Evaluating Social Work Services in Nursing Homes: Toward Quality ...

Evaluating Social Work Services inNursing Homes:Toward Quality Psychosocial Careand Its MeasurementA Report to the Profession andBlueprint for ActionBetsy VourlekisJoan Levy ZlotnikKelsey SimonsConnecting policy, practice, andeducation throughadvancement of researchInstitute 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 700Washington, DC 20002-4241iaswr@naswdc.orgwww.iaswresearch.orgProject undertaken by the Institute for the Advancement of Social Work Research in collaboration withthe University of Maryland School of Social Work and the Institute for Geriatric Social Work, BostonUniversity School of Social Work and funded in part by a grant to the Institute for the Advancement ofSocial Work Research from the U.S. Department of Health and Human Services Agency for HealthcareResearch and Quality (1R13HS015505-01).

CONTENTSiiiiiForewordExecutive Summary1 Introduction2 Background3 Summary Findings8 Conclusion and References10 Appendix A. Conference Agenda12 Appendix B. Summaries of Presentations27 Appendix C. Presenter and Discussant Biographies30 Appendix D. Conference Participants33 Appendix E. Internet Resources

FOREWORDThis Report to the Profession and Blueprint for Action is theresult of the vision and hard work of several people over amore than 2-year period. The Institute for the Advancementof Social Work Research (IASWR), a private, non-profitorganization in Washington, DC, took on this initiative inkeeping with our mission to advance the knowledge base ofsocial work practice and to promote the use of research toimprove practice, program development, and policy. However,it has its roots in the hopes and goals that many of ushad for the nursing home reform legislation that passed in1987. It was the vision of the legislation that each nursinghome resident would receive the quality of care and havethe quality of life to “attain or maintain their highest practicablephysical, mental and psychosocial well-being.” TheDecember 2004 conference Evaluating Social Work Servicesin Nursing Homes: Toward Quality Psychosocial Care and ItsMeasurement provided an opportunity to take stock of whathas been accomplished, e.g., standardized assessments andassessment tools, commitment to interdisciplinary practice,increased attention to quality improvement, a growingbody of quality-of-life research, and the development of theculture change movement. It also provided an opportunityto outline a range of ways that the social work role in nursinghomes 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 groupof practitioners, educators, researchers, advocates, consumers,and policy makers to address an area that previouslyhad not been so fully explored: social work contributionsto quality psychosocial care in nursing homes. It was aninterdisciplinary endeavor, with collaborators from federalagencies, national organizations, and academia. The Agencyfor Healthcare Research and Quality (AHRQ) of the Departmentof Health and Human Services (DHHS) awardeda conference grant to IASWR, and I want to thank AHRQstaff Charlotte Mullican and Judy Sangl for their inputand guidance. I also want to thank Bob Connolly from theDHHS Centers for Medicare and Medicaid Services for hisinput, feedback, and guidance. IASWR is grateful to theInstitute for Geriatric Social Work (IGSW), Boston UniversitySchool of Social Work (funded by Atlantic Philanthropies)and IGSW’s director, Scott Geron, in providingsupport for practitioners to attend the symposium and thedevelopment of an issue brief “Blueprint for Measuring SocialWork’s Contribution to Psychosocial Care in NursingHomes: Results of a National Conference,” Winter 2005,www.bu.edu/igsw) that summarizes the background informationand recommendations from the meeting.IASWR’s partnership with the University of Marylandwas the key to being able to undertake the grant writingas well as the planning, implementing, and follow-up tothe symposium. Betsy Vourlekis provided expertise, knowledge,and conceptual thinking in the development of thegrant, in organizing of the symposium, and in the developmentof this Blueprint for Action. Kelsey Simons was ableto use her nursing home experience and her own developingresearch career toward a new direction by serving as agraduate assistant to assist in writing the grant and developingthe background “Briefing Book” (available at www.iaswresearch.org), the literature review, and the summariesof the presentations. Each of the symposium speakers anddiscussants shared important expertise and perspective tostimulate rich discussion and assist in constructing an agendafor action. IASWR staff (Barbara Solt, senior programassociate, 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 resourcesthat will be useful to the field.This Blueprint should be useful, not only to those who attendedthe symposium, but also to individual practitioners,researchers, administrators, educators, and consultants. Itis also intended to be a source of information and actionfor national professional and provider organizations andadvocacy groups, as well as to foundations, policy analysts,and funders. There are broad arrays of actions that can betaken that will weave a path to better outcomes for thosewho live and work in nursing homes. These recommendationscan also be useful in the development of guidelinesand evaluation tools for other long–term care settings, suchas assisted living, an expanding residential option for meetingthe needs of our aging society.Joan Levy Zlotnik, PhD, ACSWExecutive DirectorInstitute for the Advancement of Social Work ResearchApril 2005ii

EXECUTIVE SUMMARYDespite improvements in the quality of nursing home caresince the passage of the Nursing Home Reform Act of 1987(NHRA), concerns persist with regards to both the qualityof care, including psychosocial care, and the quality of lifefor nursing home residents (Wiener, 2003). Social work services,a federally mandated provision, are a key contributorto meeting residents’ psychosocial needs yet current federaland state regulatory processes do not routinely assess morethan the structural absence or presence of a social serviceprovider. The contributions and impact of the social workerare not systematically examined or assessed. In December2004, the Institute for the Advancement of Social WorkResearch (IASWR), in collaboration with the Universityof Maryland School of Social Work and the Institute forGeriatric Social Work at Boston University, and supportedby the Department of Health and Human Services Agencyfor Healthcare Research and Quality (1R13HS015505-01),convened a national working conference to examine theprovision of social work services and the relationship of thesocial worker’s role and functions to improving psychosocialcare in the nursing home.The meeting brought together practitioners, researchers,policy makers, and educators across several disciplinesto address three major aims:1. Clarify and specify realizable role, function, and interventionexpectations for social work personnel alongwith their operational links to resident and facility psychosocialcare and quality of life outcomes;2. Examine existing and potential measurement approachesfor increased accountability (in process and outcomes)and quality-of-care enhancement of social workservices and psychosocial care/quality of life (QOL) atthe home, survey, and national data base levels;3. Recommend strategies to improve the monitoring andmeasurement of quality psychosocial care and of socialwork services that address resident and family members’psychosocial needs.In preparation for the symposium an extensive briefingbook (available at www.iaswresearch.org) was developedto provide background information to the participantsso they would come prepared to address the symposium’saims. The presentations and discussions led to a set of recommendedaction steps that can guide professional socialworkers, funders, provider organizations, professional associations,educators, regulators, and researchers. Highlightsof recommended action steps are described below:Specify practice interventions and develop studies to test thecore domains of social work practice in nursing homes.• Examine best practice facilities (as defined throughhigh performance on national data base quality indicatorsor those who are pioneering culture transformationapproaches) for further study of traditional andnontraditional social work involvement, roles, andpractices.• Conduct systematic reviews of the relevant evidencebase and develop practice protocols and guidelines forhigh prevalence, high-priority practice processes.• Develop/identify practitioner-friendly practice evaluationtools for facility-level applied research (qualitymonitoring and improvement), and promote theirwider dissemination and use.• Encourage field practica that involve nursing homes,providing opportunity for practice–academic partnershipsto build the empirical base for practice.• Contact and collaborate with academic nursing andmedical colleagues focused on nursing home practiceand research to identify common areas of concern,such as interdisciplinary team functioning and careplanning, diagnosis of emotional and behavioral disorders,end-of-life care.• Identify, examine, and promote successful models ofcomplementary and collaborative psychosocial careprovision by nurses and social workers.• Continue to build the statistical trail for professionalsocial work in nursing homes through examining theextent of deployment of professionally prepared personnelin 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 restorescontrol to elders and those who work closest with them. This transformation includes changing core values, choices about the organizationof 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 homepractice and outcomes.• Convene a small working group of social work researchersand practitioners to develop a detailed researchagenda for professional practice in nursing homes.• Pursue opportunities for collaboration with large-scalemultidisciplinary research efforts in NHs where a socialwork practice component could be conceptualizedand tested as part of the overall effort (e.g. depressioncareimprovement; end-of-life care improvement).• Undertake research using existing Centers for Medicareand Medicaid Services (CMS) measures andfederal and state data bases (for example numbers ofdepressed residents as a mental health outcome) tostudy social work practice.• Use reliable, state-of-the-art QOL measures (e.g., Kane,2003) for intervention research on social work practiceat both the resident (micro) and overall facility (macro)levels.• Conduct comparison analyses of social work practicein “culturally transformed” environments versus “traditional”homes.• Conduct needs assessment research on the true extentof unmet psychosocial need in NHs and identify themost prevalent barriers.Increase social work involvement in federal processes andinitiatives and national reform efforts recognizing thatsocial work’s contribution to care rests in part on increasingthe visibility of social work’s expertise and viewpoint in thewider deliberations and conversations that surround policydecisions, including those promoted by the nursing homeindustry.• Create a national virtual network of social work nursinghome experts to improve the visibility of existingNH practitioner networks and social work researchers,strengthen their collaboration, and facilitate theiridentification and involvement in CMS initiatives, includingmodifications to care-planning protocols, computerizedassessment tools, and enhanced surveyorguidelines for assessing adequacy of psychosocial careand social services.• Strengthen organizational social work involvement innursing home practice improvement (e.g. NASW, Associationfor 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 committeesand panels, and other national forums andmeetings.• Create a National Social Work Center on Long TermCare that would be a clear place of focus and consolidationfor a range of professional information and effortand that would provide social work leadership fornational strategies to promote culture transformationand stronger federal requirements for QOL that havethe potential to improve nursing home care in fundamentalways.ConclusionAccording to the Centers for Medicare and Medicaid Services,there are currently close to 17,000 nursing homesin the United States. The challenges of strengthening socialwork’s contribution to improving care arise on manyfronts. There is a continuing need to ensure that gerontologicalpractice options, including nursing home practice,are attractive to students. University–field collaborationscan be the foundation for practice enhancement efforts indeveloping practice guidelines, evaluation tools, and conductingeffectiveness research.Partnership strategies and interdisciplinary collaborationare also crucial, and some initiatives will requirefunding, whether from foundations or government. Otherdisciplines, such as nursing, share social work’s workforceand quality-of-life concerns and can be allies. Social work’spractitioners and educators must connect and contributeto the programs and initiatives of organizations representingthe nursing home industry as well as those representingconsumers. Federal agencies and social workers withinthese agencies can be important partners in the profession’sefforts.The path and cause of cultural transformation of “nursinghomes” is rooted in the centrality and defining natureof resident and family perceptions of the quality of theirpsychosocial reality. The profession’s contribution to careimprovement must be forward looking, and demonstratea courage to undertake the necessary strengthening of itseffectiveness in carrying out the fundamental tasks of psychosocialservice provision.iv

Evaluating Social Work Services in Nursing Homes: Toward QualityPsychosocial Care and Its MeasurementA REPORT TO THE PROFESSION AND BLUEPRINT FOR ACTIONIntroductionDespite improvements in the quality of nursing home caresince the passage of the Nursing Home Reform Act of 1987(NHRA), concerns persist with regards to both the qualityof care, including psychosocial care, and the quality of lifefor nursing home residents (Wiener, 2003). A 2003 federalDepartment of Health and Human Services (DHHS) Officeof Inspector General (OIG) scrutiny of psychosocialcare revealed that 39% of reviewed resident charts had inadequateplans and 46% with care plans did not receivethe planned services. The reasons that residents do not gettheir needs met are not known because there is no comprehensiveapproach to monitoring and measuring psychosocialcare and quality of life in nursing homes in the UnitedStates. This lack is an interdisciplinary and inter-organizationalconcern that requires the combined efforts of regulators,administrators and providers charged with qualitymonitoring and measurement in the nursing home, andkey research and practitioner expertise in the area of psychosocialcare. To this end the Institute for Advancementof Social Work Research (IASWR), in collaboration withthe University of Maryland School of Social Work and theInstitute for Geriatric Social Work at Boston University,and supported by the federal government’s Agency forHealthcare Research and Quality (1R13HS015505-01),convened a national working conference in December2004: Evaluating Social Work Services in Nursing Homes:Toward Quality Psychosocial Care and Its Measurement.The meeting focused on the provision of social servicesand the relationship of the social worker’s role and functionsto improving psychosocial care in the nursing home.It is evident that psychosocial care is far broader than socialservices/social work, and that all providers as well as theoverall home environment play a part. It is also the casethat social workers contribute to care in the home througha wide range of roles beyond that of social service provider.However, as a federally mandated and regulated componentof nursing home care, social services provided by professionallyprepared social workers can be clearly identifiedand examined. This therefore can lead to more effectivepractice monitoring and evaluation measurement efforts.Enhancing and demonstrating the quality and impactof social work services is a priority responsibility of the profession.Furthermore, social work expertise and worldviewcan make important contributions to research on nursinghome care and quality of life. In studying provision of psychosocialcare, social work’s person–environment perspectiveis especially important in investigating the impact ofboth resident-level interventions and home-as-a-whole interventionsand their interactions. Social work’s expertisein group and family process adds a critical dimension toboth psychosocial care provision and effectiveness researchthat can significantly expand the understanding of whatcontributes to highest quality care.In deliberations over 2 days participants at the December2004 conference addressed the following three aims:1. Clarify and specify realizable role, function and interventionexpectations for social work personnel alongwith their operational links to resident and facility psychosocialcare and quality of life outcomes;2. Examine existing and potential measurement approachesfor increased accountability (in process and outcomes)and quality-of-care enhancement of social workservices and psychosocial care/quality-of-life (QOL) atthe home, survey, and national data base levels;3. Recommend strategies to improve the monitoring andmeasurement of quality psychosocial care and of socialwork services that address resident and family members’psychosocial needs.The following sections present relevant background informationand summarize key ideas, issues, and resourcesthat emerged from the meeting for each of the three conferenceaims. The information has been distilled from formalpresentations by invited speakers, remarks by inviteddiscussants, comments and questions from participants,small group deliberations, and the final group-as-a-wholediscussion that concluded the conference. The conferenceagenda (Appendix A), summaries of presentations (AppendixB), presenter and discussant biographies (AppendixC), list of participants (Appendix D), and resource list(Appendix E) provide additional information. An extensivebriefing book that was provided to the participantsprior to the meeting is available on the IASWR website atwww.iaswresearch.org.1

