.
There are increased stressors linked to family minority caregivers due to a lack of
community resources cultural competence (Osman & Carare, 2015). For instance, there are
inadequate family caregiver support services, and that causes greater psychosocial, financial,
emotional, and physical stressors for the caregiver (Alzheimer's Association, 2016). There are
multiple reasons for caregiver stress, including a lack of a support systems which causes
overwhelmed and inadequate coping skills (Boltz et al., 2015). Also, the low utilization of both
formal and informal services and the problem behaviors of the individual with dementia
exacerbate caregiver stress (Brown, Ruggiano, Page, Roberts, & Hristidis, 2016).
For instance, African-Americans generally use fewer formal health care services and
depend more on care at home with the assistance of family caregivers than Caucasians
(Sampson, Parker, Dye, & Hepburn 2016). This is of great concern since African Americans are
CLOSING THE HEALTH GAP 6
two times more likely to be diagnosed with dementia compared to the majority population
(Osman & Carare, 2015). However, African Americans are woefully underrepresented in
dementia services (Parveen, Peltier, & Oyebode, 2017). To add to the stressors, research has
shown that a disproportionate number of African American seniors in underserved communities
tend to have the greatest psychosocial needs (Gelman, Faul, & Yankeelov, 2013).
Additionally, African American caregivers report more hours of caregiving than
Caucasians and report more challenging caregiving responsibilities (Wells, Glueckauf, Bernabe
Jr, Kazmer, & Schettini, 2017). Studies indicate that African American caregivers are more
vulnerable to health problems, and they report poorer health than Caucasian caregivers, perhaps
because of stressors, such as poverty, unemployment, and racism (Bekhet, 2014).
Social workers are uniquely qualified to meet the needs of family caregivers of
individuals with dementia because of their focus on the psychosocial needs of the clients.
However, there is a shortage of social workers who work with seniors. Studies estimate that by
the year 2030, there will be a need for seventy thousand geriatric social workers to address the
aging needs of baby boomers (Keating, Fast, Lero, Lucas, & Eales, 2014). However, the number
of gerontology programs in social work has decreased. According to the Council on Social Work
Education, only 32 percent of master’s in social work programs offered a specialization in aging
and fewer than 20 percent of undergraduate and graduate social work students pursue careers in
aging (CSWE, 2017).
The Solution
It is clear from the above evidence that addressing the needs of family caregivers has to
be addressed as it directly correlates with the care recipients' needs. The innovation will be a
certificate of cultural humility dementia care consultant. The pilot of the certification will be
CLOSING THE HEALTH GAP 7
implemented into the gerontology program at Johnson C. Smith University’s MSW program.
The curriculum will concentrate on African Americans with dementia in underserved
communities. This education will allow for a greater understanding of the African American
population and how dementia manifests itself with this population. Learning will also include a
view into African American family caregivers as they attempt to provide care on their own with
little community resources. The certification will also have a community service aspect
embedded in the field placement.
Thus, the capstone innovation is twofold intervention. The education of MSW students
will help increase awareness and understanding of the barriers to accessing assistance for
minority seniors. It will contribute to identify the targets for interventions and encourage help-
seeking in minority communities. With this innovative certification, social workers will have
increased knowledge of cultural humility as they engage with a caregiver for seniors with
dementia in a needed and overlooked segment of the population. Additionally, the innovation
seeks to increase Master of Social Work students in gerontology by offering the students a
certification which will increase their opportunities for employment in a specialty they are much
needed. The MSW students will receive valuable training which will allow them to work in the
field of gerontology after graduation which is a competitive advantage.
Education can be instrumental in helping increase awareness and understanding of the
barriers to accessing assistance for minority seniors and thus assisting family caregivers (Cho,
Ory, & Stevens, 2016). Education provides identifiable targets for interventions and encourages
help-seeking in minority communities (Parveen, Peltier, & Oyebode, 2017). Additionally, the
overall improvement in the health of family caregivers takes place because of education and
interventions in with these families in underserved communities. The innovation should
CLOSING THE HEALTH GAP 8
measurably benefit the quality of relationships between the family caregiver and the loved one
with dementia in underserved communities.
Studies that indicate cultural competent and cultural humility education improves
inequity in for many diverse populations (Parveen, Peltier, & Oyebode, 2017). For instance, a
review of the literature found that practitioners can be more comprehensively responsive to the
social and cultural needs of patients struggling with psychosocial and health problems if they are
culturally competent (Horevitz, Lawson, & Chow, 2013). According to Horevitz, Lawson, and
Chow (2013), cultural humility has become the new strategy to deal with individual differences
and affect the treatment and outcomes of diverse patients. Studies have shown that cultural
humility moves beyond mere appreciations for difference and can improve both institutional and
interpersonal practices that produce improvement inequalities (Bhuyan, Park, & Rundle, 2012).
Outcomes will validate the content of the curriculum into direct outputs, longer-term
outcomes, and societal impact. Pre and post-tests measuring cultural competence will be
administered to the MSW students enrolled in the program. There will be achievement measures
such as multiple-choice tests for each section of content. Also, the students will be followed one
year after graduation to determine if they gained employment in the field of gerontology and
have used the dementia care management certification in conjunction with their employment.
Direct Link
The direct link to the Grand Challenge of closing the health care gap realized through the
improvement of health equity for African American seniors, both the family caregiver and the
loved one with dementia. This because the innovation should help the quality of relationships,
improve resilience, and increase satisfaction with life for the informal caregivers, families, and
seniors with dementia. The dementia care consultant certification with the community service
CLOSING THE HEALTH GAP 9
aspect to aims to improve cultural humility by assisting students to improve their knowledge
base of underserved minority populations. Thus, the family caregivers will have improved
efficacy in caregiving activities which, in turn, will have better outcomes caregiver and the
patient.
The intervention involves education changes to support the diverse family who are
informal caregivers to those with dementia. The program focuses on building knowledge about
cultural humility in caregiving in underserved minority communities. The program will be a
multidimensional intervention meant to address unique factors that cause caregiver stress which
increase the cost of dementia care. Learning community outreach in underserved communities is
an essential part of the education in order to reach the families who might not otherwise be able
to use this service. This increased of knowledge for informal family caregivers of those with
dementia. In turn, assisting and educating family caregivers, reducing caregivers stress, and
decreasing the psychosocial and financial cost associated with caregiving.
Moving forward, the training and education will then expand from the pilot at Johnson C.
Smith University, to more communities. Going forward the certificate program will eventually
be implemented at other historically black colleges and universities (HBCUs) with at the
community level with a community service aspect. Once the education broadens outward, there
is excepted to be an increased awareness about the significant health equity, and the trend of the
ever-growing aging population, specifically minorities aging, dementia, and caregivers and the
equitable quality care need and deserved.
Contextual Framework

