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.

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.

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.

Staff training sessions provide the social worker with a unique opportunity to give information and knowledge to multiple departments and staff in the facility. Many nursing professionals, nursing assistants, activities personnel, and therapists enter the field of nursing homes as a secondary decision. Often these professionals do not have specific training in working with older adults and those with disabilities, except for what is offered during a brief orientation or staff development training. Therefore, staff training provides the opportunity to present not just the nuts and bolts of respectful interaction with residents, but also some of the underlying knowledge about illness, grieving, and strengths that help people cope. An in-service is a program presented to the staff within the facility. These programs represent a wide range of topics and presentation styles. Attending and hosting in-services will broaden the social worker’s knowledge and understanding of medical care information and allow the social worker to share their own knowledge with the rest of the staff.

Medications play a primary role in the care and treatment of both acute and chronic illness. The purpose of medication is to eliminate or reduce the symptoms of illness, promote healing, and increase the comfort and functionality of an individual. Social workers work in the medical setting of the nursing facility. As part of the healthcare team, social workers evaluate medication efficacy and resident medication compliance. They should be familiar with the common antipsychotic medications: Risperdal, Seroquel, Zyprexa, Invega, Abilify, and Clozaril. By recognizing these drugs and their intended action, social workers will be able to look for a matching diagnosis that may be missing in hospital, home, or other referrals. The social worker can question the referring source about the reason for the medication use, the history of use, and the benefits sought.

Social work consultation in the nursing facility can be an important function to help the social workers with their role and to assist in expanding skills and knowledge. Social work has long been a profession that has used “supervision” in its practice. Commonly, in the hierarchy of an agency, social work supervisors are involved with the evaluations of worker performance, closely supervise cases, and often are responsible for salary recommendations. There have been many discussions about the use of perpetual supervision of professionally trained, educated social workers. Consultation is a collaborative mentoring role that provides direct benefits for the social worker, the residents, and the staff. Role modeling should be an integral part of the consultation process. The chapter clarifies the difference between consultation and supervision, provides a brief description of social work consultation, and discusses the components of nursing home consultation.

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.

Abuse, neglect, and mistreatment in the nursing facility are difficult topics, particularly because there is an expectation that dedicated care is being given to vulnerable frail older adults and those with disabilities. Elder abuse is a deliberate act or failure to act that initiates or creates a risk of harm to an older adult. Abuse can be divided into physical abuse, sexual abuse, domestic abuse, psychological abuse, financial abuse, and neglect. The abuse often occurs at the hands of a caregiver or a person whom the elder trusts. All social workers, along with all other members of the nursing facility team, are generally considered mandated reporters. In all states, licensed social workers are required to report suspected or actual abuse, neglect, or mistreatment. Reporting abuse does not mean that the social worker is liable for its occurrence nor true verification of its occurrence. It is valuable for the social worker to be familiar with the definitions of abuse and to carefully review their facility’s policy defining abuse, neglect, and mistreatment and their particular policy of the mandatory reporting law. Policies can vary from facility to facility, and the social worker should not assume that every facility, even in the same state or region, handles these issues in the same manner.

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.

Essentially, an assessment is a tight summary or a succinct view of a resident’s presenting strengths and problems or needs. Assessments are made in the conceptual framework of being “person-centered,” that is meeting the goals of the person as opposed to goals of therapists or others. In the case of nursing home residents, the Minimum Data Set 3.0 drives some of the assessment. The other part of the assessment is the collection of information about the resident’s formal and informal supports, prior life setting, and physical, emotional, and psychological resources. Social workers generally gather information for an assessment from several places: interviews with the resident, including the utilization of assessment tools; interviews with the family or responsible party; reviews of accompanying medical information; observation of the resident with others; and observations and assessments of other members of the care team.