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NASW
Clinical Indicators for Social Work an Psychosocial Services in
Nursing Homes
Approved
by the NASW Board of Directors, April 1993
Contents
Monitoring the
quality and appropriateness of psychosocial and social work services
in nursing homes is an area of increasing concern to the health
care field. Social workers and their supervisors desire specific
measures of service delivery to monitor quality and to position
the profession strategically as the health care system evolves.
Survey agencies and accrediting organizations seek consistency
in data collection, analysis, assessment, and comparison across
institutions.
In response to
these concerns, the National Association of Social Workers (NASW)
has established clinical indicators to be used in the systematic
monitoring of the quality and appropriateness of resident care.
Indicator development is an ongoing process that encompasses testing,
improvement, and innovation. These indicators serve as broad guidelines
to allow for the varied needs of diverse institutions while encouraging
more uniformity in social work quality assurance.
Clinical indicators
are not intended as direct measures of the quality of clinical
performance. They are best thought of as "flags" that, at a predetermined
threshold, "go up" and signal the need for problem analysis or
peer review.
The following information
is provided for each indicator:
- Important aspects
of care: social work functions and services.
- Rationale: an
explanation of the logical connection between the "flag," social
work functions, and an important dimension of quality.
- Operational
definition: a definition of the indicator that allows for reliable
measurement across practice settings.
- Threshold: the
predetermined point at which the "flag goes up," precipitating
closer scrutiny and evaluation.
- Data elements:
the specific information needed to measure the indicator.
- Other influencing
factors: factors beyond the control of the individual practitioner
that influence the provision of care.
These clinical
indicators for social work and psychosocial services in nursing
homes were developed by a panel of recognized expert practitioners
from a variety of related settings and facilities and were reviewed
by practitioners in the field. NASW’s Board of Directors formally
accepted the indicators in April 1993.
Mission
Social work services
in long-term care are provided directly to nursing home residents
and their families to promote their social and psychological well-being.
In addition, as part of the multidisciplinary team, the social
worker is responsible for fostering climate, policy, and routines
that enhance quality of life; that respect the culture, religion,
and ethnicity of the resident; and that emphasize helping residents
retain individuality, independence, and choice.
Population Served
- All residents
- Families and
significant others
Major Functions
and Services Provided
1. Facilitate the
admissions process.
- Review appropriateness
of admission applicants and provide information and referral
to other services as indicated.
- Promote applicant’s
participation in the decision to enter the home.
- Perform a comprehensive
social history and social and psychological assessment that includes
the resident’s preferences, including cultural, racial, religious,
and ethnic background and sexual orientation, and implications
for the care plan.
- Help residents
and their families (in their social, racial, ethnic, and cultural
context) cope with the immediate effects of the decision to move
to the nursing home.
- Orient residents
and families to the facility, its services, its service limitations,
and residents’ rights.
- Assist residents
and families with financial planning.
2. Develop an individualized
plan of care.
- Involve residents
and families in care planning, including their attendance at
a care conference if they desire.
- Identify and
interpret psychosocial needs of residents for inclusion in the
care plan, addressing in particular issues of schedule, treatment,
and environment that express and reinforce individuality and
identity.
- Work with relevant
staff to implement each resident’s care plan.
3. Facilitate the
social and psychological well-being of nursing home residents and
their families.
- Enable social
functioning using group, individual, and family treatment interventions.
- Help residents
adapt to living in an institutional environment.
- Empower clients
and enable maximum client choice in matters affecting them, demonstrating
receptive attitudes and sensitivity to choices based on racial,
cultural, and ethnic heritage and sexual orientation.
- Mediate issues
that arise among residents, families, and staff.
- Ameliorate emotional
distress of residents and families.
- Provide linkage
with appropriate ethnic and racially sensitive community resources
by maintaining knowledge of other systems, making referrals,
and identifying unmet needs.
- Provide crisis
management services.
- Monitor the
effect of governmental and facility rules and regulations, and
their interpretations, on the everyday life of residents and
their families to ensure that racial, ethnic, and cultural diversity
and sexual orientation are included.
- Help residents,
family, and staff prepare for and cope with losses, including
death.
4. Involve the
entire facility in meeting psychosocial needs.
- Affect facility
policy and practice to promote responsiveness to cultural and
religious diversity and choice in schedule and lifestyle.
- Train and consult
other staff and volunteers regarding psychosocial needs that
encompass social, ethnic, religious, and cultural diversity of
individual residents; the resident group as a whole; and families
to increase staff sensitivity to the racial, cultural, ethnic,
and sexual orientation influence on resident and family participation.
- Advocate on
a case, policy, and program level.
- Participate
in policy decision making in a way that encompasses an understanding
of the issues and implications relevant to racial, ethnic, and
cultural diversity as it affects resident life and care and family
involvement.
5. Plan discharges
to ensure appropriateness and continuity of care for transfers
within and discharges from the nursing home.
Providers
Social work services
are performed by qualified social workers trained at the master’s
or bachelor’s level at an accredited school of social work. If
services are performed by someone trained at the bachelor’s level,
a qualified master’s level social worker will be available for
consultation on an as needed basis and for supervision on a monthly
basis.
Recommended
Clinical Indicators for Social Work and Psychosocial Services in
Nursing Homes
Quality of Care
Indicators (Process)
Indicator
1. Timely Psychosocial Assessment. Comprehensive resident
evaluation occurs soon after admission to the home.
Important aspects
of care. Social and psychological assessment, evaluation,
and care planning.
Rationale. Information
and conclusions of a comprehensive social history and social and
psychological assessment that includes racial, cultural, ethnic,
and religious information and sexual orientation must be available
on a timely basis to guide care planning and ongoing care provision.
