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Professional Social Workers in the Nursing Home

      The International Federation of Social Work defines social work as “a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversities are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledges, social work engages people and structures to address life challenges and enhance wellbeing” (“Global Definition of Social Work,” IFSW, July 2014, https://bit.ly/3TsJszN). Social work practice is also shaped by a professional code of ethics that focuses on person-directed care and competent practice that supports ethical decision-making when there are conflicts of interest.

      Regulations Do Not Require Professional Social Workers

      Nursing homes are required to provide residents with the “highest practicable physical, mental, and psychosocial well-being,” which the Centers for Medicare & Medicaid Services defines as “the highest possible level of functioning and well-being, limited by the individual’s recognized pathology and normal aging process” (CMS Manual System, Pub. 100-07, Provider Certification, Dec. 12, 2014, https://go.cms.gov/3SgZooA).
      Yet CMS does not require nursing homes to have a social worker unless they have more than 120 beds, and even then CMS does not require the person in the social work capacity to have a social work degree (42 CFR § 483.40). Researchers found that more than 70% of nursing homes in the United States are not required to employ a social worker, and an estimated 42% of nursing homes have someone in the social service director position who has no social work training (J Gerontol Soc Work 2021;64:699–720). Furthermore, despite the social worker being an integral part of the interdisciplinary team (IDT), CMS does not require that the social worker be part of the IDT (42 CFR § 483.21 9b) (2)).

      Professional Social Workers Are Uniquely Trained

      The dual micro/macro focus of social work education prepares social workers to be key contributors to multiple processes in the nursing home. Social work programs accredited by the Council on Social Work Education must prepare students to be competent in engaging, assessing, intervening, and evaluating practice with individuals, families, groups, organizations, and communities (2015 and 2022 Educational Policy and Accreditation Standards are available at https://www.cswe.org/accreditation/standards/2022-epas/). The overarching framework taught in social work is an ecosystems framework with a strengths perspective.
      Program evaluation and research competencies are also part of social work education. CSWE calls for programs to prepare students to engage in practice-informed research and research-informed practice, the type of skills that are needed to lead process improvement plans around behavioral health and psychosocial care.
      Although scope of practice is determined by individual state licensing boards, it always includes tasks that “promote health, well-being, and justice for all people in a diverse society” with an emphasis on those who are “vulnerable, oppressed, and living in poverty” (National Association of Social Workers, “Code of Ethics,” rev. 2021, https://bit.ly/3LNrPrS). Whether due to cognitive and/or physical frailty, nursing home residents are certainly considered to be a vulnerable population.

      Social Workers Impact Resident Well-being and Outcomes

      Social workers can provide leadership and program implementation at all points of care for behavioral health and well-being. From identification of expressions of distress to assessment, provision of care and services, and care planning, a professional social worker is trained in these areas. Social workers communicate with families regarding changes in condition, revisions to the care plan, discharge planning, and trauma-informed care.
      They also collaborate with the IDT and the medical provider about family concerns, resident history that may pose barriers to pain management and the treatment plan, financial issues, advance care planning, and end-of-life care. Thorough and defensible social work documentation supports the plan of care, optimizes person-directed care, and manages risk. Social workers identify grievances and provide competent accountability and resolution, which increases resident and family satisfaction with the latent benefits of decreased survey deficiencies and perhaps lawsuits. Many of these areas are specifically addressed in F745 Medically Related Social Services.
      Social workers also impact resident well-being by supporting staff with training on resident rights, abuse and neglect, trauma-informed care, communication, behavioral health, advance care planning, and grief and loss. They can participate in the Quality Insurance and Performance Improvement (QAPI) process by helping design, implement, and manage process improvement projects. They can help position the nursing home as an outstanding community partner by liaising with local associations and agencies. They can support a robust offering of services that might include support groups, councils, and outreach.
      Providing care that supports best practices and meets standards of care while upholding an ethical framework is integral to quality of life and quality of care for all nursing home residents. Screening, assessing, and intervening in emotionally charged and usually complex areas such as coping with change and loss, advance care planning and end-of-life care, mental illness, and trauma require staff with appropriate training, knowledge, and skills.
      Expecting an individual to engage in this level of care without the appropriate requisites is unacceptable. An analogy would be allowing a nurse to administer treatment that is outside their scope of practice, such as providing wound care without training and experience. The time has come to acknowledge that it is necessary to staff a professional social worker in every nursing home to ensure that all residents and patients receive the psychosocial care they need and deserve.

      How to Support the Role of the Professional Social Worker

      As leaders in nursing homes, medical directors and attending providers can advocate to administration for a robust professional social work staff to meet the psychosocial and behavioral health needs of all residents and patients, no matter the number of beds in the facility. Collaborate with the social workers and social services staff by acknowledging their expertise and skills. Recognize and endorse the value of the contribution of professional social workers, and support them to use their knowledge, expertise, and skills for the benefit of residents and the success of the facility. Because you are leaders, others in the facility will follow your example.
      Ms. Hector is an author, speaker, and educator specializing in clinical operations for the interdisciplinary team. She is associate editor and a member of the Editorial Advisory Board for Caring for the Ages.
      Dr. Kusmaul is an associate professor in the Baccalaureate Social Work program at the University of Maryland, Baltimore County. She was a nursing home social worker for more than a decade and is co-chair of the NASW-Maryland Committee on Aging and a fellow of the Gerontological Society of America.

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