2 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementBackgroundroles, and demonstration of the link between practice andvalued resident and home-as-a-whole outcomes.The NeedSocial work practice in nursing homes faces the imperativefor evidence-based practice at the same time as consumersand regulators search for better approaches to deliveringand assuring quality care. Yet even the necessary nationalstatistical profile for the profession’s presence in nursinghome care is lacking. Current federal and state regulatoryprocesses do not routinely assess more than the structuralabsence or presence of a social service provider. The contributionsand impact of the social worker are not systematicallyexamined nor assessed in survey and certificationprocesses, leaving no visible track record. The interplay ofseveral factors currently constricts the potential to standardize,measure, and improve the contribution made bythe discipline of social work, limiting accountability, andwith it, opportunities for higher quality care. These constraintsinclude:• Social service staffing inconsistencies (to which currentfederal regulations contribute) dilute expectationsfor a consistent set of services.• Professional practice standards are broadly inclusive ofrole and processes, but are not supported with protocolsand guidelines that would promote performanceconsistency and its measurement.• The absence of conceptual and operational links betweensocial work psychosocial care processes in nursinghomes and surveyed outcomes leads to invisibilityand diminished expectations.• There are few measurement strategies (internal or externalto the nursing home) to routinely monitor socialwork processes for results.• A rudimentary professional research base has yet toclearly demonstrate intervention effectiveness for socialwork practice in the nursing home.Despite these realities, a “critical mass” of professionalNH social workers exists—it is estimated that 60–66% ofsocial service staff have degrees in social work (Kruzich &Powell, 1995; Quam & Whitford, 1992; Simons, 2005;Vinton, Mazza, & Kim, 1998; Vourlekis, Bakke-Friedland,& Zlotnik, 1995)—providing a consistent set of services thatcan be the basis of more systematic monitoring and measurementand intervention research. A feasible blueprintneeds to be crafted to guide the development of evidencefor a set of consistently implemented social work roles andfunctions, guidelines for expected “best practice” in thoseFederal Regulation and Social WorkCurrent federal NH regulations (CMS, 1989, 42 CFR483.15) require all nursing facilities to identify the medicallyrelated social and emotional (psychosocial) needs ofeach resident and develop a plan to assist each residentin adjusting to the social and emotional aspects of his orher illness, treatment, and stay in the nursing home. Towardsthis end, the NHRA requires all nursing facilitiesto provide social services, but additionally requires nursinghomes over 120 beds to employ a ful- time social workerwith at least a bachelor’s degree in social work or “similarprofessional qualifications.” Facilities with 120 beds orfewer must still provide social services but do not need tohave a full time social worker on staff. The staffing arrangementand qualifications are left unspecified by regulationfor these homes. Although NH regulations require facilitiesto use licensed personnel, this obligation has not beenapplied or enforced in the case of social work.Psychosocial Care and Social WorkThe term “psychosocial” describes a constellation of socialand emotional needs and the care given to meet them.Psychosocial concerns in nursing homes from the perspectiveof the social work provider include recognition, diagnosis,and treatment of mental health disorders such asdepression, anxiety, dementia, and delirium, all measuredby the MDS (federally mandated Minimum Data Set completedfor each resident). Studies document the extentof NH resident mental health needs (Burns et al., 1993;Castle & Shea, 1997; Meeks, Jones, Tikhtman, & LaTourette,2000), and problems in mental health care delivery,including ineffective diagnosis, lack of follow-through withneeded services, and over-reliance on pharmacological interventions,including over-medication, in lieu of psychosocialin-home interventions (AGS & AAGP, 2003; Shea,Russo & Smyer, 2000; Snowden, Piacitelli & Koepsell,1998).In addition, psychosocial care addresses a range of issueswith more obvious social dimensions, including loss of relationships,loss of personal control and identity, adjustmentto the facility, continuity of care, and end-of-life care.Support to the resident’s family, including involvementin the resident’s care and attention to their concerns andneeds forms another component of psychosocial care. Abroader but related concept is quality of life (QOL) focused

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 3on the perspective of the residents themselves with respectto their total living experience in the home, not just theirmedical care. Kane and colleagues (2003) delineated 11domains for QOL, including autonomy, functional competence,privacy, dignity, meaningful activity, individuality,enjoyment, security, relationships, spiritual well-being, andcomfort. QOL is increasingly viewed as an essential outcomeof good NHs, and the contributions of social workprocesses in the home to this outcome are assumed, butunproven. Also of concern are how inhospitable nursinghome environments and routines can be for the well-beingof residents, leading to comprehensive considerations oftotal “culture transformation” (Fagan, Williams, & Burger,1997). The social work contribution to psychosocial carepotentially focuses on aspects of the home environmentthat affect all residents.Summary FindingsThe following provides an overview of the key issues addressedby the presentations and discussions at the symposium,which were organized by the three aims stated above.The summary findings include a specification of suggestedrecommendations and actions steps.Aim #1: Clarify and specify role, function, andintervention expectations for social work personneland link these operationally to resident and facilitypsychosocial care and QOL outcomes.• Social work roles in nursing homes are varied, includingstaff social service provider, member and psychosocialadvisor to the interdisciplinary team, social workconsultant (an external provider to a home that iswithout a “qualified” social service professional), andpsychotherapist (external provider of mental healthservices to a resident under Medicare Part B). Furthermore,social workers function as administrators,unit heads, and department directors. There are socialworker home administrators and owners of nursinghomes. The extent of social work involvement in manyof these roles is unknown. In addition, the potential existsfor new social work roles within reconfiguring careenvironments that are responsive to the culture changemovement. While recognizing the actual and possiblediverse social work roles, the December 2004 meetingfocused primarily on the roles and functions of staffsocial work provider of social services and member ofthe interdisciplinary care team.• Improvement in practice evaluation and more rigorouspractice effectiveness studies of social work serviceprovision depend on the consistent performance ofa set of social work functions, within and across settings.A convergence of agreement emerges from thecomparison of empirical studies (Vourlekis et al.,1995; Vourlekis, Gelfand, & Greene, 1992;), practiceguidelines (National Association of Social Workers[NASW], 1993, 2003; Department of Veterans Affairs,2001), and a recent statement of practice competencies(Rosen, Zlotnik, & Singer, 2002), revealing six broadfunctional areas (Greene, 2004) that form the core ofsocial work practice in the nursing home setting.1. Conduct psychosocial assessments through informationgathering (this would include mentalhealth and involve the completion of related portionsof the MDS 2.0 and related Resident AssessmentProtocols).2. Provide psychosocial interventions that enhancecoping skills for residents and their families (varietyof treatment modalities including, but not limitedto crisis intervention, mediation, and group,individual, and family counseling).3. Assist with long-term care transitions through casemanagement (linkages and referrals and admissions,discharge, etc.).4. Participate in care planning.5. Collaborate with the nursing home team (includingconsultation re: psychosocial issues).6. Attend to individualized decision-making (elicitingand facilitating resident choice and preference,including end-of-life decisions).• Further specification of the actual and most appropriatescope, tasks, strategies, and procedures used inimplementing these six functions is needed to map accountabilityfor a consistent set of services across facilities.For example, specification of a “best practice” orguideline-based approach to mental health screeningWhat is culture change? Culture change in long-term care is an ongoing transformation based on person-directed values that restorescontrol to elders and those who work closest with them. This transformation includes changing core values, choices about the organizationof 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).

4 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurementand diagnosis, prior to completion of the MDS, wouldbe necessary to measure the social worker’s contributionto improved accuracy in MDS or in efforts to distinguishbetween residents’ reactions to poor qualityNH environments versus true depression. What arethe psychosocial interventions most commonly providedby social workers to enhance coping (for example,orientation sessions for residents and family members)or to facilitate resident choice?• Specification of interventions within the six functionaldomains that are presumed to influence critical outcomes(process–outcome links) can be done at thelevel of an individual home as part of an overall facilityinternal approach to quality improvement and to“quantify” the value added of the social service provider.Demonstrating “worth” to administrators requireslinking interventions to problem reduction, such asfewer family complaints, less demand on staff from agitatedpatients, and higher bed occupancy rates.• The OIG report (cited above) as well as other datasources point to a significant gap between psychosocialneeds identification and actions actually taken. Thesocial work provider should be central to (1) identificationof psychosocial needs (assessment function); and(2) specification of services/actions (care planning),even when not responsible for providing all indicatedservices. Moreover, monitoring by social workers forfollow-through of all planned psychosocial serviceswould contribute to identifying barriers and improvingaccountability in the facility.• The problems in mental health care delivery in thehome are a priority area for social work practice improvement,including specification of interventionstrategies. Prevention activities, non-pharmacologicaltreatments for milder conditions, and follow-throughand bridging with external care providers (case management)for severe disorders are all reasonable functionalexpectations for staff social workers, highlighting theneed for practice guidelines and protocols for thesepractice functions.• Research documents multiple care provision/care environmentinfluences on resident self-reported QOL,including many that would be within the functionaldomains of social work, e.g., social circumstances, untreateddepression, involuntary moves, continuity ofcare, meaningful activity, maximization of independence,and fostering relationships (see Kane Summary,Appendix B). However, knowledge and specification ofeffective interventions, including those of social workers,and their optimal “dosage” lags behind the abilityto satisfactorily measure QOL outcomes.Aim #2: Examine existing and potential measurementapproaches for increased accountability (in processand outcomes) and quality care enhancement of socialwork services and psychosocial care/QOL at the home,survey, and national data base levels.Federal Regulatory Approaches and InitiativesExisting CMS measures of psychosocial care qualityserve as starting points in developing strategies for improvementin the measurement and monitoring of psychosocialservices, including services provided by social workers.Federal data sources include survey F-tags, RAI (ResidentAssessment Instrument) outcome data, and QI (QualityInitiative) outcome measures. While current federal measuresare problematic in many ways, and do not currentlyprovide clear-cut connections to social service provision,they are the essential platform for designing workable socialwork evaluation and measurement approaches.F-tags are best described as a line of defense againstsubstandard care rather than as indicators of quality care.Tags refer to specific sections of the regulations and,when cited by surveyors, indicate deficient care(out ofcompliance with regulatory standards) in that area. Thesix F-tags compiled in the CMS Online Survey Certificationand Reporting (OSCAR) data set currently viewedas most directly related to psychosocial care and socialservice provisions are as follows:• Residents’ right to organize and participate in residentgroups (F243)• NH policies that accommodate residents’ needs andpreferences (F246)• NH provides residents with appropriate treatment formental or psychosocial problems (F319)• NH ensures that residents do not have avoidable declinein their psychosocial functioning (F320)• NH over 120 beds employs a qualified social worker ona full-time basis (F251)• NH provides medically-related social services (F250)Severity of F-tag DeficiencyCMS has underway currently a project to upgrade surveyorguidelines for establishing the level of severity of thecare deficiency that has been identified in a facility. As apart of the upgrade, evidence concerning psychosocial severity(impact of deficient care on psychosocial well-being)as well as medical severity is now being examined so thatpsychosocial severity can be assessed as a component of anydeficiency.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 5Resident Assessment InstrumentThe federally mandated Resident Assessment Instrument(RAI), completed for every resident on a regular interval,consists of the Minimum Data Set (MDS) and itscorresponding Resident Assessment Protocols (RAPs). TheRAI is the basis for clinical assessment and care planningin nursing homes, and also serves as an additional set ofindicators of quality of care in nursing homes through themonitoring of resident outcomes as described briefly below.Social workers, as members of the interdisciplinaryteam, are typically involved in completing the MDS andRAPs, particularly sections related to cognitive, mood andbehavior patterns, psychosocial well-being, and dischargepotential (Beaulieu, 2002).• Concerns persist regarding the ability of the MDS to accuratelyidentify residents’ psychosocial problems. TheAmerican Geriatrics Society/American Association forGeriatric Psychiatry Consensus Statement (2003) statedthat the MDS is not an adequate tool for screeningresidents with depression and behavioral problems relatedto dementia. Yet, the MDS is commonly the onlyscreening tool used within facilities to assess for theseconditions. Other suggested limitations of current systematicassessment processes include data sources (toolittle of the resident’s input and perceptions), absenceof checks for assessment accuracy, and disconnect betweenassessment and actions taken (Kane & Kane,2000). Practitioners at the symposium noted that socialwork involvement in MDS and care planning isoften not “meaningful,” with a reliance on check-lists,computer generated care plans, and an absence of interdisciplinaryconversation based on a more enrichedunderstanding of individualized psychosocial circumstances.• The “engagement” items of MDS could be useful inconnection with social work interventions. There arescales available that could provide reliable measures forthese items.• Practitioners do not view current MDS items relatedto “discharge” as useful. Yet there is a need to link thesocial work function of transitional care (case management,discharge planning, community referrals, followthroughon care referrals) to a meaningful measure.Quality Initiative (QI) Outcome MeasuresAs part of a more comprehensive quality improvementinitiative, CMS has developed a set of quality indicators,based on MDS data, which are used for aggregate andcomparison purposes of nursing homes nationally. Datafor the QIs are published on the CMS Nursing HomeCompare Website for consumer review (http://www.cms.hhs.gov/quality/nhqi/). Two of the NHQI measures thepercentage of residents who have become more depressedor anxious and the percentage of short-stay residents withdelirium capture psychosocial constructs. However, thesefacility-level measures also raise questions concerning the“origin” of the assessed problems to begin with. To what extentare the documented residents’ depression, anxiety, anddelirium related to the facility QOL and QOC rather thanindividual underlying medical and behavioral disorders?Measuring Quality of LifeNursing home quality of life has been an importantconstruct of quality improvement efforts and is explicitlyaddressed in federal regulations. CMS has funded researchto improve quantification and measurement of QOL inthe nursing home as a necessary precursor to enhancementsof survey and certification processes or collection ofnational outcome data. Sampling in 100 NHs across fivestates, Kane, Kling et al. (2003) and Kane, Bershadsky etal. (2004) measured the outcome of resident QOL in 11domains. They tested for influences and indicators (aspectsof the home or care that may be related) that were associatedwith better QOL.Research FindingsImportant conclusions from the 5-year QOL Kane andcolleagues’ (2003, 2004) study include:• QOL is multidimensional and subjective and is measuredby asking the resident directly, thus allowing forindividual and cultural differences.• QOL could be reliably measured for 60% of NH residents(i.e., they could answer the questions themselves),including many whose MDS data suggested considerablecognitive impairment.• Facility level aggregate QOL data showed patterns (generallygood or bad across all domains).• The relationship between many hypothesized indicators(care processes, facility structure, etc.) was notdemonstrated because of the difficulty of consistencyin measurement. This does not mean that these indicatorshave been shown to be irrelevant. Work is neededat the individual facility level to demonstrate relationships.• Having a single room was identified as one structuralvariable that was related to multiple QOL domains.

