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Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement A Report to the Profession and Blueprint for Action Betsy Vourlekis Joan Levy Zlotnik Kelsey Simons
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Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement A Report to the Profession and Blueprint for Action Betsy Vourlekis Joan Levy Zlotnik Kelsey Simons Connecting policy, practice, and education through advancement of research Institute for the Advancement of Social Work Research Copyright 2005 by the Institute for the Advancement of Social Work Research. All rights reserved. 750 First Street, NE, Suite 700 Washington, DC Project undertaken by the Institute for the Advancement of Social Work Research in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work, Boston University School of Social Work and funded in part by a grant to the Institute for the Advancement of Social Work Research from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (1R13HS ). CONTENTS ii iii Foreword Executive Summary 1 Introduction 2 Background 3 Summary Findings 8 Conclusion and References 10 Appendix A. Conference Agenda 12 Appendix B. Summaries of Presentations 27 Appendix C. Presenter and Discussant Biographies 30 Appendix D. Conference Participants 33 Appendix E. Internet Resources FOREWORD This Report to the Profession and Blueprint for Action is the result of the vision and hard work of several people over a more than 2-year period. The Institute for the Advancement of Social Work Research (IASWR), a private, non-profit organization in Washington, DC, took on this initiative in keeping with our mission to advance the knowledge base of social work practice and to promote the use of research to improve practice, program development, and policy. However, it has its roots in the hopes and goals that many of us had for the nursing home reform legislation that passed in It was the vision of the legislation that each nursing home resident would receive the quality of care and have the quality of life to attain or maintain their highest practicable physical, mental and psychosocial well-being. The December 2004 conference Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement provided an opportunity to take stock of what has been accomplished, e.g., standardized assessments and assessment tools, commitment to interdisciplinary practice, increased attention to quality improvement, a growing body of quality-of-life research, and the development of the culture change movement. It also provided an opportunity to outline a range of ways that the social work role in nursing homes could be more fully measured and implemented, to improve quality of care and quality of life. It was an exciting endeavor to bring together a group of practitioners, educators, researchers, advocates, consumers, and policy makers to address an area that previously had not been so fully explored: social work contributions to quality psychosocial care in nursing homes. It was an interdisciplinary endeavor, with collaborators from federal agencies, national organizations, and academia. The Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services (DHHS) awarded a conference grant to IASWR, and I want to thank AHRQ staff Charlotte Mullican and Judy Sangl for their input and guidance. I also want to thank Bob Connolly from the DHHS Centers for Medicare and Medicaid Services for his input, feedback, and guidance. IASWR is grateful to the Institute for Geriatric Social Work (IGSW), Boston University School of Social Work (funded by Atlantic Philanthropies) and IGSW s director, Scott Geron, in providing support for practitioners to attend the symposium and the development of an issue brief Blueprint for Measuring Social Work s Contribution to Psychosocial Care in Nursing Homes: Results of a National Conference, Winter 2005, that summarizes the background information and recommendations from the meeting. IASWR s partnership with the University of Maryland was the key to being able to undertake the grant writing as well as the planning, implementing, and follow-up to the symposium. Betsy Vourlekis provided expertise, knowledge, and conceptual thinking in the development of the grant, in organizing of the symposium, and in the development of this Blueprint for Action. Kelsey Simons was able to use her nursing home experience and her own developing research career toward a new direction by serving as a graduate assistant to assist in writing the grant and developing the background Briefing Book (available at www. iaswresearch.org), the literature review, and the summaries of the presentations. Each of the symposium speakers and discussants shared important expertise and perspective to stimulate rich discussion and assist in constructing an agenda for action. IASWR staff (Barbara Solt, senior program associate, and Brenda Bustos, administrative coordinator) played a key role in making this happen and Rebecca Toni, IASWR s intern, organized materials and the key web resources that will be useful to the field. This Blueprint should be useful, not only to those who attended the symposium, but also to individual practitioners, researchers, administrators, educators, and consultants. It is also intended to be a source of information and action for national professional and provider organizations and advocacy groups, as well as to foundations, policy analysts, and funders. There are broad arrays of actions that can be taken that will weave a path to better outcomes for those who live and work in nursing homes. These recommendations can also be useful in the development of guidelines and evaluation tools for other long term care settings, such as assisted living, an expanding residential option for meeting the needs of our aging society. Joan Levy Zlotnik, PhD, ACSW Executive Director Institute for the Advancement of Social Work Research April 2005 ii EXECUTIVE SUMMARY Despite improvements in the quality of nursing home care since the passage of the Nursing Home Reform Act of 1987 (NHRA), concerns persist with regards to both the quality of care, including psychosocial care, and the quality of life for nursing home residents (Wiener, 2003). Social work services, a federally mandated provision, are a key contributor to meeting residents psychosocial needs yet current federal and state regulatory processes do not routinely assess more than the structural absence or presence of a social service provider. The contributions and impact of the social worker are not systematically examined or assessed. In December 