Operational
definition. The percentage of reviewed charts with assessments
completed within the time frame specified by the regulatory requirement
of the state.
Threshold. 95
percent.
Data elements. Number
of reviewed charts that have a comprehensive assessment dated within
the designated time frame divided by the total number of charts
reviewed.
Other influencing
factors. Patient dies or is rehospitalized or discharged
before the designated time frame.
Indicator
2. Comprehensive Psychosocial Assessment. Resident’s psychological
and social circumstances are assessed adequately.
Important aspects
of care. Social and psychological assessment and identification
of needs that includes racial, cultural, and ethnic diversity.
Rationale. To
adequately guide planning and decision making the psychosocial
history and assessment addresses both needs and strengths (for
example, assets and resources) in the resident and in his or her
situation and spells out the implications of this information for
care planning.
Operational
definition. The percentage of reviewed psychosocial assessments
that meet the following seven criteria for comprehensiveness:
(1) social history; (2) problems and strengths in physical and
functional status, cognitive functioning, and emotional state;
(3) current social functioning and relationships including sexual
orientation; (4) resident preferences; (5) problems and strengths
in the family and other social support systems; (6) cultural,
ethnic, and religious factors; and (7) the implications of the
assessment in (1)–(6) for care planning, including any social
work plan of intervention.
Threshold. 95
percent.
Data elements. The
number of reviewed charts that meet comprehensive criteria divided
by the total number of charts reviewed.
Other influencing
factors. Resident leaves before the time required to complete
the comprehensive assessment.
Indicator
3. Resident Involvement in Care Planning. The resident is
included in care planning and decision making.
Important aspects
of care. Care planning.
Rationale. The
resident’s plan covers matters that define the parameters of everyday
life. It must reflect his or her preferences and choices, including
cultural, ethnic, and religious background and sexual orientation.
Residents or their surrogates must be aware of what is embodied
in the care plan and must know they have the right to refuse aspects
of care.
Operational
definition. The percentage of care plans that reflect resident
preferences, that contain evidence that residents or their surrogates
were invited to participate in the care plan, and that indicate
attendance at the care conference.
Threshold. Recording
preferences, 95 percent; invitation to participate, 95 percent;
attendance at care conference, needs empirical determination.
Data elements. Number
of reviewed charts with recorded preferences, invitation to participate,
and attendance noted divided by the total number of charts reviewed.
Other influencing
factors. Resident incapable of communicating, attending,
or participating and no surrogate available.
Indicator
4. Family Involvement in Care Planning. The wishes and thoughts
of the resident’s family are explored with sensitivity to cultural
factors and lifestyle, and the family is aware of the care plan
and decisions made by the care-planning team.
Important aspects
of care. Care planning.
Rationale. Family
input into care planning provides important information to guide
decision making. Once a care plan is in place the family should
be fully informed to enhance positive collaboration. The social
worker facilitates communication between the family and the care
team before and after the care-planning conference.
Operational
definition. The percentage of resident records that reflect
communication with the resident’s family before and after a care-planning
conference.
Threshold. 95
percent.
Data elements. The
number of reviewed records that reflect contact divided by the
total number of records reviewed.
Other influencing
factors. There is no family available, or family involvement-is
not desired by the resident.
Quality of Care
Indicators (Outcome)
Indicator
1. Resident Satisfaction with Choice. Residents are satisfied
with the degree of choice available in everyday matters in the
home.
Important aspects
of care. All.
Rationale. Greater
control over one’s life is presumed to contribute to social and
psychological well-being. Though social work is not solely responsible
for positive or negative outcomes on this dimension, one function
of social work is to identify preferences and individuality in
the psychosocial assessment and to facilitate choices through working
directly with residents and their families, educating and sensitizing
staff, developing mechanisms for choice, and working at policy
levels in the home.
Operational
definition. The average degree of resident and surrogate
satisfaction with choice in everyday matters in categories such
as care routines, roommates, room arrangement, foods, and activities,
as reflected in a standardized response questionnaire.
Threshold. Needs
empirical determination.
Data elements. The
total of all satisfaction scores by category on questionnaires
completed by residents in a given time period divided by the number
of questionnaires completed in that time period.
Other influencing
factors. None.
Indicator
2. Problem Resolution. Residents’ psychosocial problems are
ameliorated.
Important aspects
of care. Psychosocial intervention.
Rationale. The
intent of social work intervention is to help residents meet psychosocial
needs and improve and solve problems related to nursing home life
and care. Problem resolution is an indicator of whether the intervention
has achieved its goal.
Operational
definition. Percentage of planned results not achieved (problem-
specific).
Threshold. Needs
empirical determination.
Data elements. Number
of social work cases worked on each month having problem X with "not
resolved" as the outcome divided by the number of social work cases
each month having problem X. (Note: Gathering data for this indicator
requires a well-defined problem list and reliable categories for
problem resolution that are compatible with a nursing home’s staffing
and role expectations for social work.)
Other influencing
factors. Resident case mix and social complexity.
Clinical
Indicators in Nursing Homes Work Group
- Sylvia Cohen,
ACSW, Baltimore, Maryland
- Roberta DuChamp,
BSW, St. Paul, Minnesota
- Natalie Gordon,
DSW, ACSW, New York, New York
- Wilma Greenfield,
PhD, Boca Raton, Florida
- Rosalie Kane,
DSW, Minneapolis, Minnesota
- Carter C. Williams,
ACSW, Rochester, New York
- Project Consultant:
Betsy Vourlekis, PhD, Bethesda, Maryland
- NASW Staff:
Joan Levy Zlotnik, ACSW, Senior Staff Associate for Children
and Families
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