6 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementQOL and Social Work ResearchThere are many possible structures and pathways to excellentnursing home care that is characterized by a betterquality of life. The feasible and reliable measurement ofresident QOL provides social work research with an importantopportunity to link a variety of practice interventionsand goals to an outcome that is central to regulatory, policymaking, culture-change principles, and consumer-activistefforts to improve care.Aim # 3: Recommend strategies to improve themonitoring and measurement of quality psychosocialcare and of social work services that address resident andfamily members’ psychosocial needs.The following provides a set of strategies and recommendationsfor action that can result in enhanced demonstrationof the outcomes of social work services and theimprovement in meeting the psychosocial care needs ofresidents and their families. Construction of the evidencebase to support high quality professional social work practicein nursing homes, and with it, efforts to improve qualityof life and care will require labor on several fronts. Theseneeded efforts are complementary, mutually reinforcing,and ask for direction and leadership from different sectorsof the professional community. Social work practice, policy,advocacy, and research expertise in nursing home liferanges across a rich landscape of issues. There are severalimportant initiatives underway in the profession with greatrelevance for nursing home practice and care. However,the profession’s voice and potential contributions are currentlylimited by the lack of a national structure to providevisibility and focus to nursing home social work services,the absence of regular opportunities for communicationsand collaborations among professionals and the absenceof organized linkages to professional initiatives in this domain.The recommendations outlined below encompassthree areas:A. Develop practice guidelines and practitioner-friendlypractice evaluation tools;B. Conduct intervention/effectiveness research; andC. Increase social work involvement in federal measurementand quality improvement processes and in nationalcare improvement initiatives.A. Develop practice guidelines and practice evaluation tools.This work requires practitioner direction and leadership,in partnership with academic research colleagues. The goalis to connect delineated best practices (processes) in thesix functional domains (outlined above) with federal, state,and Joint Commission on Accreditation of Healthcare Organizationscurrent and evolving measurement approachesin ways that can be measured meaningfully. It involves appliedresearch that can be carried out in just a single facility,but provides the necessary building blocks for systematicinvestigation of social work across multiple facilities whetherfor accountability or research on effectiveness.Recommended actions include the following:• Convene a working group of practitioners in collaborationwith academic social work gerontologist(s) to (1)further specify “normative” practice processes in thesix domains (see Greene summary, Appendix B); (2)select the highest prevalence and highest priority practiceprocesses for protocol/guideline development; and(3) confirm through further research the validity of thechoices. For example, while some assessment processesare already clearly identified and case managementprocesses have been standardized, the interventionsthat are most typically used to promote individualization,choice, and preference are unclear.• Examine best practice facilities (as defined throughhigh performance on national data base quality indicatorsor those who are pioneering culture transformationapproaches) for further study of traditional andnontraditional social work involvement, roles, andpractices. Of particular interest are social work managersand the factors contributing to their achievingpositions of leadership.• Conduct systematic reviews of the relevant evidencebase (e.g. best depression screening tools for use withthe elderly; ethical and practical pitfalls in working towardadvance directives; group interventions that promoteinvolvement of the most cognitively impaired;interventions that promote constructive family involvementin care) and develop practice protocols andguidelines for high-prevalence, high-priority practiceprocesses.• Develop/identify practitioner-friendly practice evaluationtools for facility-level applied research (qualitymonitoring and improvement), and promote their widerdissemination and use, providing assistance to NHsocial workers in their use through continuing educationand special workshops.• Schools with Hartford Funded Geriatric EnrichmentProjects or enriched field placements through thePracticum Partnership Program that involve nursinghomes should provide leadership for practice–academicpartnerships to build the empirical base for practice.The established “partnership” structures offer impor-

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 7tant opportunities for organized social work interactionwith other groups to further the applied researchagenda. For example,> Contact and collaborate with federally supportedregional Quality Improvement Organizations fortechnical support in facility-level QI efforts and forincreased visibility for social work processes in thehome.> Contact and collaborate with academic nursingand medical colleagues in the nursing home practiceand research communities to identify areas ofcommon concern such as interdisciplinary teamfunctioning and care planning, diagnosis of emotionaland behavioral disorders, and end-of-lifecare.• Identify, examine, and promote successful models ofcomplementary and collaborative psychosocial careprovision by nurses and social workers.• Continue to build the statistical trail for professionalsocial work in nursing homes through examining theextent of deployment of professionally prepared personnelin both staff and contractual capacities. TheFederal Social Work Workforce Taskforce could be thecatalyst for designing an approach to capture this informationin an ongoing process.B. Conduct intervention/effectiveness research.Social work researchers in partnership with nursinghome social work practitioners and research colleagues ofother discipline should begin rigorous studies of the impactof social work care processes to demonstrate the contributionof social work interventions to valued residentand home outcomes.• Convene a small working group of social work researchersand practitioners to develop a detailed researchagenda for professional practice in nursing homes.• Pursue opportunities for collaboration with large-scalemultidisciplinary research efforts in NHs where a socialwork practice component could be conceptualizedand tested as part of the overall effort (e.g. depressioncare improvement; end-of-life care improvement).• Undertake research using existing CMS measures andfederal and state data bases (for example numbers ofdepressed residents as a mental health outcome) tostudy social work practice. To illustrate, the process ofmonitoring the continuity and impact of mental healthtreatment in transitional care for sub-acute patientshas been identified as problematic and implicated inpersistent morbidity. This process could be the targetof social work case management to test for increasedeffectiveness.• Use reliable, state-of-the-art QOL measures (e.g., Kane,2003) for intervention research on social work practiceat both the resident (micro) and overall facility (macro)levels.• Conduct comparison analyses of social work practicein “culturally transformed” environments versus “traditional”homes.• Conduct needs assessment research on the true extentof unmet psychosocial need in NHs and identify themost prevalent barriers.C. Increase social work involvement in federal processesand initiatives and national reform efforts.This is a multi-faceted effort, potentially involving all thecomponents of professional social work. Recognition of socialwork’s contribution to care rests in part on increasingthe visibility of social work’s expertise and viewpoint in thewider deliberations and conversations that surround policydecisions, including those promoted by the nursing homeindustry. Social work practitioner and researcher expertiseis needed for federal measurement initiatives and modificationsto better capture data relevant to psychosocialconcerns and interventions. Political advocacy for strongerstandards for social work and psychosocial care in nursinghomes is needed and must draw upon credible evidencefor the value of professional personnel. Finally, social workinvolvement in shaping, testing, and ultimately advocatingfor transformations to care is as critical as efforts to influencewhat now exists.• Create a national virtual network of social work nursinghome experts to improve the visibility of existingNH practitioner networks and social work researchers,strengthen their collaboration, and facilitate theiridentification and involvement in CMS initiatives, includingmodifications to care planning protocols, computerizedassessment tools, and enhanced surveyorguidelines for assessing adequacy of psychosocial careand social services.• Strengthen organizational social work involvement innursing home practice improvement (e.g. NASW, Associationfor Gerontology Education in Social Work)at CMS, AHRQ, the Department of Veterans Affairs,and the Health Resources and Services Administration,by providing expertise to national advisory committeesand panels, and other national forums andmeetings.

