Professionals and the public have often used spirituality and religious observance interchangeably. This has contributed to a lack of clarity between the two terms. For social workers in the nursing facility, determining definitions and differences in these terms can be important for helping individuals in crisis or at the end of life. The social worker is often in a unique position to hear a resident’s needs for spiritual assistance. By the nature of counseling and sharing confidences, the resident’s needs or concerns around their beliefs may surface. If possible, the social worker can work with the culturally, ethnically appropriate religious order or clergy providing services to residents. Social workers will also need to be aware of their own feelings about spiritual and religious beliefs.

Nursing facilities often provide care for many different types of residents including those with diagnoses of dementia and mental illness. These diagnoses often have accompanying behavioral difficulties. Currently, there are three primary models used by mental health consultants in nursing facilities: the psychiatrist-centered models, the multidisciplinary team models, and the psychiatric nurse-centered models. Each of these models focuses on reducing symptoms and supporting staff interventions. The routine presence of qualified mental health clinicians in the nursing homes to provide consultation and to provide follow-up has been suggested as being very beneficial to both residents and staff in the nursing facility. This chapter discusses the role of the mental health team in the nursing facility, how referrals and assessments for mental healthcare are managed, the social worker’s role in relation to the mental health team, and some of the barriers to mental health services.

While many families and relatives are very supportive and grateful for the care their loved one receives in the nursing facility, some families present challenges. The social worker in the nursing home encounters not merely the issues of resident illness within the context of an institutional setting, but the broader issues and concerns of the family members as well. Families can arrive with a multitude of feelings, from confusion to anger, hostility, and even explosive sentiments. In some cases, experiences in the hospital setting may trigger ire that is then directed at the long-term healthcare system. Sometimes, it is merely the frustration that their loved one has not recovered sufficiently to return to their former level of functioning. In other circumstances, the family dysfunction has existed for many years, complicating communication and exacerbating the challenges of illness and recovery. Social workers in nursing homes can be in very influential, important positions to aid and support residents and families through placement, discharge, or long-term stay. Social workers are also able to assist with appropriate limit setting for families. Acknowledging the struggles of a new admission or demands of a specific family/representative is an important step in communication and trust building. At the same time, it is important to help families understand the constraints of staff and how to manage communications as well as having consideration for all the facility’s residents. It is through professional social work training and education that social workers can help negotiate and advocate for those in need.

The focus of all good care is to determine need. Long-term care (LTC) is not an extension of acute care—it is distinctive in its very nature. Because LTC continues for prolonged periods, it becomes enmeshed in the very fabric of people’s lives. Screening for LTC is one way in which the federal government and, in particular, a state attempts to eliminate unnecessary or premature placement of older or disabled individuals in nursing homes. There are two types of screening: those for a level of care (LOC) involving just medical need and those that address additional factors of care need, which assess issues such as mental illness, development disabilities, and intellectual disabilities. The determination of LOC addresses whether the individual’s care needs meet criteria for a stay in a nursing facility long term. This chapter provides an overview of long-term care screenings and how the Omnibus Budget Reconciliation Act (OBRA) has and continues to impact this process.

Confidentiality can be loosely defined as the state of keeping something secret or private. Confidence is also the state of feeling sure, assured, or reliance upon another person’s secrecy and fidelity. The nursing home is bound by the resident’s right to expect confidentiality of records during the resident’s stay in the nursing facility. All aspects of resident charts in nursing facilities are confidential. Families are also entitled to confidentiality to the extent that the information relates to the resident. Social workers can help the staff understand their role in upholding confidentiality and the reasons that this is important. Through in-services and role modeling, social workers can provide the staff with support to prevent unnecessary disclosure of private material.

In 1987, the Omnibus Reconciliation Act was designed to standardize assessments of residents in nursing homes nationwide. All facilities that participate in Medicare and/or Medicaid programs must complete the Minimum Data Set (MDS) for residents. The Resident Assessment Instrument or “RAI” is a clinical assessment tool consisting of the MDS 2.0 and the corresponding problem-focused Resident Assessment Protocols or “RAPs.” The direction of the newer MDS 3.0 has been in keeping with the greater emphasis on person-centered care. As opposed to the MDS 2.0, which gathered information from staff and the record, the format of the MDS 3.0 seeks information from interviews with the resident and family members first. For example, to assess cognitive patterns, a Brief Interview for Mental Status is attempted with all residents. This chapter discusses the intricacies of the MDS and how the social worker is involved.

Neurocognitive disorders (NCDs) are very common in the long-term care setting. Indeed, the inability to manage an independent living situation is most often because the person is having difficulty processing and managing short- and long-term memory. NCDs are a category of symptoms where cognitive impairment has not been present since birth or early life and thus represents a decline from a previously attended level of functioning. NCDs include, but are not limited to, Alzheimer’s disease, vascular NCD, NCD with Lewy bodies, NCD due to Parkinson’s disease, and frontotemporal NCD. Social workers can utilize information about these disorders to assist staff and families in planning care for the individual that is least restrictive and yet affords a supportive environment. It can be helpful for the family to have a neurocognitive evaluation for the resident.

The purpose of charts and documentation is to provide the nursing facility team with the necessary information to care for the residents. Without written records, information can be quickly forgotten or misinterpreted. Documentation is the foundation for clinical, ethical, and legal accountability. Notes of contact with the resident are intended to provide a coherent, integrative narrative focus on the needs of the reader and fit within a familiar professional structure. For the social worker in the nursing home, documentation provides the reader with both a medical, clinical view of the resident as well as psychosocial concerns. Social work records and documentation should be focused on service delivery; include assessments that are objective, comprehensive, and non-judgmental; be information focused; be inclusive of the resident role; identify cultural factors that may influence outcomes; and be written as if the client and others involved in the case have access to it.

Nursing facilities have long been viewed as institutions where care was provided for the indigent, frail, and aged individuals who did not leave the nursing home once they were admitted. Since the Patient Protection and Affordable Care Act of 2010, a number of initiatives have been developed to diminish the number of healthcare transitions. Social workers in nursing facilities, unlike their counterparts in hospitals, serve two distinct populations: those who are there for rehabilitation and those who are staying in the facility as their home. While other professional disciplines in the facility team focus on various tasks, the social worker is uniquely positioned to include a broader framework of the person’s capabilities and environment. The means that the social worker can enhance the critical decision making that often accompanies transfer and discharge and encourage all stakeholders to be fully involved in the process and outcome. This chapter reviews how transfers affect older adults, how facilities can make transitions easier on the patients, specific rules around transfers and discharges, the Money Follows the Person program, and continuity of care.

Social workers in nursing homes are asked to include questions about trauma when gathering information from residents at the time of admission. Questions about the person’s past life can include a long list of likely traumatic events, e.g., living through a hurricane, and individual episodes of trauma, e.g., rape. For some older adults, trauma can be found in their childhood experiences, having a family member with a mental health or substance use disorder, violence in the community, poverty, and systemic discrimination. The effects of childhood abuse can be life-long and can include the need for resolution at the end of life. Older adults who have had adverse childhood experiences and/or childhood sexual abuse who have protective factors have an improved outcome in navigating symptoms and risks such as poor physical and/or mental health and suicidality when they have greater self-acceptance and higher extraversion. This chapter discusses the effects of these experiences on older adults, protective factors that help residents who are affected, and helpful interventions for social workers and the facility care team.