Psychosocial care in nursing homes in the era of the MDS 3.0: perspectives of the experts

Meeting psychosocial needs of nursing home residents is increasingly regarded as a critical component of care, and the nationally-mandated nursing home care screening instrument- the Minimum Data Set (MDS) 3.0-was modified and implemented in 2010 to promote better assessment of psychosocial needs and health. Recognizing the importance of psychosocial well-being among nursing home residents, and the promise of MDS 3.0 for improving psychosocial care, this article reports recommendations derived from a conference of stakeholders representing diverse disciplines and organizations regarding next steps following MDS 3.0 screening. Results relate to seven areas of psychosocial care and address cross-cutting recommendations to improve psychosocial care.     

Expanding the Role of Long-Term Care Social Workers: Assessment and Intervention Related to Urinary Incontinence

Urinary incontinence (UI) is a common and stigmatizing problem faced by long-term care (LTC) residents. It is typically addressed by medical professionals, with social work rarely involved. The purpose of this article is to illustrate how social workers can address the psychosocial implications of UI while working with residents and their family members as part of an interdisciplinary team. Using a case example and the NASW objectives for LTC, recommendations on how the role of the LTC social workers can be expanded to better address both the needs of residents, families, and the larger LTC system are provided.     

Calling the Question of “Possible Dying” Among Nursing Home Residents

Abstract

Glaser and Strauss reported decades ago that in order for a person to be treated as dying, he/she must be defined as dying. Defining nursing home residents as “dying” can be complicated because most residents are in advanced old age with multiple chronic conditions. Using a social construction theoretical framework, this study looks at the step before the declaration of dying, that is, the consideration of the possibility of dying. This qualitative study is a secondary analysis of prospective data collected during 16 months of fieldwork on behalf of 45 nursing home residents whose health was considered declining. The purpose of this paper is to build understanding about the social construction of “possible dying” by reporting triggers that can call the question of possible dying and stimulate a discussion about the nursing home resident's status, prognosis, care options, and preferences. These triggers include: Health status decline; noncompliance with diet or medications; available medical interventions not being well suited for the residents; and family consideration of an out-of-town trip. The paper also reports barriers (family, staff, and disease process) and facilitators to calling the question of possible dying, including families having a sense of treatments they would like to avoid and having the opportunity to talk through options. Findings are discussed in light of basic assumptions of social construction. Implications for social workers include helping residents, families, and staff anticipate and address the possibility of dying, and to reflect these discussion in care plans, as well as the need to be available to help residents and family members with psychosocial issues related to living and dying in the nursing home setting, including the profound issues that can be provoked or exacerbated by resident health status decline and possible dying.     

Understanding the Impact of Early-Life Trauma in Nursing Home Residents

Reactions to early life trauma can reemerge or be exacerbated in later life as coping resources and abilities are compromised by age-related changes and declines in health. For newly admitted nursing home residents, this can impact their receptiveness to assistance with care and elicit challenging reactions to environmental and situational triggers. Unfortunately, current assessment tools fail to account for reactions to early-life trauma. In this article, we review existing literature on early-life trauma and aging and introduce a hypothetical case to illustrate the importance of identifying nursing home residents with past trauma experiences.     

End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home

Education about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N?=?300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.     

Calling the question of "possible dying" among nursing home residents: triggers, barriers, and facilitators

Glaser and Strauss reported decades ago that in order for a person to be treated as dying, he/she must be defined as dying. Defining nursing home residents as "dying" can be complicated because most residents are in advanced old age with multiple chronic conditions. Using a social construction theoretical framework, this study looks at the step before the declaration of dying, that is, the consideration of the possibility of dying. This qualitative study is a secondary analysis of prospective data collected during 16 months of fieldwork on behalf of 45 nursing home residents whose health was considered declining. The purpose of this paper is to build understanding about the social construction of "possible dying" by reporting triggers that can call the question of possible dying and stimulate a discussion about the nursing home resident's status, prognosis, care options, and preferences. These triggers include: Health status decline; noncompliance with diet or medications; available medical interventions not being well suited for the residents; and family consideration of an out-of-town trip. The paper also reports barriers (family, staff, and disease process) and facilitators to calling the question of possible dying, including families having a sense of treatments they would like to avoid and having the opportunity to talk through options. Findings are discussed in light of basic assumptions of social construction. Implications for social workers include helping residents, families, and staff anticipate and address the possibility of dying, and to reflect these discussion in care plans, as well as the need to be available to help residents and family members with psychosocial issues related to living and dying in the nursing home setting, including the profound issues that can be provoked or exacerbated by resident health status decline and possible dying.     