8 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement• Create a National Social Work Center on Long TermCare that would be a clear place of focus and consolidationfor a range of professional information and effort.For example, a Center would promote links betweenHartford Foundation initiatives, NASW’s Center forWorkforce Studies, NASW sections, the Associationof Veterans Affairs Social Workers , the Institutefor Geriatric Social Work, American Society on Aging,and the National Citizens Coalition for NursingHome Reform. A Center would provide social workleadership for national strategies to promote culturetransformation and stronger federal requirements forQOL that have the potential to improve nursing homecare in fundamental ways.ConclusionAccording to the Centers for Medicare and Medicaid Services,There are currently close to 17,000 nursing homesin the United States. The challenges of strengthening socialwork’s contribution to improving care arise on manyfronts. Educational opportunities to prepare for nursinghome practice could be made more attractive to studentsthrough the gerontological practice enrichment initiativesthat are now underway, but require sustained attentionand creativity similar to that exercised on behalf of childwelfare. Realistically, many smaller and rural area homeswill be unable to attract and employ a full-time trained socialworker. Field education and practice models for highquality social work consultation roles are needed. The university-fieldcollaboration around nursing home care is anatural point of exchange and partnership, one that couldpotentially draw in additional partners such as long termcare ombudsmen and consumer advocates to build a comprehensiveview of care delivery and improvement. Suchpartnerships could be the foundation for practice enhancementefforts in developing practice guidelines, evaluationtools, and conducting effectiveness research, if schools andlong term care settings would undertake partnership initiativesthat go beyond the training mandate.Partnership strategies are crucial to successful action inall arenas. Many needed initiatives require funding, whetherfrom foundations or government. Interdisciplinary collaborationis essential for success. Other disciplines, suchas nursing, share social work’s manpower and quality of lifeconcerns and can be allies. Social work’s practitioners andeducators must connect and contribute to the programs andinitiatives of organizations representing the nursing homeindustry as well as those representing consumers. Federalagencies and federal social workers within these agenciescan be important partners in the profession’s efforts.Social work expertise in nursing home practice is scatteredand currently no national organizational structure inthe profession offers a platform or dedicated resource tocoalesce and maintain a working “interest group.” However,there are state-level groups that could perhaps be thefoundation of a “building from the bottom up” approach.The mechanism for achieving a national critical mass ofinterest and expertise, involving practitioners and academicians,must be found.The path and case for cultural transformation of “nursinghomes” is rooted in the centrality and defining natureof resident and family perceptions of the quality of theirpsychosocial reality. This radical re-definition, focusingon resident-centered care, has the striking effect of placingthe social work perspective in the forefront, and carrieswith it the potential for social work roles and functionsunfettered by current policies and regulations pertaining tosocial service delivery. But the necessary work remains ofpractice specification that promotes consistency, guidelinedevelopment to assure that consistency is “best practice,”and investigation into the effects of consistent best-practiceinterventions on actual quality in the home. The profession’scontribution to care improvement must be forwardlooking, and include the courage to undertake the necessarystrengthening of its fundamental tasks in psychosocialservice provision.ReferencesAmerican Geriatrics Society and American Association for GeriatricPsychiatry. (2003). Consensus statement on improvingthe quality of mental health care in US nursing homes: Managementof depression and behavioral symptoms associatedwith dementia. Journal of the American Geriatrics Society, 51,1287–1298.Beaulieu, E. M. (2002). A guide for nursing home social workers. NewYork: Springer.Burns, B. J., Wagner, H. R., Taube, J. E., Magaziner, J., Permutt,T. & Landerman, L. R. (1993). Mental health service use bythe elderly in nursing homes. American Journal of Public Health,83, 331–337.Castle, N. G., & Shea, D. G. (1997). Mental health services andthe mortality of nursing home residents. Journal of Aging andHealth, 9, 498–513.Centers for Medicare and Medicaid Services. (1989). Requirementsfor long term care facilities, 42 Code of Federal Regulations,Subpart B. Washington, DC: Author.Department of Health and Human Services, Office of InspectorGeneral. (2003). Psychosocial services in skilled nursing facilities.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 9Retrieved April 1, 2005, from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdfDepartment of Veterans Affairs, Office of Social Work Services.(2001). Social worker functions in long-term care settings. Availablefrom the Department of Veterans Affairs, Office of SocialWork Services, Washington, DC.Fagan, R.M., Williams, C.C. & Burger, S.G. (1997). Meeting ofpioneers in nursing home culture change. Rochester, NY: Lifespanof Greater Rochester.Greene, R. R. (2004, December). Roles and functions of nursinghome social workers in the provision of psychosocial care. Paper presentedat the conference Evaluating Social Work Services inNursing Homes: Toward Quality Psychosocial Care and ItsMeasurement, Washington, DC.Kane, R. L. & Kane, R. A. (2000). Assessment in long-term care.Annual Review of Public Health, 3, 659–686.Kane, R. A., Kling, K. C., Bershadsky, B., Kane, R. L., Giles,K. et al. (2003). Quality of life measures for nursing homeresidents. Journal of Gerontology: Medical Sciences, 58A(3), 240–248.Kane, R. A. (2003). Definition, measurement, and correlates ofquality of life in nursing homes: Toward a reasonable practice,research and policy agenda. The Gerontologist, 43 (Special IssueII), 28–36.Kane, R. L., Bershadsky, B., Kane, R. A., Degenholtz, H. H.,Liu, J. et al. (2004). Using resident reports of quality of lifeto distinguish among nursing homes. The Gerontologist, 44,624–632.Kruzich, J. M. & Powell, W. E. (1995). Decision-making influence:An empirical study of social workers in nursing homes.Health & Social Work, 20, 215–222.Meeks, S., Jones, M. W., Tikhtman, V. & LaTourette, T. (2000).Mental health service in Kentucky nursing homes: A survey ofadministrators. Journal of Clinical Geropsychology, 6, 223–232.National Association of Social Workers. (1993). NASW clinicalindicators for social work and psychosocial services in nursing homes.Washington, DC: Author.National Association of Social Workers. (2003). Standards for socialwork services in long-term care. Washington, DC: Author.Nursing Home Reform Act of 1987, 42 U.S.C. § 1396 et seq.Pioneer Network. (n.d.). What is culture change? Retrieved May 18,2005, from http://www.pioneernetwork.net.Quam, J. K., & Whitford, G. S. (1992). Educational needs ofnursing home social workers at the baccalaureate level. GeriatricSocial Work Education, 18(3/4), 143–156.Rosen, A. L., Zlotnik, J. L. & Singer, T. (2002). Basic gerontologicalcompetence for all social workers: The need to “gerontologize”social work education. Journal of Gerontological SocialWork, 39, 25–36.Shea, D. G., Russo, P. A. & Smyer, M. A. (2000). Use of mentalhealth services by persons with a mental illness in nursingfacilities: Initial impacts of OBRA 87. Journal of Aging andHealth, 12, 560–578.Simons, K. (2005). Factors affecting nursing home social workers’ quittingintentions. Unpublished doctoral dissertation, Universityof Maryland, Baltimore.Snowden, M., Piacitelli, J., Koepsell, T. (1998). Compliancewith PASARR: Recommendations for Medicaid recipients innursing homes. Journal of the American Geriatrics Society, 46,1132–1136.Vinton, L., Mazza, N., & Kim, Y. (1998). Intervening in familystaffconflicts in nursing homes. Clinical Gerontologist, 19(3),45–67.Vourlekis, B. S., Gelfand, D. E. & Greene, R. R. (1992). Psychosocialneeds and care in nursing homes: Comparison of viewsof social workers and home administrators. The Gerontologist,32, 113–119.Vourlekis, B. S., Bakke-Friedland, K., & Zlotnik, J. L. (1995).Clinical indicators to assess the quality of Social Work servicesin nursing homes. Social Work in Health Care, 22, 81–93.Wiener, J. (2003). An assessment of strategies for improving qualityof care in nursing homes. The Gerontologist, Special Issue II,43, 19–27.

10 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementAPPENDIX AEvaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementConference AgendaDecember 2–3, 2004Vista Ballroom B, Wyndham Hotel1400 M Street NW, Washington, DCThursday, December 2, 20048:30–9:00Registration and Continental Breakfast9:00–9:30Welcome, Introductions and Overview of the Meeting Purposesand Planned OutcomesJoan Levy Zlotnik, Institute for the Advancement of SocialWork ResearchCharlotte Mullican, Agency for Healthcare Research andQualityJesse Harris, University of Maryland, School of SocialWorkScott Miyake Geron, Institute for Geriatric Social Work,Boston University9:30–10:45Roles and Functions of Nursing Home Social Workers inthe Provision of Psychosocial CarePresenter: Roberta Greene, University of Texas, Austin,School of Social WorkDiscussant: Patricia Gleason-Wynn, Baylor University,School of Social WorkBreak11:00–11:20DHHS OIG Report on Psychosocial Care in NursingHomesEllen Vinkey, Office of Inspector General, U.S. Departmentof Health and Human Services11:20–1:00Regulatory Approaches to Measuring Psychosocial ServiceQualityBob Connolly, Anita Panicker, and Jeane Nitsch, Centersfor Medicare & Medicaid ServicesDiscussant: Betsy Vourlekis, University of Maryland1:00–2:00 PMWorking Lunch: Roundtable Exchanges and Discussion2:15–3:30Meeting the Mental Health Needs of Nursing Home ResidentsUsing an Outcomes ApproachIra Katz, University of Pennsylvania, School of MedicineDiscussant: Margaret Adamek, Indiana University, Schoolof Social WorkBreak3:45–5:00Small workgroups: Identifying barriers to measuring andmonitoring psychosocial and social work service qualityFriday, December 3, 20048:30–9:45Working Breakfast (provided) and PresentationMeasuring the Quality of Life in Nursing Homes and ItsRelationship to Psychosocial ServicesPresenter: Rosalie Kane, University of Minnesota, Schoolof Public Health

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 11Discussant: Rhonda Montgomery, University of Wisconsin,Milwaukee, Helen Bader School of Social WelfareBreak10:00–11:00The Philosophy and Strategic Implementation of CultureTransformation: Implications for Psychosocial Care Measurementin Nursing HomesPresenter: Christa Hojlo, Veterans Health Administration11:15–12:15Small workgroups: Recommendations for measuring andmonitoring psychosocial and social work service quality1:30–2:15Small workgroups: Implementation and dissemination actionstepsBreak2:30–3:45Workgroups report: Developing an action plan for measuring,monitoring, and research on psychosocial servicequality3:45–4:00Concluding statements/responseJoan Levy Zlotnik, IASWR12:30–1:30Working lunch

12 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementAPPENDIX BEvaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementSummaries of Conference PresentationsRoles and Functions of Nursing Home Social Workers in the Provision of Psychosocial Care (p. 13)Presenter: Roberta Greene, University of Texas, AustinDHHS OIG Report on Psychosocial Care In Nursing Homes (p. 15)Presenter: Ellen Vinkey, Office of Inspector General, U.S. Department of Health and Human ServicesRegulatory Approaches to Measuring Psychosocial Service Quality (p. 17)Presenters: Bob Connolly, Anita Panicker, and Jeane Nitsch, Centers for Medicare & Medicaid ServicesMeeting the Mental Health Needs of Nursing Home Residents Using an Outcomes Approach (p. 21)Presenter: Ira Katz, University of Pennsylvania, School of MedicineMeasuring the Quality of Life in Nursing Homes and Its Relationship to Psychosocial Services (p. 23)Presenter: Rosalie Kane, University of Minnesota, School of Public HealthThe Philosophy and Strategic Implementation of Culture Transformation: Implications for Psychosocial CareMeasurement in Nursing Homes (p. 25)Presenter: Christa Hojlo, Veterans Health Administration

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 13Roles and Functions of Nursing HomeSocial Workers in the Provision ofPsychosocial CareRoberta R. Greene, PhDUniversity of Texas, Austin, School of Social WorkOverviewThis presentation examined the congruence of psychosocialfunctions among five sources and related the resultingcommon functions to the Council on Social WorkEducation (CSWE), Strengthening Aging and GerontologyEducation for Social Work (SAGE-SW) project’s GerontologicalSocial Work Competencies (CSWE SAGE-SW,2001). Dr. Greene suggested that the resulting matrix beused (1) to establish a common framework for practice andeducation and (2) to operationalize measurement of keysocial work activities in the nursing home (NH) in relationto key patient and total home outcomes.Sources for NH Social Work Functions• Educational needs and practice realities of NASWmembers working in nursing homes (Greene, Vourlekis,Gelfand, & Lewis, 1992)• Psychosocial needs and care in nursing homes (Vourlekis,Gelfand, & Greene, 1992)• Social worker functions in long-term care settings (CodifiedVA social worker practice standards, VA, 2001)• Standards for social work services in long-term care facilities(NASW standards, NASW, 2003)• University of Texas Nursing Home Study (Greene etal., 2004)• CSWE SAGE-SW Gerontological Social Work Competencies:65 gerontological social work competencies,developed through a literature search and input fromnational experts, were fielded in 2000 through a large,national survey of practitioners and academics with agingand non-aging interests. Survey respondents wereasked to rank the level of specialization (1=all socialworkers, 2=advanced practitioners, and 3=aging specialists)needed across three domains: (1) knowledgeabout older people and their families; (2) professionalskill; and (3) professional practice. Each competencywas rank ordered according to its mean level of specialization.Results of this work can be found at: http://www.cswe.org/sage-sw/resrep/competenciesrep.htmCommon Functions and Related EducationalCompetencies1. Conduct assessments through information gathering.• Knowledge of normal physical, psychological, andsocial change in later life• Knowledge of models of biology and social aging• Skill to gather information regarding social historyincluding social supports, culture, and social involvement• Skill to gather information on mental status, historyof any past or current psychopathology, lifesatisfaction, coping abilities, affect, and spirituality• Skill to gather information on physical status includingdisabilities, chronic and acute illness,medications, mobility and activities of daily living• Skill to conduct a comprehensive biopsychosocialassessment• Skill to assess short-term memory, coping changes,socialization patterns, behavior, and appropriatemood and affect2. Provide psychosocial interventions that enhance copingskills.• Skill to assist individuals and families in recognizingand dealing with issues of grief, loss, andmourning• Skill to enhance the coping capacities of olderadults• Skill to assess psychosocial factors that have an effecton the physical health of older adults• Skill to use empathetic interventions such as reminiscenceor life review, support groups, and bereavementcounseling (total congruence)• Engage and mediate with angry, hostile, and resistantolder adults and family members3. Assist with long-term care transitions through casemanagement.• Skill to use social work case management strategiessuch as brokering, advocacy monitoring, anddischarge planning to link elders and families toresources and services• Skill to assist older persons with transitions to andfrom institutional settings• Conduct long-term care planning with older per-