The framework for this innovation is based on several theoretical frameworks.
CLOSING THE HEALTH GAP 10
These theories include Tom Kitwood’s dementia care theory, community-based participatory
approach (CBPR), cultural competence and cultural humility, and social learning theory which is
also the program model.
Dementia Care Theory
Tom Kitwood’s work in the 1990s at the University of Bradford in England combined
beliefs and values of person-centered care specifically to dementia care (Fazio, Pace, Flinner, &
Kallmyer, 2018). Kitwood's research gave credibility to the need to realign dementia care
practices to a model oriented to the individual living with dementia. From Kitwood's work was
the beginning of Person-Centered Care as it relates to dementia and is considered the gold
standard. The person-centered dementia care framework centers around the individual not being
their dementia illness, but instead, the illness is only one aspect of their being (Love &
Pinkowitz, 2013). Person-centered care focuses on the strengths of the person living
with dementia rather than on diminished or lost abilities and capabilities (Kim & Park, 2017).
Person-centered care is a sociopsychological treatment approach that recognizes the
uniqueness of the person with dementia as it relates to the attitudes and care practices that
surround them (Kim & Park, 2017). Studies have shown person-centered care for individuals
with dementia have positive effects for managing challenging behaviors and reducing the use of
antipsychotic drugs (Kim & Park, 2017). Love and Pinkowitz believe care at home, should
include a coordinated system in which all caregivers share the values of person-centered
dementia care in order to understand their role in caring for the person who has dementia that
affirms personhood and includes respect and trust (2013). Those with dementia need to keep
their identity or selfhood, and their caregivers must help maintain this identity (Fazio, Pace,
CLOSING THE HEALTH GAP 11
Flinner, & Kallmyer, 2018). Thus, it is of the utmost importance to offer guidance to those who
care for them (Fazio, Pace, Flinner, & Kallmyer, 2018).
Community-Based Participatory Approach (CBPR) to dementia care helps to improve the
relevance, quality, validity, usefulness, and application of interventions

that join partners with
diverse skills and knowledge in addressing complex problems and helps to overcome the distrust
of communities; and provides resources for communities (Morgan, et al., 2014). CBPR improves
the relationships between health and communities that have been identified as having health
inequalities in vulnerable populations (Morgan et al., 2014). According to Morgan et al. their
study identified challenges in providing dementia care in the community, and