Assessing Training Needs for Nursing Home Personnel

The quality of care being given often reflects the level of professionalism and caring of the nursing home staff. This article provides a brief overview of factors that must be considered in making an assessment of the training needs of nursing home personnel. It also includes techniques administrators may utilize in making this assessment and recommendations for various methods of implementation of these training needs.     

State Variations in Nursing Home Social Worker Qualifications

ABSTRACT

This is the first published account of state administrative code variations in nursing home social worker qualifications. It is important to review state codes because the majority of nursing homes in the U.S. have fewer than 121 beds and therefore are not required by the federal government to employ at least one full-time qualified social worker. States have the option of extending the federal regulations to homes with 120 or fewer beds, or strengthening the federal requirements in other ways. Findings indicate enormous variation in state requirements for qualifications of nursing home social workers, and even when states define a qualified nursing home social worker (not all do), they often exempt facilities from employing one. Seven states were found to be out of federal compliance. Research describing the qualifications of people employed in nursing home social services is called for, as well as research documenting effective psychosocial interventions, especially as they relate to resident quality of life. Ten recommendations for enhancing nursing home social work services are included.     

Expanding the role of long-term care social workers: assessment and intervention related to urinary incontinence

Urinary incontinence (UI) is a common and stigmatizing problem faced by long-term care (LTC) residents. It is typically addressed by medical professionals, with social work rarely involved. The purpose of this article is to illustrate how social workers can address the psychosocial implications of UI while working with residents and their family members as part of an interdisciplinary team. Using a case example and the NASW objectives for LTC, recommendations on how the role of the LTC social workers can be expanded to better address both the needs of residents, families, and the larger LTC system are provided.     

The Influence of Sociodemographic and Psychosocial Factors on Advance Care Planning

This study investigated sociodemographic and psychosocial factors that enhance or impede the completion of advance care planning, analyzing data from the Health and Retirement Study. The analytic subsample included the panel participants who died between 2006 and 2010 and who had answered the psychosocial and lifestyle questionnaire when they were alive. Multinomial logistic regression was executed to answer the research question (N = 1,056). The study found that persons who were older, who were women, who identified themselves as White, and who had higher levels of income and education were more likely to be motivated to complete advance care planning. Having greater sense of control was found to weaken the adverse relationship between being African American and the completion of advance directives. Having cancer, suffering from the illnesses for longer periods of time, and having experience of nursing home institutionalization also predicted the completion of advance care planning. Implications include incorporating a culturally tailored approach for racial/ethnic minorities and using advance directives that are clear and easily understood. In addition, future research needs to include a larger minority population and examine the extent to which variations between racial/ethnic groups exist in relation to advance care planning.     

Home modification among families with older adults with disability in Korea

Abstract

This study explores psychosocial factors related to the use of home modification among older adults with disabilities and their caregivers in Korea. Using in-depth interviews, this study elaborates specific socio-cognitive factors leading to home modification from the multiple perspectives of care recipients, family caregivers and home care helpers. The study findings are theoretically organised into four domains: structural factors, care recipients’ service needs, socio-cognitive factors, and enabling resources. Practice and policy implications are discussed in the context of underdeveloped housing policies for ageing-in-place in Korea.     

Multilevel Factors Related to Psychosocial Care Outcomes in Washington State Skilled Nursing Facilities

As the primary providers of psychosocial services in skilled nursing facilities, social services professionals report barriers interfering with their ability to meet residents' needs. This study utilizes a 3-category quality assessment framework and a cross-sectional survey design to assess factors impacting the provision of effective psychosocial services in Washington State facilities. Hierarchical linear regression results indicate that the 3-factor model explains 26.4% of the variance in psychosocial outcomes; 4 variables exert the most influence: ownership turnover, practitioner experience, practitioner role identity, and the importance of individualizing care. Findings have implications for developing necessary supports for quality psychosocial care delivery.     

Informal Caregivers of Institutionalized Dementia Residents

When older adults are placed in nursing homes, care- giving responsibility continues, despite long held beliefs to the con- trary. Although the American family is in transition, bonds of care- giving and of filial responsibility are strong and persist into old age. Knowledge about characteristics of caregivers who have actually placed their relative in a nursing home is limited. The purpose of this study is to examine whether demographic and facility-related char- acteristics as well as knowledge about dementia and participation in support groups and workshops are signif~cant predictors of burden in caregivers of institutionalized dementia residents. Sixty-seven per- cent of caregivers of residents in a dementia unit in a nursing home participated in the study. Overall, the regression explained 68% of the variance in burden and was highly simcant statistically. In- formation gained from this study will assist social workers in mak- ing referrals to nursing homes or in direct practice with cognitively impaired nursing home residents and their families.     