14 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurementsons and their families to address financial, legal,housing, medical, and social needs4. Participate in care planning.• Skill to develop service plans that incorporate appropriateliving arrangements and psychosocialsupports for older persons• Skill to set realistic and measurable objectivesbased on functional status, life goals, symptommanagement, and financial and social supports ofolder adults and their families• Skill to reevaluate service or care plans for olderadults on a continuing basis, incorporating physical,social, and cognitive changes and adjustingplans as needed• Skill to develop service plans that include intergenerationalapproaches to the needs and strengths ofolder persons, their families, or significant other5. Collaborate with the nursing home team.• Skill to collaborate with other health, mentalhealth, and allied health professionals in deliveringservices to older adults6. Attend to individualized decision making.• Skill to identify ethical and professional boundaryissues that commonly arise in work with olderadults and family membersReferencesCouncil on Social Work Education/Strengthening Aging andGerontology Education in Social Work. (2001). CSWESAGE-SW national aging competencies survey report. RetrievedMay 17, 2005, from http://www.cswe.org/sage-sw/resrep/competenciesrep.htmDepartment of Veterans Affairs, Office of Social Work Service(2001). Social worker functions in long-term care settings. Availablefrom the Department of Veterans Affairs, Office of SocialWork Services, Washington, DC.Greene, R. R. , Graham, S., Haulotte, S., Nixon-Garica, C., Gleason-Wynn,P. (2004). A state nursing home crisis: A consumerstudy in quality care. Unpublished manuscript, University ofTexas at Austin.Greene, R.R, Vourlekis, B.S., Gelfand, D.E., & Lewis, J.S., 1992Current realities: Practice and education needs of social workersin nursing homes. Geriatric Social Work Education, 18(3/4),39–54.National Association of Social Workers. (2003). Standards for socialwork services in long-term care. Washington, DC: Author.• Skill to accept, respect, and recognize the right andneed of older adults to make their own choicesand decisions about their lives within the contextof the law and safety concerns

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 15Psychosocial Services inSkilled Nursing FacilitiesEllen VinkeyOffice of Inspector General, U.S. Department ofHealth and Human Services4. Review of Online Survey and Certification ReportingSystem (OSCAR) data• Psychosocial deficiency data5. National Ombudsman Reporting System (NORS)data• Complaints about psychosocial servicesOverviewThis presentation reviewed the Office of InspectorGeneral’s findings from their recent inspection related topsychosocial services in skilled nursing facilities (SNFs).Suggestions were made for research to further identify barriersto psychosocial care.Review of Regulations (OBRA, 1987—NursingHome Reform Act of 1987)1. All SNFs must provide “medically-related social servicesto attain or maintain the highest practicable physical,mental and psychosocial well-being of each resident”2. Facilities with over 120 beds are further required to employa minimum of one full-time social worker with• “At least a bachelor’s degree in social work or anotherhuman service field”• “1 year of supervised social work experience in ahealth care setting working directly with individuals”OIG StudyData Sources1. Random sample (N=299) recently admitted Medicarebeneficiaries• Social work credential review• Medical record review of assessment and provisionof psychosocial services2. Stratified random sample (N=84) Medicare certifiedSNFs• Telephone interviews with social work directorsand nursing home administrators3. Small purposive sample (N=32) state surveyors fromeight states• Monitoring of psychosocial servicesMajor Findings• Almost all the residents whose charts were reviewedhad a psychosocial need.> 39% of those with needs had inadequate careplans to address those needs> 46% of those with psychosocial care plans did notreceive all planned services> 5% received none of their plans psychosocial services• 15% of facilities were cited for psychosocial deficiencies.> F-246 and F-250 the most cited (lack of provisionof medically-related social services)• 1% of NORS complaints related to psychosocial services• 98% of larger facilities (those with over120 beds) metthe “120-bed rule.”• 45% of social workers reported barriers to the provisionof psychosocial services.> not having enough time> burdensome paperwork> insufficient staff (social workers and others)> role ambiguity—performing roles that they werenot trained to doOIG (2003) Recommendation“We recommend that the Centers for Medicare and MedicaidServices (CMS) strengthen the oversight processes associatedwith the psychosocial service portion of the residentassessment and the resulting care plans to ensure that SNFresidents receive necessary and appropriate care (p. iv). ”Possible Areas for Future Research• Compare graduate by undergraduate social work preparationusing the random sample (N=84) social workersinterviewed.

16 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement• Develop additional means of measuring unmet psychosocialneeds.• Investigate the causes of the problem: What needs tobe changed?• Follow-up on the barriers to psychosocial service deliveryas reported by the 45% of social workers.ReferenceDepartment of Health and Human Services, Office of InspectorGeneral. (2003). Psychosocial services in skilled nursing facilities.Retrieved May 9, 2005, from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdf

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 17Regulatory Approaches to MeasuringPsychosocial Service QualityBob Connolly, MSW, LCSW-CJeane Nitsch, MS, MSW, LCSW-CAnita Panicker RN, MSW, LCSWCenters for Medicare & Medicaid Services (CMS)OverviewThis presentation reviewed federal regulations relative tonursing home (NH) psychosocial services and described thebarriers to social work participation in quality improvementefforts. It further discussed Centers for Medicare and MedicaidServices (CMS) quality improvement initiatives andsuggested the need for social workers to play a larger role inthe development of NH regulation and quality measures.Barriers to Improving NH PsychosocialCompetencies and Skills• Focus is more on the medical model rather than psychosocialand psychiatric concerns• A need to evolve psychosocial measures and assessmenttools• Lack of professional training and research skills amongNH social work staff• Staff turnover• There are few social work, nursing, etc. students interestedin NH careers• There is no body of evidence that level of educationmakes a difference in the quality of psychosocial services(e.g., having a BA in a human service field versusa bachelor’s degree in social work [BSW] or a master’sin social work [MSW])Barriers to Social Work Involvement inStrengthening Psychosocial Care• No national story about the social work role and contributionsto the quality of care• Social work role definition in NHs can be unclear• Social workers need to better connect clinical processto resident outcomes (i.e., lack of evidence of clinicalaccountability)• Limited visibility of social worker as a stakeholder• Schools of social work can do more to train studentsfor gerontological practice, which speaks to the needfor curriculum development and development of NHfield placementsReview of Long-Term Care Regulations 42 CFR 483Related to Social Services Requirements at:Sec. 483.15 Quality of life.1. The facility must provide medically-related social servicesto attain or maintain the highest practicablephysical, mental, and psychosocial well-being of eachresident.2. A facility with more than 120 beds must employ a qualifiedsocial worker on a full-time basis.3. Qualifications of social worker. A qualified socialworker is an individual with(i) A bachelor’s degree in social work or a bachelor’sdegree in a human services field including but notlimited to sociology, special education, rehabilitationcounseling, and psychology; and(ii) One year of supervised social work experience in ahealth care setting working directly with individuals.Guidelines (State Operations Manual)Intent §483.15(g)• To assure that sufficient and appropriate social servicesare provided to meet the resident’s needs.Interpretive Guidelines §483.15(g)• Regardless of size, all facilities are required to providefor the medically-related social service needs of eachresident. This requirement specifies that facilities aggressivelyidentify the need for medically-related socialservices, and pursue the provision of these services. Itis not required that a qualified social worker necessarilyprovide all of these services. Rather, it is the responsibilityof the facility to identify the medically-relatedsocial service needs of the resident and assure that theneeds are met by the appropriate disciplines.Examples of Social Work Involvement in NHRegulatory Change• Advocacy through Congress regarding CMS changesin conditions of participation or staffing requirement

18 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement• Initiation of the DHHS Office of Inspector General(2003) study: Psychosocial Services in Skilled NursingFacilities• A DHHS national meeting on long-term care socialwork (September, 2002)• Report to Congress: The future supply of long-termcare workers in relation to the aging baby boom generation(DHHS Assistant Secretary for Planning andEvaluation, 2003)• AHRQ-funded, 2004 interdisciplinary meeting: Evaluatingsocial work services in nursing homes: Towardquality psychosocial care and its measurement.• John A. Hartford Foundation funding (Hartford GeriatricSocial Work Initiative)CMS NH Social Work Best Practice StudyHypothesis. Social workers in “best-practice” NH are includedin more interdisciplinary care, have better defined rolesand make quality contributions to resident psychosocialcareBest-practice nursing home selection based on• 2001 CMS Environmental Scan• Recommendations from CMS NH experts• Amount of survey and certification deficiencies• Publicly reported quality measuresSurvey sample• National telephone interviews were conducted using astandardized survey tool• Participants of the survey consisted of 25 best-practicenursing home social workers or social service providers> 1 social work consultant> 1 nursing home administrator> Average facility bed size=97.48 beds> Mostly middle-to-small nursing homesEducation credentials• All best-practice nursing homes had a social serviceprovider. Most of these providers (85%) were qualifiedsocial workers.> 9 BSW> 1 BA> 12 MSW> 3 designees (associate’s degree or less)Most common roles (social worker’s self-report)* Supportive care (72%)> Family support> Residents’ rights> Quality of life issues• Documentation (69%)> Completion of MDS, care plans, etc.• Direct social services (56%)> Individual> Family> GroupsRoles ranked most important to medically related socialservices (n=26)• Care planning (73%)• Family Support (73%)• Psychosocial Assessment (69%)• Training Staff (62%)• Counseling (39%)• Discharge planning (39%)Interdisciplinary roles• Care planning with nursing, activities coordinator,MDS coordinator, and physician• Discharge planning with nursing, activities coordinator,MDS coordinator, dietary, therapy, and physician• 90% of best-practice social workers led or co-led mostfamily and resident counsel groups with the activitiescoordinator (46%), administrator (36%), nursing(18%)Minimum Data Set (MDS) documentation• Most best-practice social workers (85%) took part inthe initial MDSMost frequently answered social work MDS questions• Section F. Psychosocial well-being> Question 1. Sense of initiative and involvement(96%)• Section E. Mood and behavior> Question 1. Indicators of depression, anxiety, sadmood (67%)> Question 3. Mood persistence (89%)> Question 4. Behavioral symptoms (89%)

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 19• Section Q. Discharge potential> Question 1. Discharge potential (74%)• Section B. Cognitive patterns> Question 5. Indicators of delirium/period of disorderedthinking (52%)Qualitative findings• Best-practice social workers appear satisfied and wellutilized> They are very satisfied with their roles and functions> Feel needed and valued as members of interdisciplinaryteam> Feel respected for the skills and services they provideEvidence• Consistent role definition for social work across 26NHs• Involvement in all aspects of care planning• Social workers reported being satisfied and well utilizedStudy Limitations• Small sample• Study focused on medium-sized facilities only• There were no specific “data” that could point to thesocial worker’s contribution to improved quality ofcare or facility performance on pain, pressure ulcer, orrestraints quality measures.Proposed MDS 3.0 Revisions Relevant toSocial Work (www.cms.hhs.gov/quality/mds30/DraftMDS30.pdf)Delirium. Section B• New yes/no standardized delirium questions based onthe Confusion Assessment Method (CAM)> CAM is a valid, reliable, and quick way for nonpsychiatricclinicians to detect delirium (Inouyeet.al., 1990) and is also recommended by the 2002Mood/Behavioral Expert PanelQuality of Life (QOL). Section F• CMS contract 1998–2003 with University of MN• Developed 11 domains of QOL• See also: www.cms.hhs.gov/quality/mds30Select Current CMS Quality Measures With Psychosocial/Psychiatric Components• Depressed/anxious mood worsening> Percent of residents who have become more depressedsince the last time they were assessed• Moderate/severe pain> Percent of residents with moderate or severe painduring a 7-day assessment period• Delirium> Percent of recently admitted residents from a hospitalwho have symptoms of delirium, defined as:sudden problems with attention, problems withthinking and communicating, loss of a sense oftime and place, changes in sensation and perception,changes in level of alertness, changes in sleeppatterns, loss of short-term memory, restlessnessand changes in personality.> See also: www.cms.hhs.gov/quality/nhqiConclusions: Social Work Opportunities in NHRegulatory Change• 29 Current CMS MSWs are using the following approachto nursing home improvements that could be amodel for the social work profession.> Promote NH social work using macro skills on apolicy level and not just on a direct-practice level.> Focus on improving the quality of life psychosocialand psychiatric nursing home residents need,as nursing home social work roles are not well definedand have produced limited data.> Seek solutions to upgrade the practice and trainingof social workers in nursing homes including non-MSW and non-BSW nursing home social workers.(It will take years to supply BSW and MSW manpowerto over 17,000 nursing homes and morework is needed on the social work role definitionand qualifications.)> Network and collaborate with nurses, physicians,therapists, activities professionals, and others topush for improved care, as nursing home qualityof care and quality of life concerns are common toall professions. (Social work skills are most needed,appreciated, and dynamic in an interdisciplinarymodel.)