it showed that the
early involvement of decision makers has significant improvement in understanding community
needs and priorities (2014).
Cultural Competency
According to the National Association of Social Workers (NASW), “cultural competence
requires social workers to examine their own cultural backgrounds and identities while seeking
out the necessary knowledge, skills, and values that can enhance the delivery of services to
people with varying cultural experiences associated with their race, ethnicity, gender, class,
sexual orientation, religion, age, or disability [or other cultural factors]” (2015). Additionally,
there have been many studies that indicate competent cultural education improves inequity in for
many diverse populations. For instance, according to Horevitz, Lawson, and Chow, practitioners
can be more comprehensively responsive to the social and cultural needs of patients struggling
with psychosocial and health problems if they are culturally competent (2013). Cultural
competence has become the new strategy to deal with individual differences and affect the
treatment and outcomes of diverse individuals (Horevitz, Lawson, & Chow, 2013). Furthermore,
CLOSING THE HEALTH GAP 12
research has shown that cultural competence theories move beyond the simple appreciations for
the difference but can improve both institutional and interpersonal practices that produce a
substantial difference to improve inequality (Bhuyan, Park, & Rundle, 2012).
However, bridging the gap between the classroom ideas of cultural competence and
actual practice of cultural competence will involve operationalizing specific practitioner
competencies that provide a basis for culturally competent practice (Boyle & Springer 2001).
Thus, many in the health care industry are moving to a similar but more updated concept of
cultural humility.
Cultural Humility
So, while cultural competency begins with having knowledge of different cultures or
aspects of social diversity, knowledge alone is not enough. One approach that has been
developed goes further, cultural humility. Originally developed initially for physician training, it
has been expanded to the social work field (Schuldberg et al., 2012). Humility is having a sense
that one's knowledge is limited as to what truly is another's culture. Cultural humility is about
accepting our limitations — those who practice cultural humility work to increase their self-
awareness of their own biases and perceptions and engage in a self-reflection process about how
to put these aside and learn from clients (Tervalon & Murray-Garcia, 1998). Fisher-Borne, Cain,
and Martin, (2015) have an updated model of cultural humility which is comprised of three
elements: institutional and individual accountability, lifelong learning and critical reflection, and
mitigating power imbalances.
With cultural humility, the social worker becomes the learner, and the self-reflection
process enables the social worker to determine what attitudes and values keep him or her from
learning from the client (Ortega & Coulborn Faller, 2011). Since clients can teach us about their
CLOSING THE HEALTH GAP 13
unique places at the intersections of their different cultures, those who practice cultural humility
work to understand their clients’ worldview including any oppression or discrimination that they
may have experienced as well (Ortega, & Coulborn Faller, 2011). Therefore, cultural humility is
more of a reflective practice that involves the continually challenging of oneself to learning from
those we serve.
Cultural Humility in Practice
Because there is a growing population of minority older adults who need care for
dementia and based on cultural beliefs and values and access to healthcare, studies that indicate
education along with cultural humility improves inequity in for many diverse populations (Clark,
et al. 2018). For instance, a review of the literature found, that practitioners can be more
comprehensively responsive to the social and cultural needs of patients struggling with
psychosocial and health problems if they practice cultural humility (Horevitz, Lawson, & Chow,
2013). According to Dilworth-Anderson, Pierre, and Hilliard (2016), in understanding a group’s
values, belief systems, and ways of thinking and behaving, providers, can be better prepared to
identify the cultural influences that serve as barriers and facilitators to eliminating health
disparities.
When working with the client, cultural humility places the practitioner in a learning mode
as opposed to the perceived power, control, and authority mode in the working relationship
(Ortega & Faller, 2011). The practitioners are then presumed unencumbered from the constraints
of cultural stereotypes. Cultural humility also encourages practitioners to learn not only from the
clients and communities in which they work but about their past and current experiences. In this
way, the practitioner can also learn their clients’ interpretations of those personal experiences
(Ortega & Faller, 2011). With cultural humility, practitioners can then develop a better
CLOSING THE HEALTH GAP 14
understanding of the unique personal and cultural identities of the people they serve since
cultural humility takes into account the fluidity of culture and challenges both individuals and
institutions to address inequalities (Clark, et al. 2018).
Problems of Practice and Solutions/Innovations
Description of Innovation
The intervention involves education changes to support the diverse family who are
informal caregivers to those with dementia. The program focuses on building knowledge about
culturally competent caregiving in underserved minority communities. The program will be a
multidimensional intervention meant to address unique factors that cause caregiver stress in
African American family caregivers.
The specifics involve developing curriculum for MSW students at Johnson C. Smith
University (JCSU) a Historically Black University. Throughout their history Historically Black
Colleges and Universities (HBCUs) have worked collaboratively with under-resourced
communities to address economic and social issues. HBCUs work closely with community
partners to invest in neighborhoods with untapped potential. They attempt to revitalize
communities at the margins and are committed to closing health and workforce disparities.
The Role of Historically Black Colleges and Universities
Historically Black colleges and universities (HBCUs) have a long-standing history of
engaging the African-American community. In most instances, these institutions are located in
predominantly African-American communities. Outcomes at HBCUs schools of social work
reflect students have a vested interest in working with underserved communities, which
exemplifies any School of Social Work’s mission. At HBCUs, the stated mission is to
adequately prepare urban social work leaders who are committed to the alleviation of social
CLOSING THE HEALTH GAP 15
justice and the improvement of the quality of life for diverse urban populations. (Davis Smith,
Marshall Jr., Anderson & Daniels, 2017). HBCUs have a long-standing history of preparing
students to engage communities of color that are most likely to be underserved. According to
Icard, Spearson, and Curry-Jackson (1996) HBCUs understand and embrace the significance of
community service.
The Curriculum
The curriculum will concentrate on informal family caregivers of those with dementia in
minority and underserved populations. The curriculum will develop a certification for dementia
care manager certification at JCSU, specific to the African American population. The need is
more significant in underserved communities because health inequities and these communities
are generally not recognized by healthcare and service providers. Additionally, the certification
will be catalysis to recruit MSW students into the field of gerontology which is lagging behind
the sharp increase in older adults.
The Cultural Humility Dementia Care Consultant Certification will be the last course in a
series of three courses designed to achieve gerontology certification. The course provides an
overview of social work practice in the field of aging. It presents knowledge to engage, assess,
and intervene with individuals, families, groups, organizations, and communities. The course
provides an understanding of ethical and diversity issues be used to engage in a cross-cultural
practice, specifically to the African American aging population. The students will be able to
understand better the cultural perspectives they can bring to the care situation with cultural
humility to individuals with dementia. It will interact with the community to identify where to
provide further education and support services for the African American population in the
Northwest Charlotte corridor. This innovation is an innovative course designed to increase
CLOSING THE HEALTH GAP 16
knowledge, values, and the skills needed for helping the African American elderly with the
problem-managing process by teaching interpersonal helping skills.
Regarding substantive learning, students completing this course will understand dementia
by gender, race, socioeconomic status, and the differences across cultural contexts while
recognizing the importance of cultural diversity in communicating and planning for those with
dementia and their family caregivers. Students will also learn dementia-related behaviors specific
to the population and adapt cultural humility and competence in formulating a holistic approach
toward the Alzheimer’s patients and their family. Most importantly students will learn the impact
of cultural perceptions on service use.
Social work students will then have expertise in understanding dementia symptoms and
progression, understand and manage behaviors and communication challenges caused by
dementia, understand the needed supports to manage caregiver stress, and community resources.
Learning community outreach in underserved communities is an essential part of the education
in order to reach the families who might not otherwise be able to use this service. The hope is
this education will result in increased awareness with family caregivers of those with dementia as
well as, health care community, in turn, social workers will assist and educate family caregivers,
reducing caregivers stress, and decreasing the psychosocial and financial cost associated with
caregiving. See Appendix F
Development of Curriculum
The certification would involve education about how to do community outreach to
underserved community members, assessment, and resource referrals to underserved
communities. Studies show learning in a cultural competence must include of the attitudes and
feelings of professionals by learning about their own attitudes and feelings about others, an
CLOSING THE HEALTH GAP 17
awareness of barriers to communication, and by recognizing the potential for group differences
(Reynoso-Vallejo, 2009). Students must be aware of differences in communication, behavioral
interactions, role performances, group's norms, values, and behaviors, ethnocultural specifics on
gender, education, and socioeconomic status (Kane & Houston-Vega, 2004).
Many studies have shown that dementia caregiver support programs have been found to
have many positive impacts. Most of all are the interventions that increase linkages to needed
services and increasing caregiver knowledge about dementia and how to navigate this difficult to
manage disease (Klug, Muus, Volkov, & Wagstrom Halaas, 2012). Care consultants will
recommend support programs which also reduce caregiver burden, decrease depression, and
