Social Work Services in Nursing Homes: Toward Quality Psychosocial Care

This NASW research page focuses on social work contributions to quality psychosocial care in nursing homes. Included is an overview of the topic, followed by a set of references and Web links to related social work resources.

The term psychosocial describes a constellation of social, mental health, and emotional needs and the care given to meet them. A broader, but related concept, quality of life , focuses on the nursing home residents’ perspective on their total living experience in the home, not just their medical care. The psychosocial care domain is a multifaceted one because in addition to social workers, other nursing home care providers contribute to meeting psychosocial needs and enhancing quality of life. Also contributory to quality of life are the overall home atmosphere and processes.

Federal requirements for social work services

Federal law (42 CFR 483.15) requires that all skilled nursing facilities (SNFs) provide “medically related social services to attain or maintain the highest practicable resident physical, mental and psychosocial well-being.” Nursing homes with more than 120 beds are required to employ a full-time social worker with at least a bachelor’s degree in social work or “similar professional qualifications.” Facilities with 120 beds or fewer must still provide social services, but do not need to have a full-time social worker on staff. Although federal nursing home regulations have a general requirement that facilities use licensed personnel, this regulation has not been enforced in the case of social work. The federal regulations contrast with NASW Standards for Long-Term Care (2003), which recommend that nursing home social work staff have no less than a bachelor’s degree in social work from an accredited school of social work and are licensed, certified, or registered within their home states.

A recent, national study of a random sample of nursing home social service directors (n=299) in facilities with more than 120 beds found that:

• 62 percent possessed a bachelor’s degree and 35 percent had master’s degrees. Three percent lacked the minimum federal requirement of a BA.
• 62 percent had a degree in social work, with degrees in psychology (n=35), sociology (n=21), counseling (n=10), and gerontology (n=5) also reported with frequency.
• Less than half (47 percent) were licensed or registered social workers in their home states and only 15 percent reported receiving clinical supervision by a licensed social worker.
• Caseloads averaged 90 residents per social service director (SD = 47.9; Mode = 120) and nearly one-third (30 percent) were the only social worker on staff (Simons, unpublished).

These findings highlight the continuing discrepancy between actual staffing patterns and recommended professional qualifications.

Addressing psychosocial needs

Psychosocial concerns include mental health disorders such as depression, anxiety, dementia, and delirium, as well as a range of issues with more obvious social dimensions, including loss of relationships, loss of personal control and identity, and adjustment to the facility. A lack of professionally qualified social workers in nursing homes is one of several factors that potentially contribute to inadequate and inconsistent mental health and psychosocial care in nursing homes. Numerous studies document the extent of nursing home resident mental health needs as well as significant gaps in provision of mental health services.

• High rates of mental health disorders found include 45-51 percent with dementia (Burns et al., 1993; Meeks et al., 2000); 45 percent with depression (Castle & Shea, 1997); 35 percent with personality disorders (Castle & Shea, 1997); and 17 percent with behavior disorders (Meeks et al., 2000).
• Although nursing homes are increasingly recognized as a primary provider of mental health services, there is evidence that a majority of residents with mental health disorders do not receive these services (Castle & Shea, 1997; Snowden, Piacitelli, & Koepsell, 1998; Shea, Russo, & Smyer, 2000).

The American Geriatrics Society and the American Association of Geriatric Psychiatry (2003) developed a consensus statement to improve the quality of mental health care in U.S. nursing homes: Management of Depression and Behavioral Symptoms Associated with Dementia. This statement supports the important role that nursing home social workers can play in addressing mental health needs of residents.

Are psychosocial needs adequately met?

Concerned about inadequate psychosocial care, a group of professional, consumer, and advocacy organizations filed a complaint with the Department of Health and Human Services (DHHS) in 2002, leading to an investigation by the Office of Inspector General (OIG) into the quality of psychosocial services in nursing homes. The major OIG findings ( http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf ) concluded the following:

• Some 39 percent of the residents with psychosocial needs had care plans that were inadequate to meet those needs.
• Forty-one percent of those with psychosocial needs addressed in their care plans did not receive all of their planned psychosocial services, and 5 percent received none of these services.
• A total of 45 percent of social workers reported barriers to providing psychosocial services, including not having enough time, burdensome paperwork, and insufficient staff.
• A full 98 percent of the facilities in the sample met the federal staffing requirement of one “qualified social worker” per 120 beds.

Based on their findings, the OIG recommended that the Centers for Medicare and Medicaid Services (CMS) “strengthen the oversight process associated with the psychosocial service portion of the resident assessment and the resulting care plans to ensure that Skilled Nursing Facility residents receive necessary and appropriate care” (DHHS, OIG, 2003, p. iv).

