Nursing Home Social Services Reference

Everything You Wanted to Know About Social Services Work in Nursing Homes (but were afraid to ask!) Table of Contents Opening Nursing Home Social Services Reference/Frontspiece/Foreword Comments on goals of the book Nursing Home Social Services Reference/Frontspiece/Prologue Structure of book and background of authors Nursing Home Social Services Reference/Frontspiece/Instructions for Authors Instructions for contributors Chapter 1 Introduction to Social Services Nursing Home Social Services Reference/Introduction to Social Services/Overview of the Career Overview of Social Services as a Career Nursing Home Social Services Reference/Introduction to Social Services/Prerequisites Good things to have to get and do the job Nursing Home Social Services Reference/Introduction to Social Services/Areas of Competency Competencies required for the job Nursing Home Social Services Reference/Introduction to Social Services/Rewards of the Job Why do this job? Nursing Home Social Services Reference/Introduction to Social Services/Possible Pitfalls What to avoid (title) Nursing Home Social Services Reference/Introduction to Social Services/Typical Job Description Typical job description annotated Nursing Home Social Services Reference/Introduction to Social Services/Applicable Social Work Principles What you learned in School that might help Nursing Home Social Services Reference/Introduction to Social Services/Applicable Social Work Skills What skills you have developed that might help you including: Empathy Communication Organization Critical Thinking Active Listening Self-care Cultural Patience Professional Advocacy Rapport Nursing Home Social Services Reference/Introduction to Social Services/Quality Assurance Performance Improvement The process for improving performance at your facility. What to know about the process, how to contribute, and how to track improvements in the SS Department Chapter 2 Flow of Care Nursing Home Social Services Reference/Flow of Care/Pre-Admission What SS does prior to admission Nursing Home Social Services Reference/Flow of Care/Admission What SS does as part of the admission process Nursing Home Social Services Reference/Flow of Care/Intake SS documentation at admission Nursing Home Social Services Reference/Flow of Care/Advanced Directives documentation of residents wishes for resuscitation and life sustaining treatment Nursing Home Social Services Reference/Flow of Care/Verifying Benefits and Finances SS part of helping res get benefits Nursing Home Social Services Reference/Flow of Care/Personal Needs Funds Medicaid offers some of a resident's SSA funds to be made available to the resident for personal needs. The amount varies by benefit mix and state. Nursing Home Social Services Reference/Flow of Care/Initial Care Plans Care plan at admission based on medical record or MD orders Nursing Home Social Services Reference/Flow of Care/Behaviors and Behavior Plans If there are bx issues Nursing Home Social Services Reference/Flow of Care/Adjustment and Transitions What resident may need in coming to SNF Nursing Home Social Services Reference/Flow of Care/Roommates and Room Moves How room moves work or should work Nursing Home Social Services Reference/Flow of Care/Changes in Condition What if a resident declines and needs more care or improves and requires less care Nursing Home Social Services Reference/Flow of Care/Hospitalization What SS does to help a resident get to hospital Nursing Home Social Services Reference/Flow of Care/Changes in Benefits SS awareness of any change of benefits d/t hospitalization, lottery win, etc. Nursing Home Social Services Reference/Flow of Care/Hospice SS awareness of coordination for hospice care Nursing Home Social Services Reference/Flow of Care/Discharges and Transfers How to discharge or transfer resident safely and successfully Chapter 3: Surveys and Complaints Nursing Home Social Services Reference/State Surveys/What and Why of State Surveys Awareness of goals of survey Nursing Home Social Services Reference/State Surveys/Highest Practicable Level of Well-being Goal of CMS for resident Nursing Home Social Services Reference/State Surveys/Social Services' Tags Which Tags will be SS responsibility Nursing Home Social Services Reference/State Surveys/Survey Readiness Being prepared for the day the surveyors arrive Nursing Home Social Services Reference/State Surveys/Plans of Correction (POC) How to respond to survey tags Nursing Home Social Services Reference/State Surveys/Documenting POC Compliance How to document compliance Chapter 4: Principles of Care Nursing Home Social Services Reference/Principles of Care/Dignity Offer residents dignity and respect Nursing Home Social Services Reference/Principles of Care/Highest Level of Independence Help residents maintain capabilities Nursing Home Social Services Reference/Principles of Care/Trauma Informed Care Offer care that helps residents avoid trauma triggers; reduce unwanted bxs and resident safety Nursing Home Social Services Reference/Principles of Care/Control Over Care Help residents exercise their rights over medical choices Proxies, Medical POAs, Guardians or conservators Nursing Home Social Services Reference/Principles of Care/Physical and Pharmacological Constraints Residents are to be free of these in the SNF; if these are needed residents need to be in a psychiatric facility Nursing Home