Comments and Recommendations on Nursing Home Social Work

Comments and Recommendations on Nursing Home Social Work.

The Nursing Home and Assisted Living Oversight Work Group.

December 2, 2020

Submitted By: Stephen Wanczyk-Karp, LMSW


On behalf of the National Association of Social Workers, Connecticut chapter, representing over 2,300 members, we submit this document on nursing home social work, an area of nursing home care that is rarely addressed.

It is the nursing home social worker who has primary responsibility for the resident’s psychosocial health and is the advocate for families when concerns arise. This is a significant aspect of nursing home care that has gone from difficult to nearly impossible to adequately deliver in this pandemic.

The Public Health Code is woefully inadequate when it comes to the beds-to-worker ratio for social work services. The current ratio of 120 beds to 1 full-time social worker dates back well over 30 years and bears no resemblance to a reasonable ratio for the current nursing home population. In essence, we are using a 20th century ratio to address 21st century needs of nursing home residents.

In the past 20 years the presenting issues by individual’s entering nursing homes has become much more acute in terms of complex diagnosis and mental health status. At the same time, there has been a significant increase in short-term, rehabilitative stays that has increased the workload of the social worker. The degree of care now needed demands far greater attention by the nursing home social worker, yet the staffing ratio for nursing home social work has not been adjusted in accordance with these changing needs.

Prior to Covid-19 nursing home social workers faced multiple tasks and responsibilities including but nowhere near limited to: prompt referral for patients and families in financial need, helping each patient to adjust to the social and emotional needs related to nursing home placement, family meetings, care plan meetings, staff meetings, developing plans of care for the social and emotional needs of the resident, counseling residents and family members, discharge planning, coordinating care with outside services, assisting with Money Follows the Person, dealing with issues of conservatorship, protecting resident rights, assessing cognitive and mental functioning, dealing with resident to resident altercations, providing emotional support for residents coping with loss of independence and function, and staff training on resident rights. Then add an increasingly extensive amount of paperwork that includes: assessments; care plans; Mini Mental Status Exams; MDS (Minimum Data Set) done upon admission, quarterly, annually and when a change in condition occur, Medicaid clinical evaluations, plus medical record charting of any changes with the resident. All of this and more is required of the social worker at a ratio of 1 full-time social worker (forty hours) to 120 residents. The current ratio is absurd, outdated, undoable, and downright insane, and is a major factor in why qualified social workers burn out and leave the field of nursing home social work.

 Now we add in the impact of Covid-19 on nursing home social workers. The social worker is often the primary contact between family members and the resident. The social worker is finding ways to help families to virtually meet the staff and view the facility that their loved ones are residing in. Family concerns and resident’s isolation requires significant amounts of time for the social worker. Social workers are managing increased levels of depression by residents and anxiety of family members. Social workers are arranging for virtual meetings between the resident and family that requires creativity on the social workers part and being present for one resident while others with similar needs are not being met. Moving a patient’s room due to the need for isolation often falls on the social worker to explain to the family. Plus, other staff seek assistance from the social worker as the work being performed is incredibly difficult. It is common for the facility staff to call the social worker at home, at all hours, for advice and guidance. Sometimes the social worker is called upon to assist with direct care because there is no other staff to help. Residents waiting for MFP often seek from the social worker information on where their case stands but the social worker cannot reach DSS workers who are working remotely. We have had numerous reports of insufficient PPE. Documentation has suffered despite state regulations regarding up to date charting and the importance of such charting for patient care. Two social workers told me that they are working 42-50 hours per week and they both are responsible for 60 beds, not 120. Nursing home social workers are front line essential workers that too often are forgotten by policy makers.

 We estimate that under the current ratio and given just the pre-Covid-19 responsibilities of nursing home social workers that the social worker has about 11 minutes per week to address individual resident’s concerns and needs. In the spring of 2010 NASW/CT conducted a survey of all nursing home social workers that had a 50% return rate. When asked what their biggest challenges were 72% answered it was lack of time to effectively perform their job.

 Under Money Follows the Person and other steps to balance the long term care system in Connecticut, it is the social worker who plays the key roles of identifying appropriate residents for discharge to the community, working with the resident and family to overcome obstacles, and frequently it is the social worker who arranges for a safe discharge with the necessary services in place. It is absolutely the right thing to do in putting an emphasis on rebalancing, however for rebalancing to continue to be successful, post pandemic, it is critically important that the nursing home social worker have the time to fully address the various issues and tasks that arise in returning a resident to their community.

Amending the state regulations on the nursing home ratio is a process that will take years in the making thus the answer is a legislative remedy. The National Consumer Voice for Quality Long-Term Care proposed to CMS that every facility employ at least one full-time social worker for every 50 long-stay residents and at least one full-time social worker for every 15 short-stay residents.  NASW/CT recommends a ratio of 60 residents to 1 full-time social worker, with each facility having at least one full-time social worker. Such a ratio is the only way to assure that person centered care plans for the social/emotional needs of nursing home residents will be met, and the corresponding family work can be accomplished. It is way past time for CT to adopt a realistic ratio of beds to social worker.

For those nursing homes that have a social worker to bed ratio at or close to 1/60 the NASW/CT recommendation will have little to no impact. It is those homes that are at, or just above the minimum ratio that must be deemed by the Oversight Group as having unacceptable social work staffing. A recommendation by the NHALOWG of a 1/60 ratio will go a long way to public recognition that a problem exists that must be rectified.

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