postpone the need for nursing home placements (Klug, Muus, Volkov, & Wagstrom Halaas,
2012).
Integrated Community Service
The involvement of student placement sites and dealing with institutions or populations
outside of the university adds benefits to an academic course. Both academic institutions and
communities benefit from community service students, because of the links, partnerships, and
mutually beneficial activities take place (Rosenkranz, 2012). Service-learning typically fosters an
enhanced awareness of community resources, extending what students learn in the classroom to
real-world settings. Community service learning helps students develop their critical thinking,
define their core values, build their sense of social responsibility, and practice their leadership
skills (Rosenkranz, 2012).
After a discussion with the Field Director at Johnson C. Smith University, Kai Burkins,
MSW, LCSW, there will be 12 credit hours of the second year 500 hours of field placement
dedicated to the community service aspect. Discussions are taking place with the Charlotte Area
CLOSING THE HEALTH GAP 18
Fund (CAF). CAF is a private non-profit corporation with the mission to combat poverty in the
Charlotte Mecklenburg area. CAF has provided a variety of programs and services in the area
since 1963. CAF has a program working with seniors and is interested in providing community
service opportunities with MSW in partnership with other stakeholders.
Funding Needs and Opportunities
Currently, there have been two anonymous donors from the Charlotte community. Their
contributions total $5000.00. There are opportunities for grant funding from private insurance
companies. For instance, Johnson C. Smith University’s School of Social Work has applied for a
grant from Blue Cross Blue Shield to develop curriculum for a community health worker
certification. The John A. Hartford Foundation is a significant supporter of partnerships with
others to improve the care of older adults and their families with an emphasis on the unique
needs of family caregivers of older adults with dementia. Additionally, the Duke Endowment has
been a large grant donor to Johnson C. Smith University in various aspects. This endowment
gives the majority of its grants to higher education. Currently, the Duke Endowment provides
scholarships to Johnson C. Smith's MSW students.
Social Significance of the Problem
There is inadequate caregiver support, education, and resources for those caring for
family members with dementia in their homes, specifically with minority populations, which
causes psychosocial, financial, emotional, and physical stress. Inadequate access to basic health
care, while also enduring the effects of discrimination, poverty, and dangerous environments that
accelerate higher rates of illness. African-American caregivers for persons with dementia spend
more time and experience a higher burden from caregiving than non-Hispanic whites (Desin,
Caban-Holt, Abner, Van Eldik, & Schmitt, 2016). Dementia is an epidemic in the African-
CLOSING THE HEALTH GAP 19
American community, due to the scope of the problem related to socioeconomic status and other
risk factors (Desin, et al., 2016).
The challenge to meet the physical, mental, and social needs of older adults highlights the
need for social work professionals who not only understand factors that affect aging and living
but the needs of the primary caregivers as well. The role of a family caregiver to the elderly can
be burdensome and debilitating to the family caregivers' well-being if support from other sources
are not accessible and utilized. The family caregiver has more significant physical and mental
strain due to caring for a loved one with dementia who in most cases has lost or is losing
functionality in some activities of daily living (ADLs) and instrumental activities of daily living
(IADLs) (Kim, Chang, Rose, & Kim, 2012).
In addition to caring for the elder, caregivers tend to experience stress and strain from
functioning in multiple roles such as spouse or partner, parent, working professional or business
owner, and community leader while providing caregiving to elderly parents or a family member
(Kim, et al., 2012). Family caregivers for those with dementia report their most unmet needs are
the availability of community resources, education about dementia, emotional and respite
supports, available counseling for the caregiver role, and help with medical care (Desin, Caban-
Holt, Abner, Van Eldik, & Schmitt, 2016).
Project Contributions to Improving the Closing the Health Care Gap
Many studies have shown that dementia caregiver support programs have been found to
have many positive impacts. Most of all are the interventions that increase linkages to needed
services and increasing caregiver knowledge about dementia and how to navigate this difficult to
manage disease (Klug, Muus, Volkov, & Wagstrom Halaas, 2012). Care managers or consultants
can recommend support programs which also reduce caregiver burden, decrease depression, and
CLOSING THE HEALTH GAP 20
postpone the need for nursing home placements (Klug, Muus, Volkov, & Wagstrom Halaas,
2012).
When researching similar studies and programs, most have established that providing
education to providers, stakeholders, and family caregivers are beneficial. For instance, a study
by Peterson, Hahn, Lee, Madison, and Atri, found that education is a help to caregivers with
diverse cognitive, functional and behavioral symptoms and primary physicians can help
caregivers either directly or through a referral in the form of information, education, and services
(2016). In their study they collected data from participants using semi-structured interviews and
qualitative methods of directed content analysis, to explore caregiver participant thoughts using a
set of caregiving associated interview areas (Peterson, Hahn, Lee, Madison, & Atri, 2016). In
their clinical trials of psychoeducational interventions, the study indicated helpfulness in
improving knowledge and support for family caregivers as well as, improving caregiver
confidence and overall caregiving skills (Peterson, Hahn, Lee, Madison, & Atri, 2016)
Lee, Peterson, Hahn, Arti, and Madison studied their developed educational curriculum
for family caregivers of people with dementia (2016). Their study was designed to identify
caregivers and their education needs; provide educational resources to caregivers in primary care
settings; and evaluate the efficacy of the education (Lee, Peterson, Hahn, Atri, & Madison,
2016). As expected, their pilot study demonstrated the usefulness of the education shown by
measures of resource effectiveness and reduced caregiver burden (Lee, Peterson, Hahn, Atri, &
Madison, 2016). However, none of the above programs and studies specifically to address the
diverse minority populations in underserved communities and it is not evident if any of the
participants were from these populations.
CLOSING THE HEALTH GAP 21
This project is innovative because there is no dementia care consultant certification in the
based on cultural humility. There are no certifications for dementia care management in any
Master of Social Work program. It will be piloted in a Historically Black University and service
the surrounding community. Community outreach, the innovation does not wait for families to
reach out for help. It involves the community leaders and outreach to help find families who
would benefit from the service.
Another program that is attempting to tackle the family caregiver burden is the Veteran
Administration's Caring for Older Adults and Caregivers at Home (COACH). COACH is an
advanced care coordination program through the Durham Veteran's Affairs Medical Center in
Durham, North Carolina, and part of the coordination includes utilization of dementia care
managers (Twersky & Davagnino, 2015). The program provides home-based dementia care and
caregiver support for individuals with dementia and their family caregivers. It focuses on
behavioral symptoms, functional loss, and home safety (D’Souza et al., 2015). It also provides
support, resource referrals, and education about dementia and behavioral management with the
goal of deferring skilled nursing home placement, reducing caregiver stress, and improving care
(Twersky & Davagnino, 2015).
Johns Hopkins MIND at Home model of dementia care coordination was developed to
assist with dementia care. The MIND at Home project has funding for two research projects to
study how their MIND care coordination model will "help address the increasing need to provide
high quality and cost-efficient care to persons with dementia living in the community and their
informal caregivers" (Samus et al., 2014, p. 400). MIND assists caregivers with individualized
“care planning, referral and linkages to health and community services, provision of dementia
education and skill-building strategies to caregivers, and ongoing care monitoring by an
CLOSING THE HEALTH GAP 22
interdisciplinary team” (Tanner et al., 2014). Researchers at Johns Hopkins expect that the
MIND Home model will be able to provide for a national model with the possibility and
changing how dementia care services are provided and coordinated at the community level
("MIND at Home," 2014).
A recent study from Indiana University's Aging Brain Care Program determined their
case management program change both the health outcomes and the financial impact of
providing care to those with dementia with an annual cost savings of up to $2856 per individual
with dementia (Indiana University, 2016).
Analysis of the Market
Like many other Historically Black Colleges and Universities, Johnson C. Smith
University’s location makes it uniquely positioned to have a pervasive impact on its community.
Charlotte has many communities who lack access to the growth and wealth of the area.
Continued to be plagued with segregation by poverty, wealth, and race/ethnicity are most
apparent in Charlotte when we look at maps of the county that reveal an undeniable “crescent” of
lower-opportunity neighborhoods wrapping around more prosperous areas of our community.
Not surprisingly, people of color are in the majority within this geographic area. One community
that sits within the “crescent” that is impacted by these social issues and more is the northwest
corridor, in which JCSU is located. People who live in the northeast corridor of Charlotte have
an income at the bottom 10 percent of the city. Its 52,876 residents are ethnically/racially
diverse: 64.1 percent were African Americans. The number of persons 65 and older is
approximately 10.9 percent with 11.4% living in poverty (July 2017 Mecklenburg County, North
Carolina).
CLOSING THE HEALTH GAP 23
With the rapid growth of the older adult population, the associated growth in the number
of social workers entering the gerontology field is lacking. The United States Census Bureau
data reported that up to 70,000 social workers who specialize in aging would be needed to
address the needs of the older adult population of those aged 65 years and older by 2020 (Wilks,
Cain, Reed-Ashcraft, & Geiger, 2017). The Council on Social Work Education 2015 statistics on
social work education in the United States reported that 56 Master of Social Work (MSW)
programs offered a gerontology certificate in 2015, this figure accounted for only 25 percent of
the 228 MSW programs (CSWE, 2016).
Comparative Analysis
The USC Family Caregiver Support Center (FCSC) at USC Davis School (home of
the LA Caregiver Resource Center) has placed a high priority on providing support across the
continuum of caregiving, including diagnosis, prognosis, services that help maintain the care