20 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement> Be a voice/advocate for nursing home residentneeds at national, state and local forums becausepolicy and decision making are often based onprovider, legislative, or payer needs.• Work with other professions to address NH workforceissues.> Nursing schools are having the same problems attractingstudents, faculty and long-term-care (LTC)researchers.• Accountability and interdisciplinary care> There is a need for social research and technicalexpert panels to better define the social work role,interdisciplinary tasks and the processes, outcomesand contributions that this profession makes innursing facilities.• Conduct LTC quantitative and qualitative researchthrough academic centers.> Schools of social work are not focused enough onLTC in terms of curriculum, faculty interest, fieldplacements, and research.> Identify and provide CMS with roster of LTC socialwork experts> Use CMS quality measures that are updated quarterlyfor close to 17,000 Medicare/Medicaid-certifiednursing homes: and • Work with other disciplines/agencies (e.g., NationalInstitute of Mental Health and Department of VeteransAffairs) to study depression.• Become involved in LTC monthly open-door forums:.• Present at multidisciplinary NH stakeholder meetingsand partner with NH organizations (i.e., AmericanAssociation of Homes & Services for the Aging fornon-profit NHs, American Health Care Associationfor-profit NHs, American Hospital Association forhospital-based NHs).• Comment on drafts of MDS, Interpretive Guidelines,Federal Register Notices, Consumer Assessment ofHealth Plans Survey drafts, etc.• Promote regulations and State Operations Manualguidelines to NH social work practitioners: and .ReferencesDepartment of Health and Human Services, Assistant Secretaryfor Planning and Evaluation. (2003, May). Report to Congress:The future supply of long-term care workers in relation to the agingbaby boom generation. Retrieved May 9, 2005, from http://aspe.hhs.gov/daltcp/reports/ltcwork.htmDepartment of Health and Human Services, Office of InspectorGeneral. (2003). Psychosocial services in skilled nursing facilities.Retrieved May 9, 2005, from http://oig.hhs.gov/oei/reports/oei-02-01-00610.pdfInouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal,A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusionassessment method. A new method for detection ofdelirium. Annals of Internal Medicine, 113, 941–948.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 21Meeting the Mental Health Needs ofNursing Home Residents Using anOutcomes ApproachIra R. Katz, MD, PhDUniversity of Pennsylvania, School of MedicineOverviewThis presentation defined conceptual models of themental health and nursing home (NH) care systems in relationto psychosocial services, described the impact of thesecare systems on the treatment of residents with depressionand dementia, and challenged current treatment protocolrelative to these two mental health conditions.Application of the Two-System Model (Table 1)• The intrinsic system is critical for prevention, as a soletreatment for milder conditions, and as a vehicle forimplementing specific care plans. Within the facility, servicesmust almost always be mediated through the intrinsicsystem.• The extrinsic system is more likely to be necessary withmore severe disorders.• All residents are dependent and all are vulnerable tothe NH environment. The more impaired a residentmay be, the more likely s/he is affected.Interactions Between Intrinsic and ExtrinsicSystems• For psychotherapy/behavioral treatment, staff and programsare part of the solution or part of the problem• For pharmacotherapy, facility staff is critical for:> Screening and referral> Evaluation of target symptoms and assessment ofoutcomes> Evaluations of side effectsRole of Social Work• Is critical for the inner mental health system• Should be an important part of the outer system (e.g.,by providing Part B services)• Is the best candidate for bridging between the two systemsand supporting their interactionsTable 1. Two-System Model of Nursing Home Systems and Mental Health Systems for Nursing Home ResidentsTwo Nursing Home SystemsLong Term CareSubacute CareAccounts for most bedsAccounts for most peopleEmphasizing person-environment fitTransitional care issuesAddressing mental health conditions asAddressing mental health conditions as barrierskey determinants of quality of lifeto rehabilitation, recovery, and readjustmentTwo Mental Health Systems for NH ResidentsIntrinsic/InnerExtrinsic/OuterUniversal servicesSpecialty servicesAll aspects of NH life and care should beFocused on diagnosed mental disordersinformed by knowledge of the mental disorders oflate life and of older people’s vulnerabilities to themInterface between quality of care and quality of lifeInterface between psychosocial care and generalmedical careMental health services are provided by all staffProvided by mental health specialty professionalsMedicare “Part A” Medicare “Part B”

22 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementDepressionDefinition of depression. A lack of positive affectPrevention. Is there less depression in facilities with higherquality of care/quality of life?Question. How can we deliver effective treatment for depressionto real people in real nursing homes?Conclusions• The rapid rise in antidepressant use in NHs correspondswith a decrease in antipsychotics use.• There is an overall lack of effective diagnosis and follow-upand an over-reliance on pharmaceutical interventionsfor depression in NHs.• The efficacy of antidepressants on minor depressionshas yet to be established among this population of olderadults. There is more evidence of efficacy for majordepression.• There is a need to distinguish between reactions to poorquality NH environments versus true depression.DementiaQuestion. How should we combine/ prioritize psychosocialand biomedical care for dementia?Two nursing home treatment cultures• Behavioral/environmental• Biomedical/pharmacologicalCauses of agitation• Unmet physical and psychosocial needs: Pain/discomfortand boredom/loneliness> The environment may be too demanding or stimulating> The environment may not be demanding or stimulatingenoughConclusions• There are no simple answers to managing behavioralsymptoms with dementia.• Simple models are inadequate.• Our research needs new conceptual models and designs.• Our care systems must be reinvented.Major concern. Problematic behaviors that cause seriousproblems

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 23Measuring the Quality of Life inNursing Homes and Its Relationship toPsychosocial ServicesRosalie A. Kane, PhDUniversity of Minnesota, School of Public HealthOverviewThis presentation defined the concept of quality of life(QOL) as it relates to nursing homes (NHs), described andpresented results of a study sponsored by the Centers forMedicare & Medicaid Services (CMS) to develop NH QOLmeasures, and provided suggestions for measuring and improvingNH QOL.QOL is not just lack of bad outcomes.• It allows for older person’s voice (individual and culturaldifferences)• It is multidimensional and subjective• It includes physical, psychological, social, economic,and spiritual aspectsWhen measuring QOL• It is critical to ask the resident about their QOL directlybefore asking proxies or gathering data throughobservation. Even people with substantial dementiacan tell you about their QOL.Domains of quality of life measures for residents incare settings (proposed hierarchy of needs)1. Comfort and security2. Enjoyment, relationships, meaningful activity andfunctional competence3. Individuality, privacy, autonomy, and dignity4. Spiritual well-beingCMS QOL Study: 1998–2003• Developed measures and indicators of QOL in NHs• Studied how physical environments affect QOL• Paved the way for QOL improvement efforts• Sampled more than 3,000 residents in 100 NHs acrossfive states• Conducted 45–90 minute interviews with residents• Measures:> 56 items> 3–6 items per domain> Mostly 4-point Likert scales with a dichotomous(yes/no) fall-backBrief findings• The researchers were able to reliably measure QOL domainsfor an average of 60% of NH residents.• Minimum Data Set (MDS) cognition questions were apoor predictor of the ability to interview.• Many hypothesized indicators did not work becauseof the measuring strategy (across multiple facilities). Itmay be more feasible to measure indicators (program/facility aspects) and resident outcomes at the facilitylevel.• The reliability of the scales was good.• Facility-level QOL showed patterns (generally good orbad across all domains).• Family and staff proxies significantly correlated withresident self-report, though these correlations wereweak.• Responses to staff interviews were highly correlatedto research interviewer’s responses and there were nosignificant differences between nurse and social workinterviews.• Having a single room related to multiple QOL domains.• Personality has some effects on QOL, after controllingfor functional status and cognition.Internal and External Influences on QOL• Health status including functional and sensory losses• Social circumstances• Personality (extroversion/introversion, neuroticism,creativity, etc.)• Care provision/neglectful care> Uncontrolled pain, hunger, sleep problems> Untreated depression> Excess disability due to lack of dentures, hearingaides, eyeglasses, foot care• Care environment> Involuntary moves (should be the last resort)> Continuity of care> Meaningful activity> Maximization of independence

24 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement> Fostering relationships• Public and professional attitudes> Ageism> Low expectations and pessimismSelect Questions to Identify Resident Strengths• What makes a day a good day for you?• What are the things you do each day or each weekbecause you really prefer or choose, not because youmust? What makes you get so involved that time seemsto move quickly?• What do you do well? What kinds of things did youpreviously do well? What has always given you confidenceor made you proud?Implications of Culture Change for Social WorkPracticeMuch of what social work stresses already fits with culture-changeperspectives and presents an opportunity forsocial work leadership.• The person–environment perspective• Focus on environmental interventions• Knowledge of group process (which is important inGreenhouse environments that have 8–10-personhouses instead of large units)• Focus on family systems• End of life and discharge planning• Continuous quality improvement effortsImplications of Culture Change for PsychosocialMeasurement• Measures for psychosocial outcomes are available. It’sjust a matter of using them.> There is an over-concern regarding resident burden.• Measures for independent variables (i.e., psychosocialinterventions and level of dose) are not as easy to comeby and will need to be developed.• It is important not to confuse indicators (facility process)with outcomes (resident well-being).

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 25The Philosophy and StrategicImplementation of Culture Transformation:Implications for Psychosocial CareMeasurement in Nursing HomesChrista M. Hojlo, DNSc, NHAVeterans Health AdministrationOverviewThis presentation introduced the concept of nursinghome (NH) culture change and described how it hasbeen applied in the Department of Veteran’s Affairs (VA)nursing home care units (NHCUs). It also related culturechange to psychosocial care processes and cited opportunitiesthat have emerged in VA NHCUs as a result of culturaltransformation.The culture of health care in the United States• Shaped by: funding/payment systems, specialization, institutionalization,medicalization (over-medicalization)• Strengths of system: interdisciplinary, attention toqualityCharacteristics of the traditional VA nursing homecare unit (NHCU)• Medically driven by diagnosis• Language is indicative of medical model—“patient”• The environment is hospital based• Length of stay tends not to be well defined• Care regimens vary• Prescribed expectation/norms of behavior for residents(must get dressed, etc.)• Strong commitment to serving veteransCulture change definedCulture change is not merely changing policies, procedures,and functions. It is the redefinition of care systemsand our ways of understanding and interacting withinthem: “not only of what we do, but how we do it; how wethink about how and what we do.”Characteristics of new culture• The driver of care is improvement in quality of life(QOL) and in maintaining residents’ highest practicablefunctional level.• Care is resident focused. Discipline-specific boundariesare blurred to meet residents’ needs. (“It doesn’tmatter who does it. All of us need to do it.”)• Care is based on assessed needs and resources allocatedto meet those needs in accord with resident wishes.• The interdisciplinary team clearly understands its rolein relationship to facilitating achievement of residentgoals, determined on or prior to admission. Everymember of the interdisciplinary team is responsiblefor achievement of these goals.• The environment is more home-like and speaks to wellness.• Greater attention is paid to costs and service qualityvia resident satisfaction.• At the heart of the transformation is changing the driverof care from the medical model to a model driven bynurturance, comfort, and love.The symbolism of language change• From “patient” to “resident”• From “illness” to “highest practicable functional level”Admission considerationsThree critical questions that help to identify the reasonfor admission, long- and short-term goals, and to start immediatedischarge plans:1. Why is the resident here/coming here?• S/he lacks social or other structures/supports tofacilitate achieving goals for improved function, inorder to return to the community, or to receivecomfort and care in dying. It is the role of the facilityand the interdisciplinary team to provide thestructure to achieve this goal.2. For how long will the resident need placement?• If you know that the resident should achieve his/her functional goal in 30 days, then set up the supportsin the NHCU to discharge the resident in 30days.• Short term goals are measures of progress towardgoal attainment.

26 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement3. Where will s/he go from here?• Home• Community NH• Death• Long-term stayWhy is this important?These are critical questions that design and shape theculture of care relative to service delivery.• Out of nurturance, comfort, and love, services are providedfor the resident to improve function/health or todie with dignity.• Resident preferences are at the center of care.• The philosophy guiding this model is one where rehabprinciples intersect to provide the highest quality ofcare based on assessed resident needs:> The challenge is to find that one tiny area of wellnessthat can be enhanced, regardless of diagnosis,which also discourages the sick role.> Provide safety while encouraging independence,responsibility, and participation.> Provide an approach where there is meaningfuluse of time: No time to wander aimlessly; TV as apersonal preference; Engagement in life so there isno time for problematic behaviors.Summary and ConclusionsThe development of culture change (e.g. Eden Alternative,Pioneer Network, and Wellspring) has presented manyopportunities for the VA NHCU:• Opportunity to understand and manage quality andcosts in a systematic way• Opportunity to shape the reconstruction of the MDS3.0 through partnering with CMS• Social work participation in MDS development isimportant.• Opportunity for applied research from a culture-changeperspective (e.g., the meaningful use of time)• Opportunity to shape nursing home delivery for theVA and beyond• Opportunity to let creativity out of the bag through afocus on well-being