Monitoring Psychosocial Care

CMS has created several relevant measures and indicators for psychosocial care and implemented a Nursing Home Quality Initiative (NHQI) targeting four domains: (1) regulation and enforcement, (2) consumer information, (3) community and facility-based programs including the development of quality improvement organizations, and (4) partnership and collaboration across agencies, organizations, and care providers. The development of quality indicators of residents’ acute and chronic health and mental health conditions, based on Minimum Data Set (MDS) data, has been central to the initiative. Two of the NHQI measures, the percentage of residents who have become more depressed or anxious and the percent of short-stay residents with delirium, capture psychosocial constructs. These are published on the CMS Nursing Home Compare Web site for consumer review. (http://www.cms.hhs.gov/quality/nhqi/)

Measures to Assess Resident Quality of Life

Due to widespread interest in creating more explicit regulatory attention to quality of life and quality of care in the nursing home, CMS provided support to social work researcher Rosalie Kane and her research team to undertake a five-year study to 1) develop and test measures and indicators of quality of life (QOL) for nursing home residents, and 2) to study how the physical environment, including private rooms, affected resident QOL. (http://www.cms.hhs.gov/quality/nhqi/QualityOfLife.asp) Eleven relevant domains at both the resident and facility level for which outcomes can be specified and potentially measured were identified including:

• Comfort and security
• Enjoyment, relationships, meaningful activity, and functional competence
• Individuality, privacy, autonomy, and dignity
• Spiritual well-being

Social workers can be the key to promoting improvement in quality of life domains by building on their person-in-environment perspective; implementing environmental interventions; using knowledge of group processes to build resident, staff, and family involvement; addressing end-of-life and discharge planning needs with a resident-centered context, and being involved in continuous quality improvement efforts.

Culture Change in Nursing Homes

Social workers have taken lead roles in the international movement to promote resident-centered nursing home care. The Pioneer Network (www.pioneernetwork.net) is a lead resource in promoting culture change and principles. Culture change in long-term care is an ongoing transformation based on person-directed values that restores control to elders and those who work closest with them. This transformation i ncludes changing core values, choices about the organization of time and space, relationships, language, rules, objects used in everyday life, rituals, contact with nature, and resource allocation . Reports on research for residents and facilities that have embraced the culture change principles, such as the Eden Alternative can be found at: http://www.pioneernetwork.net/index.cfm/fuseaction/Initiatives.DocList/CategoryPK/Research.cfm

Enhancing Social Work Contributions to Psychosocial Care: In December 2004, the Institute for the Advancement of Social Work Research (IASWR), in collaboration with University of Maryland School of Social Work and the Institute for Geriatric Social Work at Boston University, convened a meeting, Evaluating Social Work Services In Nursing Homes: Toward Quality Psychosocial Care And Its Measurement , bringing together researchers, practitioners, and representatives of federal agencies to:

• Clarify and specify realizable role, function, and intervention expectations for social work personnel along with their operational links to resident and facility psychosocial care and quality of life outcomes
• Examine measurement approaches for increased accountability (consistency in process and impact on outcomes) and quality care enhancement of social work services and psychosocial care/QOL at the home, survey, and national database levels and recommend strategies for their wider use and improvement
• Recommend research priorities to establish the most effective social work interventions and their contribution to quality-care outcomes in the nursing home

A Briefing Book, providing important background information (including NASW Standards for Long Term Care and NASW Clinical Indicators for Psychosocial Care in Nursing Homes) and key research findings; a Report to the Profession and Blueprint for Action that includes summaries of research presented at the symposium on social work roles and functions, mental health needs of nursing home residents, quality of life, and the nursing home culture change movement also imparts important practice, policy, and research recommendations;, and an Issue Brief that provides a short summary and highlights key practice and research recommendations can be found at: www.iaswresearch.org

This conference confirmed the need for a comprehensive approach to monitoring and measuring psychosocial care, specifically care provided by social workers, and quality of life in nursing homes. The highlights of the action agenda for improving the monitoring and measuring of social work services provides opportunities for individual practitioners, facilities, corporate providers, and university-based researchers to undertake studies that use currently available data sources (e.g., CMS OSCAR data) and create new collaborations that connect quality of life and quality of care to ensure the maximum health and well-being of nursing home residents.