recipient's independence and abilities, helping caregivers care for themselves, and manage their
well-being. Supportive services include information, assessment, individual consultations,
respite, education, and training. However, they do not offer certification.
USC Memory and Aging Center at Keck Medicine of USC in Los Angeles provides the
most advanced diagnostic and treatment services available for Alzheimer's disease, other types of
dementia and diseases related to aging. The center includes the memory clinic, the National
Institutes of Health, Alzheimer’s Disease Research Center (ADRC) and two California
Alzheimer’s Disease Centers. The team includes social workers however the focus is on the
diagnosis, treatment, and research of the disease.
University of Michigan School of Social Work offers a Web-Based Certificate in
Advanced Clinical Dementia Practice. It offers some aspects of cultural competence. However, it
CLOSING THE HEALTH GAP 24
is not developed for the African American population or underserved communities. University of
Michigan's School of Social Work offers an M.S.W. with a concentration in aging in families
and society, and this program offers students opportunities to practice within the field of
gerontology during the program. UM also offers a Specialist in Aging Certificate to social work
students in any field, but it is not explicitly geared toward dementia and caregivers. Michigan
also has the program REACH OUT which is an evidence-based caregiver support systems
designed to promote the health and well-being of adults caring for persons with dementia. The
goal is to guide others on how to implement a community-based program for dementia
caregivers. REACH OUT offers a blueprint for agencies and providers on how to create a
community-based program but does not offer certification.
The Rutgers School of Social Work has an MSW Certificate in Aging and
Health Program. The certificate program is embedded within the master's curriculum in that it
does not require students to complete any additional work beyond the credit requirements of the
core MSW curriculum. It does not have a certificate for dementia care management nor a
community service aspect. Washington University in St. Louis’ George Warren Brown’s School
of Social Work offers several options in gerontology social work. Students may choose an MSW
with gerontology concentration. Washington University does not offer a certification in dementia
care management.
All colleges and universities with a certificate in gerontology or aging did not have a
specific certification for dementia care management with cultural humility to service
underserved communities of color. Additional schools included in the search were the University
of Washington, The University of California, Berkeley, California State University, Chico, Johns
Hopkins Certificate on Aging, and the University of Wisconsin Eau Claire.
CLOSING THE HEALTH GAP 25
Project Structure, Methodology, and Action Components
Program Model
Because the innovation is structured around education, social learning theory is the
program model and theory of change. Social learning theory is also one of the primary theories
that inform the practice of social work. Social learning theory, a system of learning most
commonly associated with behaviorist Albert Bandura, is most commonly applied in educational
settings (Lewis, 2015). People learn from each other through observation and socialization, and
social learning can be applied to almost any social and behavior change that targets influencing
social behaviors (Bandura, 1977).
Also, social learning theory can be used through demonstration or modeling and when
adopting or practicing a particular behavior requires overcoming barriers or challenges (Bandura,
1977). Social learning demonstrates how a person can overcome challenges and succeed and is
an integral part of change theory because people tend to adopt and practice behaviors they see
others doing. The theory seeks to change behaviors by making them seem more familiar and
providing social support (Bandura & Barab, 1971). Thus, learning empowers individuals to
adjust to demands, and for students, it assists in acquiring the information and skills.
Additionally, social learning is about helping each other and building networks, thus the
community service aspect of the certification is a necessary and unique to this particular
dementia care management certification (Ferraro, & Farmer, 1996). The MSW students will be
preparing the skills they will need to be successful in the workforce, where most learning is done
through on-the-job experiences and interaction with others. The family caregivers will also be
empowered by social learning theory and will expand their networks and help-seeking behaviors.
Logic Model
CLOSING THE HEALTH GAP 26
So, based on the program model of social learning theory, it is expected the most
important outcome will be increased ability of minority family caregivers to care more
effectively for a family member with dementia because of increased knowledge and linkage to
services. Based on social learning theory, social work students learned, and they changed
behavior by learning about cultural humility and dementia care for African Americans. Then it is
expected as a long-term outcome that the students are now practicing social workers, will impart
knowledge to African American family caregivers and change behavior.
The inputs are funding, curriculum development community agency involvement, student
participation, education, community leaders, focus groups, research, and community buy-in. The
outputs of the logic model measure fifteen students trained with eight weeks of three-hour credit-
based education in dementia care consulting. For further details see Appendix A
Overview of Gantt
The curriculum development has been started which is meaningful to relevant
practitioners, stakeholders, and the populations. The Curriculum Council at Johnson C. Smith
has approved the content. There is also buy-in from the Dean of the School of Social Work, Dr.
Helen Caldwell, Ph.D. and the Director of the MSW program, Dr. Melvin Herring, Ph.D. The
planning and preparation will involve focus groups within the community. Community
stakeholders and leaders agree to partner in the innovation. The focus groups consisting of
community leaders, in the political, religious, and health care field will begin in January 2019.
The recruitment of students into the dementia care management certification at Johnson
C. Smith University has also begun with informational sessions conducted with first-year MSW
students. Advanced standing students will be given information about the certification at the
open houses for the MSW program, and at the orientation for those starting in the Summer
CLOSING THE HEALTH GAP 27
semester 2019. The dementia care manager certification will be implemented during the Fall
semester of 2019.
The first graduating class in the dementia care manager certification will be May 2020.
The pre-test will be given to the students in the Gerontology Program Fall 2019, and the post-
testing will take place at the end of the program in May 2020. It should indicate a marked
improvement in cultural competence. The students will then be followed after graduation to
determine if they are employed in the field of gerontology and if they are utilizing the
certification. All the outcome data should be collected by August 2020 and ready for reporting to
funders and publication before Fall semester 2020.
The Reporting will detail what the students learned, how many students were recruited
into the Gerontology Scholars program compared to the year prior and if they benefited from the
certification concerning employability. The hope is by the beginning of 2021, and a partnership
will begin with other HBCUs in the State of North Carolina to expand throughout the state. Talks
have already begun with Livingston University a Historically Black University in Salisbury,
North Carolina to implement both certification in gerontology and the certification in dementia
care consulting. Then by the beginning of 2023, the will expansion will be Nationwide to all
HBCUs with social work programs. See Appendix B for the complete Gantt Chart.
Barriers and Facilitators
There are many barriers and facilitators in the current dementia care systems. While
services and supports are available, accessing them requires alliances across different care
organizations and stakeholders, which is not simple when it comes to dementia care systems that
lack clear care paths, lack combined health and social care, or are wanting in communication
between health professionals and between different areas (Broda, et al., 2017).
CLOSING THE HEALTH GAP 28
Research documents that African American cultural norms are family-centered with
defined roles for the caregivers (Pharr, Francis, Terry, & Clark, 2014). Caring for their own or a
family first mentality is the premise by which African American caregivers operate to make the
sacrifice of time, resources, and self before considering any other options (Lindauer, Harvath,
Berry, & Wros, 2015). Even though family-centered norms can strengthen the bond between the
caregiver and the family member with dementia these cultural norms also can act as a boundary
for keeping outsiders at bay (Pharr, Francis, Terry, & Clark, 2014).
Patients with dementia and their caregivers may have barriers to accessing services. For
instance, not wanting to involve outsiders, not seeing the need for services, and concerns about
services’ cultural or religious appropriateness. (Greenwood, Habibi, Smith & Manthorpe,
2014).To have the highest chance of being useful, the intervention would have to come from a
trusted source and be targeted at the relevant population and should be delivered to people for
whom it would have more salience (Mukadam, Cooper, & Livingston, 2013).
Based on current internal financial systems at Johnson C. Smith University (JCSU)
funding opportunities are limited. The program will need funding for a clinical professor position
in the school of social work who will administer the program. Both a facilitator and a barrier,
JCSU has a new president. While he has asked all departments to reduce budgets, he has hired
employees who specialize in higher education grants and fundraising. Although, resources are
constrained the president has promised to assist the school of social work in whatever way
necessary. This is an inner facilitator because there is an opportunity for funding. An outer
facilitator for financing is the current relationship JCSU has with two of the major hospital
systems in the Charlotte area. JCSU already has a partnership with Novant Health, and Atrium
Health to create community-based outreach into the northwest Charlotte corridor.
CLOSING THE HEALTH GAP 29
Among the barriers related to external factors, organizational constraints are of vital
importance. Therefore, improvements in the organization of care are necessary, which may be
promoted by the standardization of processes and procedures and the development of protocols.
Also, the care setting has to be considered during the development of a guideline and links to
quality management may improve adherence. The facilitators will be external champions which
include community leaders. Leaders of the African American community in Charlotte will assist
with focus groups and educational outreach visits to gain community buy-in.
Potential inner barriers will be students interest in the certification with the MSW program and
the potential of the students working in the gerontology field once graduated. However, the
