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.

The Omnibus Budget Reconciliation Act (OBRA) is a piece of legislation that was passed by the U.S. Congress in 1987. Its primary purpose was to improve the quality of care provided by long-term care facilities and to enhance the quality of life of the residents. The regulations outlined by OBRA were aimed at facilities that participate in Medicare and Medicaid systems of payment; private, nonparticipating nursing facilities have also been influenced by these new regulations to some extent. It is important to note that the passage of OBRA also included funding for states to implement and regulate the process. This chapter provides an overview of the some of the key points of the legislation. It is relevant for social workers to be very familiar with OBRA and the requirements for nursing facilities because these regulations are a hallmark in resident’s rights and access to quality care.

Knowledge about legal representatives is helpful for social workers as they work with residents and families. The Health Insurance Portability and Accountability Act Privacy Rule establishes federally protected rights that permit individuals to uses and disclosures of their protected health information. In the event that persons cannot speak for themselves, the legal system has devised categories of designates to represent the person under certain conditions. These include living wills, healthcare proxies, and guardianships. A legal representative can be a person who has authority given by either a person or the courts to be a representative of another. Nursing facilities can assume the role of representative payee for a resident if there are not any family/fiduciary representatives to assume the task. The quarterly care plan meeting is a good time to review all information pertinent to the living will, healthcare proxy, guardianship, and durable power of attorney.

The importance of diagnosing depression and providing subsequent treatment to nursing home residents has been acknowledged and supported by the Centers for Medicare & Medicaid. The Mood section of the Minimum Data Set (MDS) 3.0 includes the Patient Health Questionnaire, Nine Questions (PHQ-9), in order to help identify depression. Depression is also associated with other chronic diagnoses such as Alzheimer’s disease, Parkinson’s disease, cancer, and arthritis. Substance use is often seen in the nursing home as a co-morbidity of depression for older adults. Depression and the diagnosis of depressed mood is a significant concern for social workers in long-term care. The social worker should be familiar with key signs and symptoms of depression, as well as the current modes of intervention, drug treatment, and psychotherapy.

Community services are expanding at an ever-increasing rate with the aging boom. By having a more complete understanding of the range of older adult choices and opportunities, the social worker can assist the resident and family to make the most helpful choices that meet their needs. One of the social worker’s roles is to have the knowledge and skills to link residents and families to available choices once they leave the nursing facility. Social workers in nursing homes who are making referrals to visiting nurse associations can also help the acquisition of appropriate services by ensuring the resident’s medical information is as complete as possible. This chapter discusses some of the many community resources and opportunities for care continuation.

The frequency of pain and pain undertreatment in older persons has been increasingly brought to the forefront of the care of older adults in long-term care settings. Pain is a subjective experience and there are no specific tests to objectively measure it. Older adults who may be not able to communicate effectively about their pain are of particular importance to caregivers in long-term care settings. Older adults with untreated chronic pain also become less likely to engage in independent activities; their activities become more narrow and debility increases. The social worker can provide education to families about the physiological changes that occur in older adults that contribute to the absorption of medications, as well as comorbidities such as multiple diagnoses, chronic disease presence, and polypharmacy. In addition, the social worker can contribute to greater understanding of the need for pain management to avoid losses in physical function (ambulation), self-care, mental acuity, and socialization.

Room changes may present controversies for social workers for a variety of reasons. Over time, the room and the staff become familiar to the resident and the resident’s family. When rehabilitation is complete and residents remain long term, they are often reluctant to shift to another room even within the same facility because of their familiarity with the physical location and association with the staff. However, most facilities have specific areas for short- and long-term stays. The reasons for this vary, but primarily, rooms that are used for short-term stays may not have the same features as those used for long-term stays. Additional reasons for a room change can include the following: moving a resident because of a medical condition (e.g., infection or precautions) that indicates a need for isolation or more observation; moving a resident at the request of either the resident or the family; moving a resident in order to access a particular section of the facility, such as a specialized Alzheimer’s Unit; moving a resident to support a facility administrative need; and moving a resident because of a change in the status of payment.

Grounding the role of social work in the nursing home setting is the history of the role. Social work in nursing homes has been largely dependent upon the requirements of the regulatory agencies, the public, and the internal structure of facilities. Continuing educational training for current facility workers can assist in providing important information about nursing home residents’ needs and developing necessary skills. In some facilities, efforts are made to provide untrained social workers with support. These supports can include consultation and supervision by qualified social workers. Advocating for more social work hours and/or alleviation of certain duties (such as writing care plan invitations or arranging the seating in the dining room) can be helpful in managing tasks in a busy facility. This chapter provides an overview of social work in nursing facilities and some of the challenges and opportunities of the role.

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.