2004, the Institute for the Advancement of Social Work Research (IASWR), in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work at Boston University, and supported by the Department of Health and Human Services Agency for Healthcare Research and Quality (1R13HS ), convened a national working conference to examine the provision of social work services and the relationship of the social worker s role and functions to improving psychosocial care in the nursing home. The meeting brought together practitioners, researchers, policy makers, and educators across several disciplines to address three major aims: 1. Clarify and specify realizable role, function, and intervention expectations for social work personnel along with their operational links to resident and facility psychosocial care and quality of life outcomes; 2. Examine existing and potential measurement approaches for increased accountability (in process and outcomes) and quality-of-care enhancement of social work services and psychosocial care/quality of life (QOL) at the home, survey, and national data base levels; 3. Recommend strategies to improve the monitoring and measurement of quality psychosocial care and of social work services that address resident and family members psychosocial needs. In preparation for the symposium an extensive briefing book (available at was developed to provide background information to the participants so they would come prepared to address the symposium s aims. The presentations and discussions led to a set of recommended action steps that can guide professional social workers, funders, provider organizations, professional associations, educators, regulators, and researchers. Highlights of recommended action steps are described below: Specify practice interventions and develop studies to test the core domains of social work practice in nursing homes. Examine best practice facilities (as defined through high performance on national data base quality indicators or those who are pioneering culture transformation approaches) for further study of traditional and nontraditional social work involvement, roles, and practices. Conduct systematic reviews of the relevant evidence base and develop practice protocols and guidelines for high prevalence, high-priority practice processes. Develop/identify practitioner-friendly practice evaluation tools for facility-level applied research (quality monitoring and improvement), and promote their wider dissemination and use. Encourage field practica that involve nursing homes, providing opportunity for practice academic partnerships to build the empirical base for practice. Contact and collaborate with academic nursing and medical colleagues focused on nursing home practice and research to identify common areas of concern, such as interdisciplinary team functioning and care planning, diagnosis of emotional and behavioral disorders, end-of-life care. Identify, examine, and promote successful models of complementary and collaborative psychosocial care provision by nurses and social workers. Continue to build the statistical trail for professional social work in nursing homes through examining the extent of deployment of professionally prepared personnel in both staff and contractual capacities. What is culture change? Culture change in long-term care is an ongoing transformation based on person-directed values that restores control to elders and those who work closest with them. This transformation includes changing core values, choices about the organization of time and space, relationships, language, rules, objects used in every-day life, rituals, contact with nature, and resource allocation. This definition is from the Pioneer Network (www.pioneernetwork.net). iii Enhance research endeavors related to nursing home practice and outcomes. Convene a small working group of social work researchers and practitioners to develop a detailed research agenda for professional practice in nursing homes. Pursue opportunities for collaboration with large-scale multidisciplinary research efforts in NHs where a social work practice component could be conceptualized and tested as part of the overall effort (e.g. depressioncare improvement; end-of-life care improvement). Undertake research using existing Centers for Medicare and Medicaid Services (CMS) measures and federal and state data bases (for example numbers of depressed residents as a mental health outcome) to study social work practice. Use reliable, state-of-the-art QOL measures (e.g., Kane, 2003) for intervention research on social work practice at both the resident (micro) and overall facility (macro) levels. Conduct comparison analyses of social work practice in culturally transformed environments versus traditional homes. Conduct needs assessment research on the true extent of unmet psychosocial need in NHs and identify the most prevalent barriers. Increase social work involvement in federal processes and initiatives and national reform efforts recognizing that social work s contribution to care rests in part on increasing the visibility of social work s expertise and viewpoint in the wider deliberations and conversations that surround policy decisions, including those promoted by the nursing home industry. Create a national virtual network of social work nursing home experts to improve the visibility of existing NH practitioner networks and social work researchers, strengthen their collaboration, and facilitate their identification and involvement in CMS initiatives, including modifications to care-planning protocols, computerized assessment tools, and enhanced surveyor guidelines for assessing adequacy of psychosocial care and social services. Strengthen organizational social work involvement in nursing home practice improvement (e.g. NASW, Association for Gerontology Education in Social Work) at CMS, AHRQ, the Department of Veteran s Affairs, and the Health Resources and Services Administration, by providing expertise to national advisory committees and panels, and other national forums and meetings. Create a National Social Work Center on Long Term Care that would be a clear place of focus and consolidation for a range of professional information and effort and that would provide social work leadership for national strategies to promote culture transformation and stronger federal requirements for QOL that have the potential to improve nursing home care in fundamental ways. Conclusion According to the Centers for Medicare and Medicaid Services, there are currently close to 17,000 nursing homes in the United States. The challenges of