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 27APPENDIX CEvaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementPresenter and Discussant BiographiesMargaret E. Adamek, MSW, PhDMargaret Adamek is the director of the PhD programin social work at Indiana University in Indianapolis, IN.As a member of the first cohort of Hartford Geriatric SocialWork Faculty Scholars, she conducted a study focusingon depression among long-term care residents. Her otherresearch interests include suicide among older adults andmental health policy.Robert Connolly, MS, LCSW-CBob Connolly has worked primarily with quality measurementand quality improvement in nursing homes,hospitals, and home health agencies since beginning hisgovernment service in 1988. Since 2002, Bob has beenthe co-task leader for the Minimum Data Set, Version 3.0(MDS 3.0) design and development team. At CMS he hasdeveloped partnerships with the Department of VeteransAffairs and the Agency for Healthcare Research and Qualityto enhance the MDS development. Prior to coming toCMS, Bob was the assistant director at the Johns HopkinsOncology Center, director of social work geriatrics atUnion Memorial Hospital in Baltimore, and clinical socialwork lead at Children’s Hospital in Oakland, California.Patricia Gleason-Wynn, PhD, LCSWPat Gleason-Wynn is currently a lecturer in the Schoolof Social Work at Baylor University, Waco, Texas. Her primaryarea of interest is gerontology with a particular focuson nursing home social work where she has practiced forover 25 years. She has provided, and continues to provide,consultation to numerous nursing homes and social workersin Texas. She is the current chair of the Committee onAging-National Association of Social Workers Texas Chapter,and the aging delegate from Texas for the 2005 NASWDelegate Assembly.Roberta Greene, PhDRoberta Greene is professor and the Louis and AnnWolens Centennial Chair in Gerontology and Social Welfareat the School of Social Work University of Texas atAustin. She previously was professor and dean at the IndianaUniversity School of Social Work and has worked atthe Council on Social Work Education and the NationalAssociation of Social Workers. Dr. Greene has authorednumerous publications including Resiliency Theory: AnIntegrated Framework for Practice, Research, and Policy;Social Work With the Aged and Their Families; and HumanBehavior Theory and Social Work Practice.Christa M. Hojlo, RN-C, DNSc, NHAChrista Hojlo has been employed by the Department ofVeterans Affairs since 1993. Currently she serves as chiefof nursing home care for the Department of Veterans Affairs,responsible for national policy, quality, planning, andprogramming for the VA’s 133 nursing home programs.Currently she has initiated and provided leadership forthe transformation of the culture of nursing home care inVA nursing homes. Prior to working at the VA she was anursing home administrator in Maryland and taught at theCatholic University of America School of Nursing. She hastaught the Nursing Home Administrator course in Marylandand provided consultation and feedback on the use ofthe MDS for payment to the state of Maryland.Rosalie A. Kane, PhDRosalie A. Kane is a professor of public health at theUniversity of Minnesota, and a faculty member in the Centerfor Biomedical Ethics and the School of Social Work.Her research focuses on long-term care and she served onthe Institute of Medicine’s Committee on Quality of Long-

28 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementTerm Care (1998–2000). She led a 5-year national study onMeasurement, Indicators, and Improvement of the Qualityof Life in Nursing Homes (funded by the Centers forMedicare & Medicaid Services) and a national study onthe Home Care/Assisted Living Connection (funded bythe Home Care Resource Initiative of the Robert WoodJohnson Foundation).Ira R. Katz, MD, PhDDr. Ira Katz is a professor of psychiatry and directorof geriatric psychiatry at the University of PennsylvaniaMedical Center, as well as director of the Mental IllnessResearch Education and Clinical Center of the PhiladelphiaVA Medical Center. He conducts research into thecauses and treatment of depression and other psychiatricillnesses in the aged, especially among those institutionalizedin long-term care settings. He has also explored issuesrelated to delirium and acute cognitive changes amongthe institutionalized aged. He is principal investigator ofan NIMH-supported Center for Interventions and ServicesResearch that is investigating depression in late lifeand psychiatric-medical comorbidity. He also serves on numerousprofessional and scientific societies including theAging Committee of the Group for the Advancement ofPsychiatry, and is past president of the American Associationof Geriatric Psychiatry. He is an associate editor forthe American Journal of Geriatric Psychiatry.Rhonda J. V. Montgomery, PhDRhonda Montgomery holds the Helen Bader EndowedChair in Applied Gerontology at the University of Wisconsin–Milwaukeewhere she is a professor in the School ofSocial Welfare and in the Department of Sociology. Priorto joining the faculty of UWM, she was the director ofthe Gerontology Center at the University of Kansas whereshe also served as the director of the Doctoral Program inGerontology. Throughout her career, Dr. Montgomery hasconducted numerous regional and national studies focusedon public policy, the role of family, and the role of staff inproviding long-term care. She has been the principal or coprincipalinvestigator for more than 20 studies that havebeen supported by private foundations, the Alzheimer’sAssociation, the Administration on Aging, the NationalInstitutes of Health, and the Health Resources ServicesAdministration.Jeane Nitsch, MS, MSW, LCSW-CJeane Nitsch works in the Division of Nursing Homesat the Centers for Medicare & Medicaid Services. Her primaryrole is the development and implementation of nationalpolicies for nursing homes in areas such as physicaland chemical restraints use, abuse and neglect, and otherquality-of-life issues pertaining to survey and certification.Prior to coming to CMS in 1998, she worked as the directorof admissions and social work in a hospital-based subacuteunit. Her experience has primarily been in nursinghomes, as well as continuing care retirement communities,and assisted living facilities. Ms. Nitsch earned a master ofsocial work degree specializing in aging from the MarylandSchool of Social Work, and she holds a master of sciencedegree in Health Care Management from the University ofMaryland University College.Anita G. Panicker, RN, MS, LCSW, MSWAnita G. Panicker works in the Office of Clinical Standardsand Quality at the Centers for Medicare & MedicaidServices (CMS). She is a Licensed Certified Social Workerand Registered Nurse. She brings her management andclinical experience from the hospitals, nursing homes,and residential treatment centers where she worked priorto joining CMS. She has master’s degrees in nursing andsocial work. At CMS she is the lead analyst for nursinghomes. She has experience in writing regulation for nursinghomes, hospitals, hospice, and other providers. Thisincludes researching, evaluating and analyzing the aspectof care, evaluating existing rules, and identifying needs fornew regulations. She has been the project officer for therespiratory therapy study in nursing homes.Ellen Vinkey, MSEllen Vinkey is a team leader in the U.S. Department ofHealth and Human Services Office of Inspector General.Her team is currently beginning an evaluation of woundcareservices to Medicare beneficiaries. In addition to theirrecent work on Medicare psychosocial services, she has performedevaluations on a number of Medicare-related topicsincluding the following: the medical review process utilizedby Medicare carriers, the role of the physician in overseeinghome health services, and access to post-acute servicesafter hospital discharge. She has been with the OIG for 8years. Prior to joining the OIG, she served as a manager inNew York City government. She holds a master of sciencedegree in urban policy analysis from the New School forSocial Research.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 29Betsy Schaefer Vourlekis, PhDBetsy Vourlekis is professor emerita of social work atthe University of Maryland School of Social Work. She iscurrently co-principle investigator on intervention researchprojects testing case management, including screening andbrief treatment for depression and anxiety, to improve adherenceto diagnostic follow-up and adjuvant treatmentin breast and cervical cancer screening and treatment,funded by the CDC and the NIH’s National Cancer Institute.She has served on the NIMH Task Force on SocialWork Research (1988–1991) and chaired the follow-up NationalImplementation Committee (1991–1993). She wasthe project consultant and field researcher for NASW’sClinical Indicator Guideline project that developed qualityimprovement monitoring indicators for social work/psychosocial services in medical and psychiatric hospitals,nursing homes, hospice care, dialysis centers, and homehealth agencies.Joan Levy Zlotnik, PhD, ACSWJoan Levy Zlotnik, PhD, ACSW, has served as the executivedirector of the Institute for the Advancement of SocialWork Research (IASWR) since 2000, working to build socialwork research resources and to translate research topractice, policy, and education. She is actively involved inthe national policy arena, in regard to enhancing the wellbeingof disempowered populations, promotion of behavioraland social science research opportunities, respondingto the demographics of aging, promoting evidence-basedpractices, and in addressing the child welfare workforce crisis.Previously she served as director of special projects andspecial assistant to the executive director at the Council onSocial Work Education, and as staff director for the Commissionon Families and Government Relations Associateat the National Association of Social Workers. She developedand implemented legislative and regulatory strategiesto advocate for prevention and early intervention servicesfor vulnerable children, families, and older persons. Herareas of interest include aging, child welfare, workforce development,building community–university partnerships,and inter-professional and inter-organizational issues.

30 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementAPPENDIX DEvaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementConference ParticipantsMargaret AdamekProfessorIndiana University School of Social WorkElise BeaulieuConsultant, PhD studentSimmons CollegeMercedes Bern-KlugHartford Geriatric Social Work Faculty ScholarUniversity of Iowa School of Social WorkAshley BrooksCo-director, Gero-Ed CenterCouncil on Social Work EducationMirean ColemanSenior Policy AssociateNational Association of Social WorkersMolly DavisAssociate ProfessorGeorge Mason UniversitySusan DavisCommunity Services MentorMeadowlark HillsThomas DuganAdministratorSt. John Vianney CenterSusan EnguidanosDirector, Research CenterPartners in Care FoundationColleen GalambosDirector and Associate ProfessorUniversity of Missouri–Columbia School of Social WorkPatricia Gleason-WynnLecturerBaylor University School of Social WorkJesse HarrisDeanUniversity of Maryland School of Social WorkSara HuntLong Term Care ConsultantIra KatzDirector/Professor of Geriatric PsychiatryUniversity of Pennsylvania, Section on Geriatric PsychiatryPhilip McCallionProfessorUniversity at Albany, SUNY School of Social WorkCarmen MoranoAssociate ProfessorUniversity of MarylandAnn MurfittManager Social ServicesHCR-ManorcareEvvie MunleySenior Health Policy AnalystAmerican Association of Homes and Services for the AgingJeane NitschHealth Insurance SpecialistCenters for Medicare & Medicaid ServicesAnita PanickerOffice of Clinical Standards and QualityCenters for Medicare & Medicaid ServicesWarren PhelpsCoordinator, Quality of LifeRoyal Management of LexingtonHealth Care CentersSusan ReinhardProfessor and Co-directorRutgers, Center for State Health PolicyJudith SanglHealth Scientist AdministratorAgency for Healthcare Research and QualityBarbara SoltSenior Program AssociateInstitute for the Advancement of Social Work Research

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 31Robyn StoneExecutive DirectorInstitute for the Future of Aging ServicesCatherine TompkinsBSW Program DirectorGeorge Mason UniversityDinh TranSocial Service ConsultantWisconsin Department of Health and Family Services,Bureau of Quality AssuranceBetsy VourlekisProfessorUniversity of Maryland, School of Social WorkUniversity of Maryland Baltimore CountyKelly WrightDirector of Social ServicesImmaculate Mary HomeJoan Levy ZlotnikExecutive DirectorInstitute for the Advancement of Social Work ResearchJean BadalamentiFamily Outreach CoordinatorNational Citizens Coalition for Nursing Home ReformWilliam BensonPresidentThe Benson Consulting GroupLinda BergofskySocial Science AnalystU.S. Department of Health and Human ServicesVicki BoyleProject ManagerMPRO (Michigan Health Care Quality ImprovementOrganization)Brenda BustosAdministrative CoordinatorInstitute for the Advancement of Social Work ResearchRobert ConnollyHealth Insurance Specialist, MDS 3.0 Development TeamCenters for Medicare & Medicaid ServicesKristin DayDeputy Director, Social Work ServiceDepartment of Veterans AffairsJavier EvansNational Institute of Mental HealthScott Miyake GeronDirector, Principal InvestigatorInstitute for Geriatric Social Work, Boston UniversityRoberta GreeneLouis and Ann Wolens Centennial Chair in Gerontologyand Social WelfareUniversity of Texas at AustinBernice HarperMedical Care AdvisorU. S. Department of Health and Human ServicesChrista HojloChief, Nursing Home CareDepartment of Veterans AffairsRosalie KaneProfessorUniversity of MinnesotaStuart KauferTBI Waiver Regional Resource Development SpecialistCenter for Independence of the Disabled, New YorkRuth KneeSocial Work PioneersNational Association of Social WorkersRhonda MontgomeryHelen Bader Endowed Professor of Applied GerontologyUniversity of Wisconsin–MilwaukeeCharlotte MullicanSenior Advisor for Mental Health ResearchAgency for Healthcare Research and QualityKaren NeumanAssociate ProfessorVirginia Commonwealth UniversityVivian OmagbemiProgram ManagerMontgomery County Health and Human ServicesLisa PetersonDirector of Social Services and AdmissionsMaplewood Park PlaceStephanie ReedAssociate Director, Government AffairsAmerican Association for Geriatric PsychiatryAnita RosenSenior Projects AdvisorCouncil on Social Work EducationKelsey SimonsDoctoral CandidateUniversity of Maryland, Baltimore, School of Social WorkSidney StahlChief, Individual Behavioral Processes BranchNational Institute on Aging

32 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementJeanette TakamuraDeanColumbia University School of Social WorkRebecca ToniMSW InternInstitute for the Advancement of Social Work ResearchEllen VinkeyTeam Leader/AnalystOffice of Inspector GeneralOffice of Evaluation and InspectionsElizabeth Law WatkinsProfessor Emerita, School of Public HealthUniversity of North Carolina at Chapel HillSheryl ZimmermanProfessor of Social Work and Public HealthThe University of North Carolina at Chapel Hill