facilitator is the opportunity to gain employment immediately after graduation with the Charlotte
Area Funding agency which has indicated they would like to partner in this innovation. Another
outer facilitator will be professional organizations like the Alzheimer’s Association of Western
Carolina who have been contacted and expressed interest. For EPIS charts see Appendix C and
D.
Methods for Assessment
Measurement evaluation will involve the training program delivery and execution
including curriculum, attendance, and assessment tools, to determine if the right training was
provided. More specifically the measurements will occur in three stages. First, dementia care
consultant certification curriculum and outcome effectiveness will be measured. Then there will
be a qualitative analysis follow-up of the students after graduation to determine if they have
provided education in the community and effectiveness. Finally, a qualitative survey of the
providers who received education from the students who have graduated.
CLOSING THE HEALTH GAP 30
The first stage of curriculum and educational effectiveness will be measured with pre and
post testing of the second year MSW students who are registered for dementia care consultant
certification program. The pre and post-testing will assess knowledge, skillset, and cultural
competence about dementia and family caregivers in the minority population. There will be
demographic information collected about the students including race, age, and gender. A
documenting and monitoring the process will be used to ensure evidence-based procedures like
randomization designed to reduce or eliminate bias and potential for an alternate explanation of
findings. A control group will be used. For instance, a group of first-year students who are
similar to the second-year students being certified will be established to gather a baseline for
both groups. This way, an analysis of the post groups at the can be measured as to whether the
second-year students' knowledge base change more than first-year students.
Geriatric Social Work Competency Scale II with Lifelong Leadership Skills (Gero
Competencies Scale). The purpose of the scale is to evaluate gerontological social work
educational programs and the field experiences students undergo while enrolled The current 50-
item Gero Competencies Scale solicits information related to Gero practice competencies
ranging from knowledge of values and ethics, assessment and intervention skills, understanding
programs and policies, to leadership skills Students self-rate their current skill for each item on a
five-point Likert response format ranging from 0—not skilled at all to 4—expert skill. Total
global scores on the Gerontology Competencies Scale range from 0 to 200, with higher global
scores indicating a greater mastery of gerontology social work practice competencies (CSWE,
2016).
MSW students’ will also be evaluated using the Multicultural Awareness-Knowledge-
and-Skills Survey (MAKSS). The MAKSS tests three key aspects of multicultural education,
CLOSING THE HEALTH GAP 31
students' awareness about their attitudes toward ethnic minorities, students' knowledge about
minority clients, and students' cross-cultural communication skills (Hall & Theriot, 2016). The
MAKSS is composed of 60 items that form three subscales, and the 60 items are scored on a
Likert-type scale (Hall & Theriot, 2016).
Next, the program design will be evaluated by a post-student survey after six months
after graduation. Open-ended questions would ask participants if they gained knowledge with
what they needed to successfully apply their learning in promoting the adoption of evidence-
based practices within their practice and organizations. The survey will also ask graduated
students will be asked for feedback on whether the certification meets overall program objectives
in a yes-no format. The second section of the survey will ask participants to rate their agreement
(strongly agree to disagree on a 1-5 Likert-type scale strongly) to statements about the program's
facilitation of their learning.
Lastly, the students who have graduated will be asked if they are practicing in the field of
gerontology, how much community outreach and consulting with family caregivers of dementia,
and how many received the education about dementia care education. Reporting will detail what
the students learned, how many students were recruited into the Gerontology Scholars program
compared to the year prior with the certification and if they benefited from the certification in
terms of employability.
Benchmark for Success
There will be three benchmarks of success of the pilot. The first benchmark will be how
many students report improved cultural competency and gerontology competencies as well as,
receive certification. The projection for the pilot is fifteen students. The next benchmark for is
how many students report working in gerontology and using the certification. If seven to ten
CLOSING THE HEALTH GAP 32
students report this after graduation the pilot will be considered a success. Lastly, if a local
agency in conjunction with the Johnson C. Smith University can coordinate funding to hire the
students.
Financial Plans
The budget is relatively simple because for the first three years, there will be one
employee. The income would come from my salary as a full-time assistant professor at Johnson
C. Smith University estimated at $57,600.00. The other income will be a small grant for
$18000.00. Cost include office cost of office space, supplies, electric, water, and internet access
will total $21540.00 for the first year. Next, research expenses to employee a research assistant
and related computer expenses which total $12,200.00. There will be a small travel expenses in
order to conduct focus groups, network, and conduct community outreach. This expense totals
$2400.00. The total expenses for the pilot year are $36,140.00. This leaves revenue over
expenses at $40,260.00. The projection for the next two years beyond the pilot year are not
expected to increase substantially. For detailed budget see Appendix E.
Relevant Stakeholder Involvement and Perspectives
Since the innovation focuses on family caregivers in the African American community,
they are the primary stakeholders along with their loved ones with dementia. As the innovation
moves forward the inclusion of family caregivers as well as though in the beginning stages of
dementia would have tremendous importance in the focus group. Additionally, community
spiritual leaders, senior area agencies, a home health agency, healthcare systems Novant Health
and Atrium Health has already expressed interests in taking part in focus groups as well as, other
areas of the innovation.
CLOSING THE HEALTH GAP 33
Dr. Clifford A. Jones, Sr. from Friendship Missionary Church was contacted. Dr. Jones is
the pastor at Friendship Missionary Baptist Church is a friendly and mission-oriented church, a
church that focuses on meeting the needs of individuals, families, and communities. Dr. Jones
and the church are prominent in the African American northwest corridor of Charlotte, and he
offered to become a member of the focus group as well as, a referral source. Black churches have
been instrumental in developing self-help for their members. African American churches area
valuable neighborhood resources for congregational caregivers (Sheridan, Burley Hendricks, &
Rose, 2014).
The Western Carolina Alzheimer’s Association Redia Baxter, MPA, Health Systems
Director was contacted about the innovation and offered her assistance if needed. City
Councilman Braxton Winston and Charlotte’s first African American Mayor Harvey Gantt also
expressed interest in becoming members of the focus group.
Likely Improvement on Practice
Because family caregivers of people with dementia are critical to the quality of life of the
care recipients. Caregivers vulnerable to adverse effects can be identified, as can factors which
improve or stress. By adding a dementia care consultant to assist with social support, social
workers can help to guide caregivers toward a source of natural help that, in turn, might
encourage them to access even more formal help. The program has the potential to help reduce
the stigma associated with help-seeking. Thus, it will reduce the future demand for health and
social care and will be cost-saving. This innovation also ensures a strategic focus on
communities with the most significant risk and assists in reducing disparities in access to health
care. It also will increase the gerontology workforce which will identify and address disparities.
CLOSING THE HEALTH GAP 34
Working with community stakeholders will ensure that community health needs are identified,
and that needs and barriers are addressed.
Conclusions, Actions, and Implications
Limitations and Challenges
The ultimate challenge moving forward will financing. However, there will be active
grant writing and partnering with health care providers with community agencies to defuse the
cost. Another limitation is that not enough students participate in the certification. If there are not
enough MSW students participating, the certification will be made available to social workers
already licensed and working in the field, as well as, opening up the certification to the public
virtually. Another identified limitation could be a lack of field placement sites. However, through
community networking and possibly creating an agency specifically for the innovation, this
limitation will be solved.
Plan for Advancing Next Steps
The project is sustainable since it will be implemented at other Historically Black
Colleges and Universities (HBCUs). After pilot at Johnson C. Smith University the intent is to
get this certification at other regional HBCUs, then Statewide. North Carolina has eight of the
top fifty HBCU schools of social work. The innovation will be fully implemented once it is of
scaled nationally. Progress has been made on the regional level, as stated earlier, discussions
have transpired with Livingstone University in Salisbury, North Carolina.
In summary, it is clear that there is an increasing need to improve access to dementia
services for minority groups to ensure that everyone has access to the same potential health
benefits. Increasing knowledge relating to dementia has been shown to increase help seeking
from health services. Provide culturally appropriate information on dementia and caregiving. The
CLOSING THE HEALTH GAP 35
first part of the innovation is to increase awareness through education and community outreach.
Then linking family caregivers to local resources and services. This will then increase help
seeking.
The education social work students will receive emphasize that they should provide
culturally relevant communication about dementia. African American families generally benefit
more if social workers offer caregiver support and training in their homes, learn what individuals
and families would find helpful and provide education about accessing services. In addition,
African Americans have a strong connection to their faith and communities. Social work students
will learn how to provide outreach with local African American organizations and churches to
build relationships and communication channels. These relationships will likely increase
utilization of available resources as awareness and respect for these services increase. Education
and knowledge is the key to disrupting social norms the surround African American family
caregivers and will change the equity imbalance of dementia in the health care system.

