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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

Introduction

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:

  1. Important aspects of care: social work functions and services.
  2. Rationale: an explanation of the logical connection between the "flag," social work functions, and an important dimension of quality.
  3. Operational definition: a definition of the indicator that allows for reliable measurement across practice settings.
  4. Threshold: the predetermined point at which the "flag goes up," precipitating closer scrutiny and evaluation.
  5. Data elements: the specific information needed to measure the indicator.
  6. 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. NASWís Board of Directors formally accepted the indicators in April 1993.

Scope of Practice for Social Work and Psychosocial Services in Nursing Homes

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 applicantís participation in the decision to enter the home.
  • Perform a comprehensive social history and social and psychological assessment that includes the residentís 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 residentsí 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 residentís 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 masterís or bachelorís level at an accredited school of social work. If services are performed by someone trained at the bachelorís level, a qualified masterís 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. Residentís 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)Ė(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 residentís 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 residentís 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 residentís 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 oneís 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. Residentsí 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 homeís 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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