Social Services Reference/Principles of Care/Equitable Access to Care and Privileges MCD, private and MCR residents should have access to appropriate services and care regardless of their insurance status Nursing Home Social Services Reference/Principles of Care/Advocacy for Residents SS workers are ethically required to advocate for residents who may need this Nursing Home Social Services Reference/Principles of Care/Confidentiality HIPAA requires that PHI be kept undisclosed unless there is written permission from resident (or guardian) for disclosure Nursing Home Social Services Reference/Principles of Care/On-Going Support SS workers cannot withdraw their care and support if it is needed by a resident on an on-ongoing basis Nursing Home Social Services Reference/Principles of Care/Managing Grief, Loss and Depression These mental health issues may require special help and often is a part of resident life as a residents experience functional decline and lose friends and family Nursing Home Social Services Reference/Principles of Care/Differences between Dementia, Delirium, Depression SS worker may have to distinguish these for proper support, appropriate care plans, workable assessments and useful consultation at PsychPharm meetings Chapter 5: Emergencies and Crises Nursing Home Social Services Reference/Emergencies and Crises/Behavioral Issues and Changes D/t drugs, psychosis, delusions or poor emotional control, bx issues will need to be planned for and managed; SS is the nexus of this care Nursing Home Social Services Reference/Emergencies and Crises/Mental Health Crisis Like behavioral crises, episodes that leave resident in mental crisis must be dealt with (30 day bed hold, Medicare uplevel) Nursing Home Social Services Reference/Emergencies and Crises/Addiction and Substance Abuse This is a difficult topic requiring coordination with nursing, admin and SS Nursing Home Social Services Reference/Emergencies and Crises/Family Crises Resident family can often be a source of conflict and bx issues for their resident and others Nursing Home Social Services Reference/Emergencies and Crises/Death A resident death has an impact on other residents and the community; SS has a part in helping the dying resident and the community process this; going through and returning deceased's belongings to family/friends and/or donation Nursing Home Social Services Reference/Emergencies and Crises/Elopement When a resident disappears or leaves without notice, there are steps to take to cover SNF's responsibility; SS is an important part of the search and rescue team Chapter 6: Contexts of Care Nursing Home Social Services Reference/Context of Care/Business of Nursing Homes Knowing how the SNF runs its business will help SS make choices for the department and resources for residents Nursing Home Social Services Reference/Context of Care/Resident Family Issues Issues with resident family that do not rise to the level of crises can still cause issues to be dealt with or managed Nursing Home Social Services Reference/Context of Care/Safe Discharges Residents who leave the facility for non-financial reasons have a right to expect a discharge to a safe and appropriate level of care Chapter 7 Psychopharmacology Nursing Home Social Services Reference/Psychopharmacology/Classes of Psychopharm Medications Drugs come in various categories and are not always used for s/s for which the drugs might appear to be designed Nursing Home Social Services Reference/Psychopharmacology/Gradual Dose Reductions GDRs are req'd by CMS and are complicated; SS may have to be aware or record changes in bx Nursing Home Social Services Reference/Psychopharmacology/Black Box Warnings Some Rxs are "off label" and need special monitoring by the team; nurses are key here Nursing Home Social Services Reference/Psychopharmacology/Side Effects Every drug has side-effects; good to know the major ones and how to observe and plan for them Nursing Home Social Services Reference/Psychopharmacology/Polypharmacy and Drug Interactions Drugs can interact with each other in good and bad ways; as eyes and ears for the PCP, it is good to know some Nursing Home Social Services Reference/Psychopharmacology/Overmedication This is important to detect for the resident's well-being. Nurses might be first to see it; SS should know the signs Nursing Home Social Services Reference/Psychopharmacology/Abuse Cheeking meds and saving them is a tactic for abuse, selling or for a suicide plan; nurses will be the first line; but know what to look for and when to look Chapter 8 Pathologies with Psychiatric Signs and Symptoms Nursing Home Social Services Reference/Medical Psychiatric Pathologies/UTI UTIs can cause delirium/hallucinations in older people and it is common among older people (including men). Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Delirium Delirium can be caused by fevers, meds and other conditions; it requires medical assessment and may appear like psychosis Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Parkinson's Disease causes visual hallucinations in some sufferers Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Hepatic Encephalopathy Some liver conditions can impact brain function and appear like delirium and / or dementia Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Brain Tumors and TBIs This kind of damage can affect emotions, thoughts, hallucinations, cause seizures and other issues Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Dementia with Behaviors and/or Psychosis Dementia can cause behavioral or psychotic episodes as part of the cognitive decline and brain damage that occurs Nursing Home Social Services Reference/Medical Psychiatric Pathologies/Huntington's Disease Huntington's affects physical strength and coordination but can also impact mental capacities causing hallucinations and delusions as well as distress. Chapter 9 Career Paths Nursing Home Social Services Reference/Career Paths/License A SS job qualifies as supervisable work toward an LCSW. It also provides valuable experience for the Nursing Home Administrator (NHA) license. Nursing Home Social Services Reference/Career Paths/Social Services Director SSD is a first step up from Social Services staff member or Assistant and is a path to a corporate SS director or possibly an Administrator (NHA) Nursing Home Social Services Reference/Career Paths/Corporate Social Services Coordinator In facilities run by corporations, there is often a coordinator/director or corporate Vice President in charge of social services Nursing Home Social Services Reference/Career Paths/Nursing Home Administrator Operating a nursing home requires an executive with an understanding of SS and many more talents and skills. Nursing Home Social Services Reference/Career Paths/Community Mental Health CMH Agency's offer important skills for maintaining mental well-being for residents. Nursing Home Social Services Reference/Career Paths/Medical Social Worker With the experience of being a SS worker, transitioning to Medical Social Worker can be rewarding and use all the knowledge and skills learned in the nursing home. Chapter 10 Self Care Nursing Home Social Services Reference/Self Care Intro Overview and enumeration of important areas of self care Nursing Home Social Services Reference/Self Care/Boundaries in Self Care Discussion of boundaries: which boundaries, how to create them and enforce them consistently Nursing Home Social Services Reference/Self Care/Support Systems Actively building communities of support Nursing Home Social Services Reference/Self Care/Self-Awareness Being self aware to see issues of self care before it's too late Nursing Home Social Services Reference/Self Care/Review and Reflection Making time to think about career, self-expression, power and resilience Nursing Home Social Services Reference/Self Care/Rest and Relaxation Scheduling time for sufficient rest and recharging Nursing Home Social Services Reference/Self Care/Self-Compassion Giving yourself unconditional self-regard Nursing Home Social Services Reference/Self Care/Meaningful Engagement Engaging with communities, movements or activities such as advocacy that uplift your values and vision of the world. Appendix A: Resources Resident and Resident-Family Advocacy Organizations LTCCC https://nursinghome411.org/about/ Consumer Voice https://theconsumervoice.org/about/ Nursing Home Abuse Center https://www.nursinghomeabusecenter.com/about/ Justice in Aging https://justiceinaging.org/about/ PsychPharm Aids Nursing Home Social Services Reference/Appendix/Beer's List List of recommended maximum doses of psychoactive meds for demented res (guideline) NIH Version of article: https://pmc.ncbi.nlm.nih.gov/articles/PMC3571677/ USC copy of pocket version: https://gwep.usc.edu/wp-content/uploads/2023/11/AGS-2023-BEERS-Pocket-PRINTABLE.pdf There's an App for That! Nursing Home Social Services Reference/Appendix/PsychoTech Applications on iPads or other tablets and laptops can provide some supportive care for anxiety, insomnia and depression. This has the advantage of being accessible with the resident needs them and the disadvantage that familiarity with such technology is required. For older adults that already have these skills, this option is ideal. For those who might require training, there may be opportunities for Occupational Therapy interventions. Groups that assist with this could also be identified as an activity for residents sponsored by the Activities Department of the facility. Certificate Programs Nursing Home Social Services Reference/Appendix/Foundational Competencies in Older Adult Mental Health This course is highly recommended as an overview of geriatric issues. It is on-line and offers CE or free non-CE participation. Non-CE participation still obtains the certificate. Colorado licensing does not require CEs. See Rush Medical School for more information or search for the above title in your favorite search engine. Nursing Home Social Services Reference/Appendix/Non-Violent_Crisis_Intervention This course helps with intervening with behaviors that could lead to violence. Glossary Nursing Home Social Services Reference/Appendix/Glossary A list of terms that you may encounter and the meaning of these terms. Appendix B: References Minimum Data Set (MDS) B. Fries and K. Murphy, Development of the Nursing Home Resident Assessment Instrument in the USA. Age and Aging, 1997 found at: https://www.academia.edu/15976682/Development_of_the_Nursing_Home_Resident_Assessment_Instrument_in_the_USA?auto=download&email_work_card=download-paper [Retrieved June 30, 2025] Survey Tags and Severity Matrix LTCCC Guide Nursing Home Overview, Appendix 1,2 and 3 at https://nursinghome411.org/wp-content/uploads/2021/10/Guide-Appendices.pdf [Retrieved January 24, 2025] __INDEX__ Category:Social Work Category:Nursing Homes