CLOSING THE HEALTH GAP 36

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CLOSING THE HEALTH GAP 46

Appendix A: Logic Model

Logic Model: Dementia Care Consultants Certification Pilot
Problem: Minority family caregivers have inadequate knowledge of caregiving for loved one with
dementia and caregiving suffers

Inputs
(What we invest)

Outputs
(What we do and who we do it to)

Outcomes – Impact
(The incremental events/changes
that occur as a result of the outputs)

Funding

Curriculum
development

Field Placements

Student participation

Educating

Community Leaders
Commitment

Focus Groups

Stakeholders
Focus Group

Time

Research

Buy-in from the
community

Educating students
on the needs
assessment in the
underserved
minority community

Students have more
cultural humility
surrounding family
caregivers

8 of the graduated
students work the
field of Gerontology

5 of the graduated
.
A Program evaluation
would be assessed
through quantitative
measures pre and
posttest MAKSS.
Qualitative measures -
questions and
interviews, the
effectiveness of these
inputs in helping to
accomplish the long-
term goal.

15 MSW Students at
Johnson C. Smith
University taking
certification

80% of MSW Students
taking certification

Practicing social
workers who graduated
from Johnson C. Smith
University

Increased ability of minority family
caregivers to care more effectively for family
member with dementia because of
increased knowledge and linkage to
services.

African American family caregivers have
more knowledge which decreased caregiver
stress and improves caregiving skills. They
then provide better care which decreases
healthcare costs.

CLOSING THE HEALTH GAP 47
Appendix B: Gannt Chart

Remember the Caregivers
Period Highlight: 1
PERIODS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Planning 1 5 8/1/18 4
0%
Research 1 6 8/1/18 6
0%
Fundraising 2 7 12/2/18 5
0%
Community
Outreach 4 8 12/15/18 6
0%
Writing
Curriculum 6 8 1/3/19 8
0%
Student
recruitment 7 10 12/1/19 6
0%
Implimentation 7 11 8/1/19 7
0%
Teaching
Certification 8 12 8/15/19 8
0%
Graduation of
Students 10 15 5/10/20 10
0%
Collection of
data 10 15 5/10/20 11
0%
Reporting 12 16 7/1/20 12
0%
Presentation to
Funders 12 13 7/1/20 13
0%
Publication 13 13 9/20/20 13
0%
Expansion
Statewide 16 20 8/1/21 20
0%
Expansion
Nationwide 20 25 8/1/23 35
0%
% Complete (beyond plan) Select a period to highlight at right. A legend describing the charting follows.
ACTIVITY PLAN START
PLAN
DURATION
ACTUAL
START
ACTUAL
DURATION
PERCENT
COMPLETE
Plan Duration Actual Start % Complete Actual (beyond plan)

CLOSING THE HEALTH GAP 48
Appendix C: EPIS Model

EPIS Model
Exploration
Outreach
Focus groups
Preparation
IRB
Fundraising
Implementation
Students Educated
Measurement
Sustainment
Increase numbers of
students, schools, etc.
Agencies
CLOSING THE HEALTH GAP 49
Appendix D: EPIS Barriers and Facilitators
EPIS Summary Table

Components Barriers Facilitators
Finance (Inner)

Finance (Outer)
Limited funding through JCSU.

