Social workers need to be sensitive to the ethnic and cultural minorities who both work and live in the nursing facility setting. Knowledge, information, and cultural humility about diverse groups can assist in forming positive, supportive relationships. Cultural humility is a way of viewing the understanding of culture as being more than a simple master of certain beliefs or “facts” about a particular culture. By being sensitive to other cultures, the social worker who uses cultural humility is aware of beliefs, values, and biases that are brought to each resident/family encounter. This self-reflection and self-critique help one maintain humility, an important factor in communicating empathy and interest in the well-being of the resident and family. Social workers are particularly well positioned to help by continue to endeavor to learn, to build partnerships with residents and families, and to respect all differences. Through being aware of their own biases, striving to be culturally sensitive, and utilizing knowledgeable approaches, social workers can promote effective healthcare for diverse populations.
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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.
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.
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 LTCcontinues for prolonged periods, it becomes enmeshed in the very fabric of people’s lives. Screening for LTCis 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 LOCaddresses 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.
Funeral arrangements are often difficult for people in our culture to discuss. Indeed, for many, the issue of dying and death and the process of making decisions around a person’s death are almost taboo. During the admissions process, social workers can address the topic of funeral arrangements as a general issue. The simple question “Have you, or the resident, a preference for a funeral home?” can open the door to discussions of end-of-life decisions, as well as reveal tensions over illness, loss, and dying. The social worker can assist the family with addressing funeral arrangement issues by discussing the Medicaid application where prepaid funeral arrangements can be an allowable expense. Social workers in nursing facilities are in a prime position to help residents and their families around this key advanced directive issue, and this chapter outlines the key elements of funeral arrangements and other issues related to death in the nursing facility.
Although there are certain key functions of social work in the nursing facility setting across the country, the role of the nursing facility social worker can vary from facility to facility even in the same state or county. This chapter highlights the social service functions that are important for residents and families. The role of the social worker in the long-term care setting has been delineated in many ways. Primarily, social work in nursing homes can be defined as involving the following: psychosocial; counseling; resource allocation; advocacy; planning and treatment; and mediation. The role of the social worker is enhanced by specialized knowledge in the following areas: aging and disabilities; medical and mental health diagnoses; medical diagnoses; nursing care; and social work training.
Both the federal government as well as the states mandate annual surveys. Nursing facilities participating in the rules and regulations of Medicaid (Title XIX) and Medicare (Title XVIII) must conduct surveys as a requirement. Federal Registrar Part 483 outlined and defined the basis and scope of these for participating nursing facilities. Joint Commission on Accreditation of Healthcare Organizations (
JCAHO) accreditation is a separate private, nonprofit entity providing accreditation services to a majority of healthcare provider types. Facilities pay a fee to have JCAHOsurvey and accreditation. Interviews with residents and families, the documentation in charts, and care plans form the basis of the process. Proactively, social workers can maintain their notes and care plans, provide staff in-services on key topics so that they are ready for these annual surveys. It should be remembered that surveys are not used as “teaching” the staff. All staff should be well versed on the rules and regulations regarding care.
Nursing facility policies set the standard for the nursing home and provide the base for all other departments, including social service, for performance of duties. Policies in nursing facilities cover two key areas: facility personnel and residents. Policies, particularly policies that relate to resident’s rights and dignity, should be regularly reviewed by the social worker. Social workers may help with the routine in-service education of the staff around specific policies, such as resident grievances or neglect and abuse. Policies provide the form and shape of the institutional response to resident care, treatment, and rights. Good, well-written policies assist everyone in understanding their roles and establish rules for action and departmental obligations and boundaries. Social workers may assist by helping to formulate policies, by serving on facility policy committees, by reviewing policies with a family and/or resident council or board of trustees, and by assisting with annual updates.
In the community setting, social workers have long been associated with resolving financial issues for those who are indigent and in need. As a result, finances in the nursing home have often been assigned to the social worker to help determine which financial programs will assist a resident’s stay or discharge. Interventions of the social worker may range from acquiring a responsible party for residents, such as a guardian or conservator, to filling out and filing applications so that the residents may financially access the needed care and services. Social workers also often coordinate resolutions with the resident, family, legal representative, facility business office, and administrator. In some situations, social workers may work directly with local Medicaid offices to determine eligibility. This chapter addresses how and when financial issues are recognized in the nursing facility, the social worker’s responsibilities related to resident finances, the role of Medicaid and the Medicaid Estate Recovery Program, and resident assets.
- Go to chapter: Trauma-Informed Care and Adverse Childhood Experiences with Older Adults in Nursing Facilities
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.
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. NCDsare 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. NCDsinclude, but are not limited to, Alzheimer’s disease, vascular NCD, NCDwith Lewy bodies, NCDdue 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.
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.
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.
Being prepared for a crisis or a disaster is very helpful. The movement from one healthcare setting to another under the best of circumstances can be difficult, but under the pressure of emergency evacuation, it can be traumatic. The social worker should be aware that the psychiatric trauma of disaster and post-emergency work could impede caregiving and put residents at risk. During pandemics, key guidance and protection for residents, staff, and community safety is very important in managing contagion and spread. In addition, the social worker should have an active role in advocating for resident quality of life, including enhancement of communication/visitation, appropriate activities to assist with dispelling isolation, and adequate staffing. Disasters and pandemics are incredibly stressful for residents, facility staff, and the community, and the social worker can make a difference in their facility roles through support, advocacy, and reassurance.
