Professional  Social Work Services in Skilled Nursing Facilities

Survey of Current Practice and Recommendations

In few areas is there such a chasm between what is required by federal law and what actually occurs than in the delivery of mental health and psychosocial services to the vulnerable residents of the nation’s 17,000 skilled-nursing homes (SNFs). In addition, the role of professional social workers in the delivery of such services often has been misunderstood. The authors undertook a project to survey programs, regulation, and literature to assess current practice and staffing within nursing homes for mental health and social work services. The following is a summary of the project.

The Omnibus Budget Reconciliation Act of 1987 (OBRA, P.L. 100-203, the "Nursing Home Reform Act"), passed by an overwhelming vote of Congress, requires a broad range of mental health and social services for the nation’s 1.6 million nursing home residents. However, because of lack of clarity regarding social work practice domains, weak enforcement of regulations, inadequate funding, and industry resistance, residents of most facilities are receiving minimal psychosocial services, often provided by untrained staff, even though 70 percent to 90 percent of SNF residents have some type of mental health or cognitive problem.

Project Findings

Definitions

OBRA requires a qualified social services director in SNFs with more than 120 beds. To the Health Care Financing Administration (HCFA, 1995), the federal agency charged with enforcement of OBRA, qualified means an MSW or supervised BSW from an accredited social work school, or a bachelor’s degree in a related field such as special education or rehabilitation counseling. In practice, almost any degree is acceptable and there is no differentiation between of education, certification, licensing or appropriate professional expectations.

SNFs with 120 or fewer beds are not required to have qualified social workers on staff, although they are required to provide mental health and psychosocial services (HCFA, 1995). Some states have regulations that are more stringent than those of the federal government.

Five types of social services providers work in SNFs: (1) licensed clinical social workers (master’s level or above); (2) consultants, usually clinical social workers who either provide direct service to residents or supervision to social services staff;(3) bachelor’s-level social workers; (4) those with a bachelor’s degree in another field who are deemed "social service designees"; and (5) those without any degree, often with little training, who have been "grandfathered" into a "social services designee" position.

Enforcement and Compliance

There is extreme variation in compliance with HCFA regulations regarding psychosocial services depending on state enforcement, attitude of the HCFA regional office, and availability of qualified social workers. Some SNFs have social work staff headed by a licensed social worker with an MSW degree. Others hire people with any degree from newspaper advertisements; assign a nursing aide or licensed practical nurse to provide psychosocial services; periodically hire consultants to handle mental health and behavioral problems; or combine the activities and social services functions, assuring that neither will be done adequately (O’Neill, 1998).

Social workers complain that enforcement of regulations is so indifferent that much of the mental health and psychosocial agenda outlined in OBRA is being ignored. Enforcement of HCFA guidelines is so lax that there is little penalty if facilities flout the regulations. Studies show that there are fewer fines than in past years. "Deficiencies in the new statutory areas of residents’ rights and quality of life are virtually ignored by the enforcement system. And, in practice, few enforcement actions are actually taken so that compliance with the 1987 nursing home reform law remains largely a voluntary matter" (National Senior Citizens Law Center, 1998, p.1) Enforcement strategy has shifted so that fines are not levied when violations are found but only after warnings are issued and nursing homes do not remedy problems (Rudder & Phillips, 1998). Fines are small, and the numbers issued are decreasing.

SNFs developed from the medical model, which emphasizes a minimum quality of care, with little thought and effort given to quality of life, mental health, or psychosocial needs, according to experts (Kane, 1996). Patients often suffer from loneliness, helplessness, and boredom (Thomas, 1994). Nursing aides, low-paid people with minimum training who often speak a different language and come from a different culture than residents, have between 80 percent and 90 percent of interactions with patients (American Association of Retired Persons [AARP], 1993). They have no time and few skills to interact with or nurture residents.

Staffing

When staffing levels are examined, it is clear that physical care is considered far more important than mental health and psychosocial well being. The total amount of staff time per resident day in SNFs is 5.7 hours, the vast percentage given to physical care. Nursing care represents 60 percent, or 3.4 hours per resident-day; housekeeping represents 13 percent, or 46 minutes per resident-day; dietary personnel, 12.5 percent, or 43 minutes per resident-day; administrative staffing, 4.9 percent, or 17 minutes per resident-day; activities staff, 2.8 percent, or 10 minutes per resident-day; physical therapists and their aides, 2.6 percent, or nine minutes per resident-day; social workers, including professionals and social work staff, account for 1.8 percent, or six minutes per resident-day; occupational therapists and their aides, 1.4 percent of total time, or five minutes per resident-day; speech pathologists, 0.5 percent, or two minutes per resident-day; and physicians, pharmacists, mental health practitioners, podiatrists, and dentists, all less than one minute per resident-day (Harrington, Zimmerman, Karon, Robinson, & Beutel, 1997).