Limited external funding found
through grants for clinical position.
New president committed to school
of social work.

Partnership with two major hospital
systems, possible funding
opportunity.
Socio-cultural (Inner)

Socio-cultural (Outer)
Students not accepting training from
non-African American.

Minority community not accepting
of social work students.
Students wanting to assist their
communities.

Educating the community through
stakeholders and community leaders
Leadership (Inner)

Leadership (Outer)
Possible pushback from JCSU
administration to implement change
in curriculum.

Readiness for change, pushback
from community leadership and
healthcare system
Culture/Climate willingness of
school of social work to innovate in
the community.

The hospital systems have already
approached JCSU with similar
community-based education.
Interorganizational Networks (Inner)

Interorganizational Networks
(Outer)
The students’ willingness to take
part in additional training

Change not accepted by community
agencies
Higher education are excellent
partners for change and innovation

Professional organizations like the
local hospitals can be advocates.

CLOSING THE HEALTH GAP 50

Appendix E: First Year Budget

CLOSING THE HEALTH GAP 51
Appendix F: Course Curriculum
Week Student Learning Readings & Assignments
Week 1

Ethics & The Aging
Population
Diversity

Competencies: 1 & 2
Cultural perceptions of
dementia, illness, and
older people and the
impact of cultural
perceptions on service
use

Alzheimer's disease and
Dementia by gender,
race, social class and
the differences across
cultural contexts
MAKSS Cultural
Competency
Assessment & Geriatric
Social Work
Competency Scale II

Reflection Journal &
Discussion
Yoe, G. Chapter 1 & 2

Week 2
Practicing with
Diversity, Difference, &
Redress

Competencies: 1, 2, 3, & 4
Practice with African-
American Older Adults

Help-Seeking Models
Practice Within a
Cultural Context

Person-Centered Care

Yoe, G. Chapter 3
Article: Fazio, S., (2018)

Reflection Journal &
Discussion

Week 3
Incorporation of Values
& Ethics in Practice with
Older Adults

Competencies: 1, 2, 3, 4, & 5
Ethical Standards &
Principles

Assessment of Older
Adults, Their Families,
& Their Social Supports

Article: Moon, H.,
(2016)

Reflection Journal &
Discussion

Week 4
Geriatric Case
Management

Competencies: 1, 2, 3, 4, 5, &
6
The Helping Process
with African-American
Elders

Strengths-Based
Assessment

Case Manager’s
Repertoire of Skills

Yoe, G. Chapter 4
Article: Molony, S. L.,
(2018)

Reflection Journal &
Discussion

CLOSING THE HEALTH GAP 52
Week 5
Assessment and Care
Planning

Competencies: 1, 2, 3, 4, 5, &
6
Cultural diversity plan
of care for those with
African-American’s with
dementia

Putting the Resilience-
Enhancing Model into
Action

Whitfield & Baker
Chapter 19

Reflection Journal &
Discussion

Midterm

Week 6
Care Management
Cultural competent
communication with the
African-American
population

Competencies: 1, 2, 3, 4, 5, &
6
Creating care plans for
underserved families

Communication skills
including strategies and
helping strategies for
difficult behaviors
Article: Graham-
Phillips, A. (2016)

Reflection Journal &
Discussion

Week 7

Support for Physical
Functioning/Daily
Activities

Competencies: 1, 2, 3, 4, 5,
6, 7 & 8
Medical management in
underserved
communities
Information, education
and support for
caregivers
Advocating for those
with dementia &
caregivers in
underserved
communities
Whitfield & Baker
Chapter 4 & 5

Article: Hirschman, K.
B., (2018)

Reflection Journal &
Discussion

Week 8
Community Capacity
Building in Underserved
Communities

Competencies: 1, 2, 3, 4, 5,
6, 7, & 8

Exploring barriers to
service engagement in
African-American &
underserved
community programs
Transitions and
coordination of services

Reflection Journal &
Discussion
Final
MAKSS Cultural
Competency
Assessment & Geriatric
Social Work
Competency Scale II

CLOSING THE HEALTH GAP 53

Appendix G: Letter of Support

Dear Members of the Doctoral Committee,

It is with great pleasure that I write on behalf of Johnson C Smith University’s School of
Social Work, MSW program in support of Professor Nancy Greene’s proposal to create a
culturally competent dementia care managers certification course to reduce health disparities
related to dementia in the African-American community.

I strongly support this curriculum and the focus on reducing health disparities
among underserved African-American aging population by increasing education
surrounding community-based dementia care.

As a new school of social work, whose mission is to promote culturally competent and
community-oriented approach to education, Professor Greene’s ongoing efforts to reduce
health disparities, involvement with the target community, and relationship with Johnson C.
Smith University’s School of Social Work, makes this innovation an excellent fit.

Professor Greene is already serving as an adjunct professor, teaching our electives in
gerontology. Through this letter, we acknowledge specific roles and responsibilities we will
fulfill in partnership with her innovation. We would expect our role in the certification to
include founding a student certificate in gerontology, developing community outreach
programs, and conducting research on how to address the epidemic of dementia in the African-
American population.

We look forward to working with you in eliminating health disparities in our community
and achieving health equity.

Sincerely,

Melvin Herring, Ph.D., MSW
MSW Director
School of Social Work

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Asset Metadata

Creator Greene, Nancy Alison (author)

Core Title Closing the health gap

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 02/22/2019

Defense Date 11/30/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag African Americans,caregiver stress,cultural competence,cultural humility,dementia,family caregivers,health equity,OAI-PMH Harvest,underserved communities, gerontology

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee member), Navarro, Ernelyn (committee member), Singh, Melissa (committee member)

Creator Email ng537@yahoo.com,ngreene537@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-126191

Unique identifier UC11675613

Identifier etd-GreeneNanc-7110.pdf (filename),usctheses-c89-126191 (legacy record id)

Legacy Identifier etd-GreeneNanc-7110.pdf

Dmrecord 126191

Document Type Capstone project

Format application/pdf (imt)

Rights Greene, Nancy Alison

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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