Comments to CMS on Nursing Home Social Work

Comments to CMS on Nursing Home Social Work

Long-term Care – HPA45

 The National Association of Social Workers, CT Chapter representing over 2,400 members offers the following comments on HPA45. We understand that the focus of HPA45 is nursing, however we offer this document to help CMS understand the urgent need to also address social work services in long-term care facilities. The positive steps Connecticut has taken on long-term care social work services can be a roadmap for CMS.

 The social worker is the sole professional in the home responsible for the psycho-social needs of the 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 the current ratio. The existing ratio 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. In CT 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. In one CT facility two social workers told me that they are working 42-50 hours per week and they are responsible for 60 beds each, not 120 as was allowed in CT prior to January 1, 2022. Nursing home social workers are front line essential workers that too often are forgotten by policy makers.

 We estimate that under the previous CT ratio of 120/1 with 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.

Ratios of social worker to beds needs to be no more than 1 worker to 60 beds.

The lack of social work training also must be changed to require at minimum a baccalaureate trained social worker. In 2014 CT executive branch agencies went to preference in hiring of baccalaureate (BSW) and master (MSW) trained social workers for the state classification of social worker. It proved so successful that in 2019 the State of Connecticut codified the preference for all state social worker classified positions. The reason the State of Connecticut did this was that client outcomes improved, as did productivity and professionalization of staff. Equal results will occur in long-term care facilities.

It is a travesty that CMS allows non-social work trained persons to be employed as long-term care social service workers. Nursing home residents are amongst the most vulnerable of persons and they deserve professional social workers working with them. Families of long-term care residents deserve the same quality of worker.

To summarize: CT staffing ratio is now 1 social worker for every 60 beds. CT requires the social worker to have at minimum a BSW degree (related degrees are not allowed). CMS should use CT as a model for social work long-term care regulations. We urge CMS to propose adequate training and ratios for social work services in long-term care facilities.

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