strengthening social work s contribution to improving care arise on many fronts. There is a continuing need to ensure that gerontological practice options, including nursing home practice, are attractive to students. University field collaborations can be the foundation for practice enhancement efforts in developing practice guidelines, evaluation tools, and conducting effectiveness research. Partnership strategies and interdisciplinary collaboration are also crucial, and some initiatives will require funding, whether from foundations or government. Other disciplines, such as nursing, share social work s workforce and quality-of-life concerns and can be allies. Social work s practitioners and educators must connect and contribute to the programs and initiatives of organizations representing the nursing home industry as well as those representing consumers. Federal agencies and social workers within these agencies can be important partners in the profession s efforts. The path and cause of cultural transformation of nursing homes is rooted in the centrality and defining nature of resident and family perceptions of the quality of their psychosocial reality. The profession s contribution to care improvement must be forward looking, and demonstrate a courage to undertake the necessary strengthening of its effectiveness in carrying out the fundamental tasks of psychosocial service provision. iv Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement A REPORT TO THE PROFESSION AND BLUEPRINT FOR ACTION Introduction Despite improvements in the quality of nursing home care since the passage of the Nursing Home Reform Act of 1987 (NHRA), concerns persist with regards to both the quality of care, including psychosocial care, and the quality of life for nursing home residents (Wiener, 2003). A 2003 federal Department of Health and Human Services (DHHS) Office of Inspector General (OIG) scrutiny of psychosocial care revealed that 39% of reviewed resident charts had inadequate plans and 46% with care plans did not receive the planned services. The reasons that residents do not get their needs met are not known because there is no comprehensive approach to monitoring and measuring psychosocial care and quality of life in nursing homes in the United States. This lack is an interdisciplinary and inter-organizational concern that requires the combined efforts of regulators, administrators and providers charged with quality monitoring and measurement in the nursing home, and key research and practitioner expertise in the area of psychosocial care. To this end the Institute for Advancement of Social Work Research (IASWR), in collaboration with the University of Maryland School of Social Work and the Institute for Geriatric Social Work at Boston University, and supported by the federal government s Agency for Healthcare Research and Quality (1R13HS ), convened a national working conference in December 2004: Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement. The meeting focused on the provision of social services and the relationship of the social worker s role and functions to improving psychosocial care in the nursing home. It is evident that psychosocial care is far broader than social services/social work, and that all providers as well as the overall home environment play a part. It is also the case that social workers contribute to care in the home through a wide range of roles beyond that of social service provider. However, as a federally mandated and regulated component of nursing home care, social services provided by professionally prepared social workers can be clearly identified and examined. This therefore can lead to more effective practice monitoring and evaluation measurement efforts. Enhancing and demonstrating the quality and impact of social work services is a priority responsibility of the profession. Furthermore, social work expertise and worldview can make important contributions to research on nursing home care and quality of life. In studying provision of psychosocial care, social work s person environment perspective is especially important in investigating the impact of both resident-level interventions and home-as-a-whole interventions and their interactions. Social work s expertise in group and family process adds a critical dimension to both psychosocial care provision and effectiveness research that can significantly expand the understanding of what contributes to highest quality care. In deliberations over 2 days participants at the December 2004 conference addressed the following three aims: 1. Clarify and specify realizable role, function and intervention expectations for social work personnel along with their operational links to resident and facility psychosocial care and quality of life outcomes; 2. Examine existing and potential measurement approaches for increased accountability (in process and outcomes) and quality-of-care enhancement of social work services and psychosocial care/quality-of-life (QOL) at the home, survey, and national data base levels; 3. Recommend strategies to improve the monitoring and measurement of quality psychosocial care and of social work services that address resident and family members psychosocial needs. The following sections present relevant background information and summarize key ideas, issues, and resources that emerged from the meeting for each of the three conference aims. The information has been distilled from formal presentations by invited speakers, remarks by invited discussants, comments and questions from participants, small group deliberations, and the final group-as-a-whole discussion that concluded the conference. The conference agenda (Appendix A), summaries of presentations (Appendix B), presenter and discussant biographies (Appendix C), list of participants (Appendix D), and resource list (Appendix E) provide additional information. An extensive briefing book that was provided to the participants prior to the meeting is available on the IASWR website at 1 2 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement Background roles, and demonstration of the link between practice and valued resident and home-as-a-whole outcomes. The Need Social work practice in nursing homes faces the imperative for evidence-based practice at the same time as consumers and regulators search for better approaches to delivering and assuring quality care. Yet even the necessary national statistical profile for the profession s presence in nursing home care is lacking. Current federal and state regulatory proc
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