The figures above indicate that social workers, the only staff people in SNFs who may have specific education and training to assess and provide for mental health and psychosocial care, have but six minutes daily for each resident. To compound the problem, many of the social service providers are "social services designees" who have no social work training. Some of these designees do not have college degrees. Other professions are not treated in the same way. For instance, there are no "nurse designees" or "administrator designees"; nurses and administrators need education, experience, credentials and licenses to help ensure quality.

Neither HCFA or any other government agency has surveyed SNFs to determine the number, training, or credentials of "social workers" and "social services designee" staff positions in HCFA-certified SNFs. HCFA has not seriously attempted to clearly define the scope of practice and credentials of those providing "social services," medical social work, and clinical social work in SNFs ("Final Rule," 1998; O’Neill, 1998).

A logical place to begin to enhance mental health and psychosocial services is with trained and educated social workers. There is no other profession whose members are trained to handle the functions required by HCFA’s OBRA mandate: to assess and treat mental health needs and to enhance quality of life. The education of professional social workers seeks to prepare them to carry out these functions, including providing psychosocial services and counseling to patients and their families and to afford residents dignity when they are dying.

A national conference of 130 experts on aging and mental health in SNFs made three major recommendations: (1) increase staff training on mental health and behavioral problems, (2) retain a mental health coordinator for every nursing home to provide training on care of individuals with mental illness and to develop prevention programs to foster a culture of mental wellness, and (3) use a comprehensive approach to treating residents with mental and behavioral problems that makes use of activities, nursing interventions, and family involvement, as well as medication (Emerson Lombardo, 1994). These are the types of functions that professional social workers are educated and trained to do.

Additional evidence of the paucity of mental health and psychosocial services comes from an AARP-sponsored telephone survey of 369 SNFs (Emerson Lombardo, 1994). The study found that 2.3 percent of SNFs had a psychiatrist on staff, and 31.5 percent more had one under contract; 3.4 percent had a psychologist on staff, and 21.9 percent had one under contract; and 11.8 percent had a clinical social worker (master’s level) on staff, and 13.0 percent had one under contract. The problem is that these mental health professionals under contract are seldom consulted. Regular and timely referrals to mental health specialists are not part of regular nursing home practice. Directors of nursing reported that 24 percent of SNFs made referrals weekly, and 28 percent said they were made monthly. Thus, in just under half of SNFs surveyed, referrals occurred less than once a month.

Psychosocial Services and Quality of Life

Looking at the level of mental health services provided in SNFs compared to the prevalence of mental illness, it is obvious that facilities are not complying with the letter or intent of OBRA. For more than half of nursing home residents, mental and behavioral symptoms are the primary cause of their disability, so their identification and treatment are an essential part of primary care. Data from the National Nursing Home Survey showed that 2.3 percent of residents had contact with a mental health professional in the prior month, and 2.2 percent received some mental health attention from a general physician. This contrasts with a diagnosis of mental disorder for two-thirds of residents: 51 percent with dementia, 4 percent with schizophrenia/other psychosis, and 11 percent with other mental disorders such as depression and anxiety. Only 17 percent of residents diagnosed with schizophrenia had seen a mental health professional. The most likely treatment is psychotropic medication, often prescribed inappropriately by general practitioners (Burns & Taube, 1990; Burns et al., 1993).

A study of 3,262 seriously ill hospitalized adults found that 30 percent said they would "rather die" than live permanently in a nursing home; 26 percent were very unwilling to live in a nursing home; 11 percent were somewhat unwilling; 19 percent were somewhat willing; and 7 percent were very willing (Mattimore et al., 1997). Figures like these indicate the low regard of elderly people for SNFs, perceptions that must be based, at least in part, on their knowledge of quality of life in SNFs.

A study of social services workers and nurse aides in a southeastern state showed that nurse aides knew more about common mental and behavioral problems than did the social services workers (Tirrito, 1996), a finding not surprising considering the minimal level of training of those providing social services. This is a strong argument for hiring professional social workers to do social work in SNFs.

Social workers and consultants interviewed agree with a federal study (U.S. Department of Health and Human Services, 1996) that social workers often lack time to perform needed psychosocial services, even when they have the level of education and skill to deliver them. There are heavy paperwork burdens and different expectations of them depending on administrators’ knowledge of social work functions.

Social work administrators and consultants say a bachelor’s - level social worker can be hired in a nursing home for $20,000 to $30,000 annual salary. Master’s-level social workers can be engaged for $30,000 to $35,000. For BSWs, this is not substantially different than the $11.62 per hour (about $24,000) average compensation for a "social services coordinator" from an industry survey (Fisher, 1997).

The figures developed by Harrington et al. (1997) of six minutes per resident per day for social work services indicate that there is one social services provider for every 80 nursing home residents, assuming a 40-hour work week. The education and background of those providing this service are unknown. This means that there are 20,000 social services providers in SNFs. The number of SNF residents could triple to 4.6 million in the next 40 years (Gutheil, 1990), meaning another 40,000 social services providers will be needed in the nation’s SNFs. What will be their preparation and professional training? What kinds and quality of service will these persons be providing?