Enhancing Collaborative Leadership in Palliative Social Work in Oncology

The Institute of Medicine (IOM) Report—Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs—provided recommendations for meeting the palliative care needs of our growing population of older Americans. The IOM report highlights the demand for social work leadership across all aspects of the health care delivery system. Social workers are core interdisciplinary members of the health care team and it is important for them to be well prepared for collaborative leadership roles across health care settings. The ExCEL in Social Work: Excellence in Cancer Education &; Leadership education project was created as a direct response to the 2008 Institute of Medicine. (2008). Cancer care for the whole patient: Meeting psychosocial health needs. Washington, DC: National Academies Press. [Google Scholar] IOM Report. This article highlights a sampling of palliative care projects initiated by outstanding oncology social work participants in the ExCEL program. These projects demonstrate the leadership of social workers in palliative care oncology.     

The Role of Family Care and Living Arrangements in Acute Care Discharge Recommendations

This study examined placement recommendations of elderly acute care patients who are identified by hospital discharge planners as vulnerable to institutionalization. The purpose of the research was to determine the role of available family care and living arrangements prior to hospitalization in the placement recommendations made by discharge planners. Results indicated that elderly who lived with family compared to those who lived alone were in poorer mental, physical and functional health but had considerably more available family care and fewer service needs that could not be met in the community. Additionally, available family care was found to be significantly related to nursing home recommendations, even with living arrangements controlled. Analysis of placement recommendations by prior living arrangements indicated that family care may be especially important in mitigating the consequences of deficient activity of daily living skills and mental complications. Implications of this research to the role of family care in placement decisions are discussed.     

Understanding the impact of early-life trauma in nursing home residents

Reactions to early life trauma can reemerge or be exacerbated in later life as coping resources and abilities are compromised by age-related changes and declines in health. For newly admitted nursing home residents, this can impact their receptiveness to assistance with care and elicit challenging reactions to environmental and situational triggers. Unfortunately, current assessment tools fail to account for reactions to early-life trauma. In this article, we review existing literature on early-life trauma and aging and introduce a hypothetical case to illustrate the importance of identifying nursing home residents with past trauma experiences.     

Managing the Care Home Closure Process: Care Managers' Experiences and Views

This paper reports case study research that set out to identifywhat care managers do during independent care home closures.Little research has focused on the way in which care homes forolder people are closed in England, or what those involved thinkabout the process. This paper reports the activities and viewsof care managers directly involved in helping older people relocatefrom care homes that were closed by their owners. During suchclosures, residents and their families have no choice but tomove, usually to a deadline, and with little control over theprocess. Care managers have a responsibility to help arrangealternative care for those current residents who are publiclyfunded, and to offer information and support to those fundingtheir own care (the ‘self-funded’). Closure relatedactivities could involve considerable staff time. Care managementarrangements, including the organization of teams and provisionof needs assessments, varied across authorities. The care managersdescribed drawing on emotional counselling and inter-personalskills, as well as practitioner knowledge and experience, particularlywhen offering support and advice about finding appropriate newhomes. Tensions between aims, constraints on their actions andviews of good practice are identified.     

Current Realities

This article reports survey data from nursing home professional social workers on their practice circumstances, prior education and training, and current training needs. This data supports the growing body of evidence that a significant portion of social work practitioners are unlikely to have received the depth of information and the specialized skills required to work with the aged and their families during their formal education. Assuming limited personnel and time, and the responsibility of many different persons for psychosocial care -the practice reality in nursing homes today-- this data can guide education and training efforts.     

Sheltered Housing and Community

This paper considers the role of sheltered housing following the introduction of new community care arrangements in 1993 and examines the continuing uncertainty about its exact role as community care continues to develop. It reports on a study conducted in Shropshire, using a postal survey and interviews with older people and service professionals. The study highlights the importance of sheltered housing for older people, particularly in relieving them of concerns about maintenance and repairs, social isolation and security. These factors were crucial for their overall peace of mind and quality of life. While only a small proportion of tenants received help under social services' community care arrangements, the additional support, monitoring and service coordination provided by wardens helped some of them to remain in sheltered housing when residential or nursing home care might otherwise have been necessary. Sheltered housing was overwhelmingly popular with older people — but their satisfaction was closely associated with the availability and quality of the warden service. Although sheltered housing is not currently in vogue in housing policy, the paper argues that it plays a vital role in local provision for older people and needs to be more closely integrated into community care policy, while at the same time preserving the characteristics that make it popular with its residents.