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 33APPENDIX EEvaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementInternet ResourcesAging, Health, and Long-Term CareOrganizationsAmerican Association of Geriatric Psychiatryhttp://www.aagponline.org/The American Association of Geriatric Psychiatry(AAGP) is a national association representing and servingits members and the field of geriatric psychiatry. It isdedicated to promoting the mental health and well-beingof older people and improving the care of those with latelifemental disorders. Their website contains resources forfamilies, caregivers, and professionals. Information gearedtoward health care professionals includes fact sheets andresearch overviews on the demographic characteristics ofthe elderly population. It also contains information abouttreating and diagnosing particular mental health challengesfacing the elderly and information about accessing andfinancing mental health care. There is a job bank, fundingopportunity listing, and AAGP fellowship information.American Association of Homes and Services for the Aginghttp://www2.aahsa.org/The American Association of Homes and Services forthe Aging (AAHSA) has a vision of advancing the vision ofhealthy, affordable, and ethical aging services for America.Their website provides an overview of AAHSA’s programsand initiatives such as Quality First. It also provides linksto their various publications, provides information aboutupcoming conferences and events, and maintains a legislativeaction center.This list of resources was developed February, 2004, by theInstitute for the Advancement of Social Work Research,Rebecca Toni, MSW Intern, iaswrintern@naswdc.org,www.iaswresearch.orgAmerican Geriatrics Societywww.americangeriatrics.org/The American Geriatrics Society (AGS) is a nationwide,not-for-profit association of geriatrics health care professionals,research scientists, and other concerned individualsdedicated to improving the health, independence, andquality of life of all older people. The website containssome member specific information as well as sections forthe general public. There are also pages for the educationarena listing educational products and resources, awards,funding opportunities, jobs, and a student section.American Health Care Associationhttp://www.ahca.org/The American Health Care Association (AHCA) is anonprofit federation of affiliated state health organizationsthat represent the long-term care community to the nationat large. The website contains a portion specific to members.The general public can learn more about AHCA,read news updates pertaining to long-term care, and learnabout upcoming events and conferences. The research anddata section contains links to studies conducted on Medicare/Medicaid,staffing, health care liability, surveys, statesummaries, and links to data sources.Gerontological Society of Americahttp://www.geron.org/The Gerontological Society of America (GSA) is a nonprofitprofessional organization dedicated to promoting theconduct of multi- and interdisciplinary research in agingand to disseminating gerontological research knowledge toresearchers, practitioners, and decision and opinion makers.Their website provides information about the organizationas well as the ability to search their journals. There is asection listing grant and research opportunities in aging.

34 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its MeasurementJoint Commission on Accreditation of HealthcareOrganizationshttp://www.jcaho.org/The Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) evaluates and accredits more than15,000 health care organizations and programs in the UnitedStates. It is the nation’s predominant standards-settingand accrediting body in health care. Their website providessome consumer and professional resources such as QualityCheck. There are also links to resources and educationalopportunities. Details about online seminars and otherevents and programs can be found online.National Citizen’s Coalition for Nursing Home Reformhttp://www.nccnhr.orgThe National Citizens Coalition for Nursing Home Reform(NCCNHR) is a group of consumers and advocateswho define and achieve quality for people with long-termcare needs. This is accomplished through informed, empoweredconsumers, effective citizen groups and ombudsmanprograms, promoting best practices in care delivery, publicpolicy being responsive to consumer needs, and enforcementfor consumer-directed living standards. NCCNHR’swebsite provides a wealth of resources including consumerand family information about choosing a nursing home,learning about Medicare’s prescription drug program, orknowing about residents’ rights. There are also resourcesfor ombudsmen, updated fact sheets, detailed informationabout government policy, and online access to their newsletterand other reports and publications.Pioneer Networkhttp://www.pioneernetwork.netThe Pioneer Network advocates and facilitates deep systemchange and transformation in the culture of aging. Toachieve this, they create communication, networking, andlearning opportunities, build and support relationshipsand community, identify and promote transformations inpractice, services, public policy and research, and developand provide access to resources and leadership. Their websiteaccomplishes these aims by providing a discussionboard, job postings, and an event calendar. There are alsolinks to resources such as publications, research, and anonline store.Federal Agencies and ResourcesAdministration on Aginghttp://www.aoa.gov/The Administration on Aging’s (AoA) mission is to promotethe dignity and independence of older people, and tohelp society prepare for an aging population. Their websitecontains resources for the elderly and their families such asan Alzheimer’s resource room and elder rights resources.Information for professionals includes resources about addressingdiversity and statistical information. There is alsoinformation about AoA’s grant program and funding opportunities.Agency for Healthcare Research and Quality (AHRQ)http://www.ahrq.gov/The Agency for Healthcare Research and Quality’s(AHRQ) mission is to improve the quality, safety, efficiency,and effectiveness of health care for all Americans. Theirwebsite provides information divided for consumers andpatients, including clinical information, funding opportunitiesand data, and surveys. There are also links to specificresearch findings, media resources, and quality assessmenttools such as the National Quality Measures Clearinghouseand the Consumer Assessment of Health Plans (CAHPS).Centers for Medicare and Medicaid Serviceshttp://www.cms.hhs.govThe Centers for Medicare and Medicaid Services (CMS)seeks to assure health care security for beneficiaries.CMS Guidance to State Survey Agency Directors and CMSRegional Officeshttp://www.cms.hhs.gov/medicaid/survey-cert/letters.aspCMS memoranda, letters, and instructions to StateSurvey Agency Directors and CMS Regional Offices areposted here by category.CMS MDS 3.0http://www.cms.hhs.gov/quality/mds30/The information posted on this site is intended toassist nursing homes, state agencies, software vendors,professional associations, and other federal agencies inthe activities underway to refine and evaluate the MDS.It includes a section for providing feedback and othermaterials for public comment.

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 35CMS Nursing Home Quality Initiativehttp://www.cms.hhs.gov/quality/nhqi/Provides links to information specific to nursinghome quality initiatives. There are also links to informationabout quality measures, information about choosinga nursing home, and links to the nursing homecompare website.CMS Open Door Forum on Skilled Nursing Facilities andLong-Term Carehttp://www.cms.hhs.gov/opendoor/snf-ltc.aspThese forums address the concerns and issues ofthe Medicare SNF, the Medicaid NF, and the long-termcare industry generally, including the Long-Term CareHospital PPS. The types of issues that come up duringthese forums are often related to the Minimum DataSet, SNF Consolidated Billing, the roles and responsibilitiesof different SNF, NF or LTC professional staffunder CMS regulations, clarifications of issues that arecovered during a survey and certification process, andthe many rules and requirements under which differentrelated services can be payable. Links to informationabout schedules and registration are found here as well.CMS Quality Initiativeshttp://www.cms.hhs.gov/qualityThis page provides links to a few of CMS’ variousquality improvement efforts. This includes informationabout quality initiatives in general and links to data collectionsuch as MDS 3.0.CMS State Operations Manual Appendiceshttp://www.cms.hhs.gov/manuals/107_som/som107_appendixtoc.aspThis page contains links to documents found in theappendix of the State Operations Manual. These documentsgive specific guidance for issues such as providingintermediate care to persons with mental retardation orinterpretive guidelines for long-term care facilities.Nursing Home Comparehttp://www.medicare.gov/nhcompareThis site allows consumers and professionals tolearn about the past performance of every MedicareandMedicaid-certified nursing home in the country.Nursing homes can be searched by geography,proximity, or name.Department of Veterans Affairshttp://www.va.gov/The goal of the Department of Veterans Affairs (VA) isto provide excellence in patient care, veteran benefits, andcustomer satisfaction.Patient Education and Family Materialshttp://www1.va.gov/GeriatricsSHG/page.cfm?pg=27This website provides links to more specific informationfor patients and families. This informationspans topics such as the role of the caregiver, workingwith bureaucracies, aggressive behavior, and financialand legal advice.VA Social Workhttp://www1.va.gov/socialwork/This site has information for veterans, their families,the public, social work students, and prospectiveemployees. It contains general information about whatsocial workers do and how to contact a VA social worker.There are also links to social work resources and informationabout educational opportunities at the VA forstudents.Veterans Health AdministrationGeriatrics and Extended Care Strategic Healthcare Grouphttp://www1.va.gov/geriatricsshg/The Geriatrics and Extended Care Strategic HealthcareGroup advances quality care for aging and chronicallyill veterans by providing policy direction for thedevelopment, coordination, and integration of geriatricsand long-term care clinical programs. This siteprovides links to their various programs such as homeand community based long-term care, VA nursing homecare, and hospice and palliative care. They also providea VA facility locator search engine, links to handbooksand directives, and a schedule of upcoming educationalevents.National Institute on Aginghttp://www.nia.nih.govThe National Institute on Aging’s (NIA) mission is toimprove the health and well-being of older Americans bysupporting and conducting research, training researchers,developing resources, and disseminating information.Their website contains links to publications and informationabout research sponsored by and conducted at NIA. Italso contains a link to the NIH Senior Health site, which

36 Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurementis oriented toward seniors and has information addressingvarious health concerns. There are also links to informationabout grant and training opportunities.National Institute of Mental Healthhttp://www.nimh.nih.govThe mission of the National Institute of Mental Health(NIMH) is to reduce the burden of mental illness and behavioraldisorders through research on mind, brain, andbehavior. Their website provides links to news, researchfindings, health information, and funding opportunities.Geriatrics Research Branchhttp://www.nimh.nih.gov/datr/a4-gp.cfmThe Geriatrics Research Branch supports programs ofresearch, research training, and resource development inthe etiology and pathophysiology of mental disorders oflate life, the treatment and recovery of persons with thesedisorders, and the prevention of these disorders and theirconsequences. Their site provides links to informationabout the various branch programs subsumed in this division.Office of Inspector General, Department of Health andHuman ServicesReport: Psychosocial Services in Skilled Nursing Facilitieshttp://oig.hhs.gov/oei/reports/oei-02-01-00610.pdfThis website links to a pdf file containing the completeOIG report.Social Work OrganizationsCouncil on Social Work Educationhttp://www.cswe.orgThe Council on Social Work Education (CSWE) is anational association that preserves and enhances the qualityof social work education for practice that promotes thegoals of individual and community well-being and socialjustice. Their website provides access to various resourcesincluding publications and social work links. The websitealso offers access to information about their various projectsand programs such as SAGE-SW and the Gero-EdCenter.Hartford Geriatric Social Work Initiativehttp://www.gswi.orgThe Geriatric Social Work Initiative site provides informationabout the many resources available to social workersin geriatrics. It lists funding opportunities, educationalresources, job opportunities, upcoming events, scholarshipopportunities, and detailed links and information for newresearchers.Institute for the Advancement of Social Work Researchhttp://www.iaswresearch.org/The Institute for the Advancement of Social Work Research(IASWR) strives to strengthen the connections betweenresearch and policy and practice, build the researchcapacity of the profession, and advance the knowledge basethrough social work research. The website will provide accessto information from the conference such as these webresources and the information contained in the briefingbook. It also provides access to various publications, links toresources and information, about funding opportunities.Institute for Geriatric Social Work—Boston Universityhttp://www.bu.edu/igsw/index.htmlThe Institute for Geriatric Social Work is dedicated toadvancing social work practice with older adults and theirfamilies. Their website provides access to information abouttraining and educational opportunities. This includes informationabout their small-grants program and distancelearningcourses. They also provide access to publications,information about research and advocacy opportunities,and links to related information sources.National Association of Social Workershttp://www.socialworkers.orgThe National Association of Social Workers (NASW) isa membership organization of professional social workers.NASW works to enhance the professional growth and developmentof its members, to create and maintain professionalstandards, and to advance sound social policies.NASW Clinical Indicators for Social Work and PsychosocialServices in Nursing Homeshttp://www.socialworkers.org/practice/standards/nursing_homes.aspThis site connects to an online publication of ClinicalIndicators for Social Work and Psychosocial Services

Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement 37in Nursing Homes. The clinical indicators are dividedinto process and outcome indicators. Process indicatorsinclude timely psychosocial assessment, comprehensivepsychosocial assessment, resident involvement in careplanning, and family involvement in care planning.Outcome indicators include resident satisfaction withchoice and problem resolution.NASW Standards for Social Work Services in Long-Term CareFacilities.http://www.socialworkers.org/practice/standards/NASWLongTermStandards.pdfThis site connects to a pdf. file containing this publication.The document details 11 standards such asethics and values, staffing, professional development,documentation, and cultural competence.Society for Social Work and Researchhttp://www.sswr.orgThe Society for Social Work and Research is a professionalmembership organization dedicated to advancing socialwork research and to assisting novice and experiencedresearchers in a variety of ways. Their website provides informationabout their annual conference, award opportunities,and provides membership-specific areas. There arealso links to relevant websites and job postings.

INSTITUTE FOR THEADVANCEMENT OFSOCIAL WORK RESEARCHThe mission of the Institute for the Advancement ofSocial Work Research (IASWR) is to advance the scientificknowledge base of social work practice by enhancing theresearch capacity of the profession; to promote the use ofresearch to improve practice, program development andpolicy; to strengthen the voice of the profession in publiceducation and public policy determinations by ensuringthat social work is represented within the nationalscientific community. IASWR fulfills this missionthrough expanding opportunities for social work research,preparing social work researchers, disseminating findingsto inform policy, representing the profession in scientificand policy communities, and establishing linkages withother related disciplines.