Research and Policy Implications

There are obvious policy issues that needed to be decided. There is the question of whether the public will tolerate lack of mental health and psychosocial services where there is such obvious need. Another question is whether it is reasonable or just to have uneducated, untrained people providing social services when SNFs could hire qualified, licensed social workers who are trained mental health professionals.

The State of Maryland commissioned a study (Booz-Allen & Hamilton, 1987) to determine the minimum qualifications needed to perform social services jobs effectively. The findings strongly supported high educational levels, saying that overall performance of MSWs was significantly higher than non-MSWs. A similar study of social workers in SNFs might yield similar findings.

Research Issues

Some research issues suggested by this project include:

• The need for a survey of the credentials, qualifications, and scope of practice of social services designees and those holding social work positions in SNFs;
• Outcomes research, based on psychosocial criteria, that address the effect on quality of life and quality of care by various levels of professional social workers in SNFs?;
• Clear definition of the scope of practice and staffing levels necessary to address OBRA’s Nursing Home Reform law regulations regarding mental health and quality of life; and,
• The availability of qualified social workers to staff SNFs; also how long it would take to obtain a sufficient number of BSW and MSW graduates with gerontological training.

Policy and Advocacy Issues

Some policy and advocacy issues suggested by this project include:

• Adequate enforcement of OBRA’s requirements for quality of life and mental health services;
• Clear delineation of scope of practice issues by HCFA in relation to education and credentialling for social services, social work, medical social work, and clinical social work;
• Expansion of the availability and access to clinical social work consulting services for nursing home residents and staff; and,
• Attention to the substantial mental health needs of SNF residents by policymakers, payors and regulators.

References

American Association of Retired Persons. (1993). Nursing home life: A guide for residents and families. Washington, DC: Author.

Booz-Allen & Hamilton (1987). The Maryland Social Work Services Job Analysis and Qualifications Study, prepared for the Department of Human Resources of the State of Maryland.

Burns, B. J., Wagner, H. R., Taube, J. E., Magaziner, J., Permutt, T., & Landerman, R. (1993). Mental health service use by the elderly in nursing homes. American Journal of Public Health, 83, 331-337.

Burns, B. J., & Taube, C. A. (1990). Mental health services in general medical care and in nursing homes. In B. S. Fogel, A.

Furino, & G. L. Gottlieb (Eds.), Mental health policy for older Americans protecting minds at risk (pp.63-84). Washington, DC: American Psychiatric Press.

Emerson Lombardo, N. B. (1994). Barriers to mental health services for nursing home residents. Washington, DC: American Association of Retired Persons, Public Policy Institute.

Final rule. (1998, April 23). Federal Register, pp. 20110- 20131

Fisher, C. (1997, December). Creating career paths in long-term care. Provider (The Journal of the American Health Care Association), pp. 24-27.

Gutheil, I. (1990). Long-term care institutions. In A. Monk (Ed.), Handbook of gerontological services (2nd ed.). New York: Columbia University Press.

Harrington, C., Zimmerman, D., Karon, S. L., Robinson, J., & Beutel, P. (1997). Nursing home staffing and its relationship quality. Madison: University of Wisconsin, Center for Human Health Systems Research and Analysis.

Health Care Financing Administration. (1995). Survey procedures for long-term care facilities: State operations manual. Baltimore: Author.

Kane, R. A. (1996, July). Assuring quality of life in nursing homes: Regulatory strategies. Paper commissioned by the Health Standards and Quality Bureau, Health Care Financing Administration for "Improving Quality of Life for Nursing Home Residents: The Challenge and the Opportunities," Baltimore.

Mattimore, T. J., Wenger, N. S., Desbiens, N. A., Teno, J. M., Hamel, M. R., Lie, H., Califf, R., Connors, A. F., Lynn, J., & Oye, R. K. (1997). Surrogate and physician understanding of patients’ preferences for living permanently in a nursing home. Journal of the American Geriatrics Society, 45, 818-824.

National Senior Citizens Law Center. (1998, February). A study of enforcement under the nursing home reform law funded by the Commonwealth Fund. Nursing Home Law Letter, Issue 1-2, February 13.

Omnibus Budget Reconciliation Act of 1987, P.L. 100-203, 101 Stat. 1330.

O’Neill, J. (1998). [Informal telephone survey of SNF administrators, directors of social services, and HCFA contractors].

Rudder C., & Phillips C. D. (1998). Citations and sanctions in the nursing home enforcement system in New York State: Their use and effects. Generations, 21(4), 25-29.

Thomas, W. (1994). The Eden Alternative: Nature, hope and nursing homes. Sherburne, NY: Author (Available from Eden Alternative, RR1 Box 3134, Sherburne, NY, 13460, 607-674-5232 (tel.),

Tirrito, T. (1996). Mental health problems and behavioral disruptions in nursing homes: Are social workers prepared to provide needed services? Journal of Gerontological Social Work, 27, 73-86.

U.S. Department of Health and Human Services, Office of Inspector General. (1996). Mental health services in nursing facilities (OEI-02-91-00860). Washington, DC: Author.