Research Agenda

• Specify practice interventions and develop studies to test the core domains of social work practice in nursing homes identified by Greene (2004)
• Build a statistical trail and track records for social workers employed in nursing homes through studies that: (1) document the extent of personnel who hold professional social work credentials; (2) demonstrate the range of resident-centered and facility-oriented roles and functions performed by social workers; and (3) assess the impact of social workers on the quality of life and quality of care
• Undertake research using the existing CMS measures (MDS and Resident Assesssment Instrument [RAI]) and continue to develop new measures to assess and analyze psychosocial domains
• Engage nursing home social workers in the use and refinement of applied measurement tools and link the use of these tools to practice outcomes and research at the facility level
• Develop mentorship models for facilities with social service designees to assist in monitoring and measuring services
• Examine best-practice facilities (e.g., culture-change models) and study the social work qualifications, roles, and functions at these facilities
• Use mental health outcomes in nursing homes, for example, facilities with lower levels of depressed residents, to study social work roles in those facilities
• Facilitate use of data available from nursing homes at the federal, state, or local level for researchers studying social work in those facilities

Practice Agenda

• Encourage social work input into the development of federal initiatives with respect to care plan protocols, computerized assessment tools, and surveyor guidelines
• Provide social work input into the management and system interventions that will lead to culture change and improved quality of life
• Identify evidence-based mental health interventions for nursing home residents (reimbursable through Medicare Part B) that will increase the effectiveness of care provided by professionals from outside the nursing home
• Encourage social work field placements in nursing homes
• Increase visibility of nursing home social workers within the profession
• Examine attributes of social workers in leadership and management roles in nursing homes
• Promote interdisciplinary practice with medicine, nursing, psychiatry, psychology, and paraprofessionals to build expertise and interest in nursing home care
• Encourage involvement of professional associations to ensure that the voice of social work is heard at CMS, in workgroups, advisory committees, and through open door sessions hosted by CMS which provide an opportunity for the nursing home community to give input to CMS

References

 

American Geriatrics Society and American Association for Geriatric Psychiatry. (2003). Consensus statement on improving the quality of mental health care in U.S. nursing homes: Management of depression and behavioral symptoms associated with dementia. Journal of the American Geriatrics Society, 51, 1287-1298.

Beaulieu, E. M. (2002). A guide for nursing home social workers. New York : Springer.

 

Burns, B. J., Wagner, H. R., Taube, J. E., Magaziner, J., Permutt, T., & Landerman, L. R. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331-337.

Castle, N. G. & Shea, D. G. (1997). Mental health services and the mortality of nursing home residents. Journal of Aging and Health, 9, 498-513.

 

Department of Health and Human Services, Office of Inspector General. (2003).

Psychosocial services in skilled nursing facilities . Retrieved from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf

 

Greene, R. (2004, December 2). Roles and functions of nursing home social workers in the provision of psychosocial care. Presented at evaluating social work services in nursing homes: Toward quality psychosocial care and its measurement. , Washington , DC .

Kane, R. (2004, December 3). Measuring good (or better) QOL for nursing home residents: Relationship to social workers & psychosocial services. Presented at Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and its Measurement, Washington , DC .

 

Meeks, S., Jones, M. W., Tikhtman, V., & La Tourette, T. (2000). Mental health service in Kentucky nursing homes: A survey of administrators. Journal of ClinicalGeropsychology, 6, 223-232.

 

 

Shea, D. G., Russo, P. A., & Smyer, M. A. (2000). Use of mental health services by persons with a mental illness in nursing facilities: Initial impacts of OBRA 87. Journal of Aging & Health, 12, 560-578.

 

 

 

Simons, K. (2005. Factors affecting nursing home social workers’ quitting intentions. Unpublished doctoral dissertation, University of Maryland , Baltimore .

 

 

Snowden, M., Piacitelli, J., Koepsell, T. (1998). Compliance with PASARR recommendations for Medicaid recipients in nursing homes. Journal of the American Geriatrics Society, 46, 1132-1136.

 

Vourlekis, B. S., Bakke-Friedland, K., & Zlotnik, J. (1995). Clinical indicators to assess the quality of social work services in nursing homes. Social Work in Health Care, 22, 81-93.

Vourlekis, B. S., Greene, R., & Gelfand, D. (1992). Psychosocial needs and care in nursing homes: Comparison of views of social workers and home administrators. The Gerontologist, 32, 113-119.

Web Resources

AGING, HEALTH & LONG-TERM CARE ORGANIZATIONS

American Health Care Association
http://www.ahca.org/
The American Health Care Association (AHCA) is a non-profit federation of affiliated state health organizations that represent the long-term care community to the nation at large. The Web site contains a portion specific to members. The general public can learn more about AHCA, read news updates pertaining to long-term care, and learn about upcoming events and conferences. The research and data section contains links to studies conducted on Medicare/Medicaid, staffing, health care liability, surveys, state summaries, and links to data sources.

Joint Commission on Accreditation of Healthcare Organizations
http://www.jcaho.org/
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits more than 15,000 health care organizations and programs in the United States . It is the nation's predominant standards setting and accrediting body in health care. Their Web site provides some consumer and professional resources such as “Quality Check.” There are also links to resources and educational opportunities. Details about online seminars and other events and programs can be found on the Web site.