Most residents admitted to nursing facilities come directly from acute care hospitals and are admitted for rehabilitation. This means that social workers are often helping residents and families at the critical juncture of posthospitalization. This chapter addresses the typical processes involved during preadmission and admission to the nursing facility and the involvement of various staff members. Social workers assist on multiple levels and help provide residents and families with essential information and support during the process. Through skill and knowledge, the social worker can help guide residents and families to make the choices with the best outcomes whether the resident chooses to return to the community or remain in the facility for the long term.
- Go to chapter: The Interdisciplinary Meeting: Care Planning with Residents, Facility Staff, and Community Representatives
The Interdisciplinary Meeting: Care Planning with Residents, Facility Staff, and Community Representatives
The interdisciplinary meeting is the time when the care team gathers to review the plan of care for a resident. Prior to the meeting, the team is given a list of resident meeting times that are scheduled to coordinate with a resident’s admission, routine Minimum Data Set 3.0 review, or a significant change in the resident’s health. The interdisciplinary care plan meeting is an opportunity to review the on-going work with the resident and allow the resident and/or their family to voice opinions, concerns, and, oftentimes, appreciation for the care given. Although often time-consuming, the care plan meeting can help with communication and defusing potential contentious situations around care. It is the opportunity for the staff to “shine” in their knowledge of a resident’s preferences and care. The social worker can help to make this a meaningful experience through the encouragement of attendance and active follow-up of any concerns addressed in the meeting.
The nature of the facility and workload may often leave the social worker with little time for those long-term stay residents and families. Groups are important in nursing facilities, and they are effective in reaching a number of residents, families, or staff at one time. There are a number of different kinds of groups that can be conducted in nursing facilities. Obviously, there are slightly different processes and modifications for different groups, but there are some primary areas to consider in planning for the group. Social workers can look to mentors within the facility as well as individuals outside the facility for support. This chapter reviews the basics of groups in the nursing facility and also discusses remotivation therapy, which is a five-step technique designed to increase socialization and enhance self-esteem of patients, particularly those who have mental illness, posttraumatic stress, or substance use.
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.
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.
The Long-Term Care Ombudsman Program (
LTCOP) is a federally mandated program that was developed to respond to complaints and grievances about government-funded programs, services, and operations in the long-term care industry. The term “ombudsman” is a Swedish term that means “a person who represents someone.” It is a position that receives complaints, may make independent investigation, and has the authority to make recommendations for action. It is a position that provides for the individual’s rights against the errors by government or other authority. This chapter provides information for social workers about the history of the program as well as the benefits for long-term care residents and families. Social workers may lend their support to the LTCOPthrough advocacy with legislative constituency and having residents and/or family members speak about the program’s importance during state legislative budget sessions.
Many residents of nursing facilities are too sick or confused for sexual activity, but at the same time, there are also residents who are capable and interested. Sexuality, like a medical diagnosis or ethnicity, is a part of the individual who is in the long-term care facility. Therefore, it is important to have a common understanding of resident sexuality among staff. There are myths about older adults and sexuality, staff is often not well-prepared to address sexuality and/or activity with residents, and residents can be equally reluctant to address concerns about sexuality with young staff. These factors present an opportunity for the social worker to work with the staff to create greater knowledge and understanding about this topic. The social worker may be of assistance by providing staff in-service education and role modeling.
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.
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.
The ethical controversies in long-term care have become increasingly complex as our regulatory agencies expand their involvement and our resident population becomes increasingly frail. By the very nature of their role, nursing home social workers are responsible for aiding residents and their families through the bureaucratic labyrinth that constitutes the U.S. healthcare system. Ethical dilemmas can occur during each stage of the process and during any component of contact with the elder person and family member from the preadmission meeting through the discharge from the facility. This chapter reviews how social workers can become involved in ethical issues, the resources available to help resolve conflicts, end-of-life treatment choices, ethical issues in admissions and discharges, and the role of ethics committees.
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.
As with many other professions throughout the United States, the legal requirements for social work practice are driven by the respect for the client’s need for competent services. The social worker in the nursing facility is responsible for a wide array of services for older adults and those with disabilities. State and federal laws and regulations govern social work functions in the nursing facility. Many states regulate both the social work in nursing facilities as well as the licensure of all social workers. Both the federal government and the individual states have enacted specific laws that govern the general description of the social worker’s qualifications, as well as the range of services to be provided to residents in nursing facilities. This chapter discusses the laws regarding the professional social worker position in nursing facilities.
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.
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.
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 OBRAwere 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 OBRAalso 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 OBRAand the requirements for nursing facilities because these regulations are a hallmark in resident’s rights and access to quality care.
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.
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.
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.
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.
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 MDS2.0 and the corresponding problem-focused Resident Assessment Protocols or “ RAPs.” The direction of the newer MDS3.0 has been in keeping with the greater emphasis on person-centered care. As opposed to the MDS2.0, which gathered information from staff and the record, the format of the MDS3.0 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 MDSand how the social worker is involved.
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.