Nursing Home Social Services Reference/Flow of Care/Intake

Intake After a resident is admitted, there is a time when the key elements of their medical chart are completed. This is called the intake process. All of the pre-admission and admission paperwork is available for review and nurses, doctors, activities and social services begin their entries into the chart. These initial assessments confirm or offer more details to fill out the impression of the client at admission. A care plan specific to the resident in the facility is created. Nursing, social services and activities create this. Assessments are completed for this point in time and to provide a baseline. Social services asks questions to assess and help residents with adjustment to the facility or to being in a nursing home. This process integrates the resident and their medical needs into the nursing schedules and procedures, their social engagement and attentional needs into the activities program and their social, behavioral and emotional needs into the social services system. This includes care conference schedules, assessment schedules, and psychpharm reviews. An Minimum Data Set (MDS) entry is created at this time to capture these impressions for CMS reporting. This captures or summarizes this baseline review. The MDS is typically coordinated by an MDS coordinator. An RN is required to sign off on these entries. To complete this for the social services pieces, sections C, D, F and Q. For more info see: https://www.socialworkers.org/assets/secured/documents/practice/aging/WKF-MISC-51310.AgingPU.PDF Cognitive Assessment This information is summarized in MDS section C. The social services worker can use several tools to help assess this aspect of residents well-being. This will be important for activities and nursing to adjust their interactions and expectations. The most important tool is a Mental Status exam. There are several of these with various levels of precision. Some of these require a subscription and many are free. The classic, MSSE costs money to use. Of the free instruments, the SPMSQ offers a quick assessment with minimal questions and interaction. It is not very precise and is insufficient for the MDS. The MDS offers the BIMS which is also short and not very precise but offers a general sense of the cognitive ability of the resident. Both the SPMSQ with 8 questions and BIMS with 10 questions offer good test/retest and inter-tester validity. This means that if you were to give the test frequently or under different conditions or with different people administering the test, the score would be similar (or insignificantly different). There are times when you may wish to be more precise in evaluating levels of neurocognitive decline. The SLUMS, the clock test, the multi-step task test and others offer better resolution of capability than the previously mentioned Mental Status tests. These tests take some training to administer accurately, but this is minimal. SLUMS is used by the VA for assessing dementia and though it takes some time to administer is generally helpful in assuring residents that their cognition is either normal, in the Mild Neuro-Cognitive Decline (MNCD) category or in dementia. The level of dementia is not graduated, but there is a sense of the severity in the score. For more information , see: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php Completing the Intake Phase The MDS assessments and other tools that are used at intake are input to the care plan for the resident. A completed care plan and review of the chart for completeness are done. Orientation such as a tour of the facility, introductions to roommate and table mates in the dining room, discussion and introduction to first-line staff, locating the activities calendar, an invitation to engage in activities and an overview of the community rhythms complete the intake phase. It is important to remind residents that they choose how and in what to participate. Follow-up to see how residents are adjusting should also be a temporary part of the care plan. Adjustment typically takes residents a few weeks or up to three months (citation?). The care plan item for this should be closed out when resident seems to be participating in teh community in the way that they have chosen.