National Citizens’ Coalition for Nursing Home Reform
http://www.nccnhr.org
The National Citizens’ Coalition for Nursing Home Reform (NCCNHR) works to define and achieve quality for people with long-term care needs by promoting informed, empowered consumers, effective citizen groups, and ombudsman programs; promoting best practices and public policies responsive to consumer needs; and enforcement for consumer-directed living standards. NCCNHR’s Web site includes consumer and family information about choosing a nursing home and about resident’s rights; provides resources for ombudsmen;detailed information about government policy; and other reports and publications.

 Pioneer Network
http://www.pioneernetwork.net
The Pioneer Network advocates and facilitates dramatic system change and transformation in the culture of aging. To achieve this, they create communication, networking, and learning opportunities; build and support relationships and community; identify and promote transformations in practice, services, public policy, and research; and develop and provide access to resources and leadership. Their Web site accomplishes these aims by providing a discussion board, job postings, and an event calendar. There are also links to resources such as publications, research, and an online store.

Federal Agencies and Resources

Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov/
The Agency for Healthcare Research and Quality (AHRQ)’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Their Web site provides links to specific research findings, media resources, and quality assessment tools such as the National Quality Measures Clearinghouse and the Consumer Assessment of Health Plans (CAHPS).

Centers for Medicare and Medicaid Services
http://www.cms.hhs.gov
The Centers for Medicare and Medicaid Services (CMS)’s mission is to assure health care security for beneficiaries.

CMS Guidance to State Survey Agency Directors and CMS Regional Offices
http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp
CMS memoranda, letters, and instructions to State Survey Agency Directors and CMS regional offices are posted here by category.

CMS MDS 3.0
http://www.cms.hhs.gov/quality/mds30/
The information posted on this site is intended to assist nursing homes, state agencies, software vendors, professional associations, and other federal agencies in the activities that are underway to refine and evaluate the MDS. It includes a section for providing feedback for public comment and other materials.

CMS Nursing Home Quality Initiative
http://www.cms.hhs.gov/quality/nhqi/
Provides links to specific information on nursing home quality initiatives. There are also links to information about quality measures, information about choosing a nursing home, and links to the nursing home compare Web site.

CMS Open Door Forum on Skilled Nursing Facilities and Long-Term Care
http://www.cms.hhs.gov/opendoor/snf-ltc.asp
These forums address the concerns and issues of the Medicare SNF, the Medicaid NF, and the long-term care industry, including discussion of the Minimum Data Set (MDS), SNF Consolidated Billing, the roles and responsibilities of different SNF, NF or LTC professional staff under CMS regulations, clarifications of issues that are covered during a survey and certification process, and the many rules and requirements under which different related services can be payable. Links to information about schedules and registration is found here as well.

CMS Quality Initiatives
http://www.cms.hhs.gov/quality
This page provides links to a few of CMS’ various quality improvement efforts. This includes information about quality initiatives in general and links to data collection such as MDS 3.0.

Nursing Home Compare
http://www.medicare.gov/ Click on “ Compare Nursing Homes in Your Area”
This site allows consumers and professionals to learn about the past performance of every Medicare and Medicaid-certified nursing home in the country. Nursing homes can be searched by geography, proximity, or name.

National Institute on Aging Individual Behavioral Processes Branch
http://www.nia.nih.gov/ResearchInformation/ExtramuralPrograms/BehavioralAndSocialResearch/Programs.htm
This National Institute on Aging branch supports research and training on bio-psychosocial processes linking health and behavior, cognitive functioning, human factors, and integrative approaches to the study of social, psychological, and physiological influences on health and well-being during the lifespan. Personality and social/interpersonal relationships are investigated as causal variables and as mediators or moderators of the relationships between social/structural characteristics and health outcomes.

 National Institute of Mental Health Geriatrics Research Branch
http://www.nimh.nih.gov/datr/a4-gp.cfm
The Geriatrics Research Branch supports programs of research, research training, and resource development in the etiology and pathophysiology of mental disorders of late life, the treatment and recovery of persons with these disorders, and the prevention of these disorders and their consequences. Their site provides links to information about the various branch programs subsumed in this division.

 National Association of Social Workers
Clinical Indicators for Social Work and Psychosocial Services in Nursing Homes
http://www.socialworkers.org/practice/standards/nursing_homes.asp
This site connects to an online publication of Clinical Indicators for Social Work and Psychosocial Services in Nursing Homes. The clinical indicators are divided into process and outcome indicators. Process indicators include timely psychosocial assessment, comprehensive psychosocial assessment, resident involvement in care planning, and family involvement in care planning. Outcome indicators include resident satisfaction with choice and problem resolution.

NASW Standards for Social Work Services in Long-Term Care Facilities
http://www.socialworkers.org/practice/standards/NASWLongTermStandards.pdf
This site connects to a pdf file containing this publication. This document details 11 standards such as ethics and values, staffing, professional development, documentation, and cultural competence.