Hi can you help me with this question that I have attached along with the chapter?(the question is at the end of the chapter)There is a 125 minimum word count.

 

Social Services, Admission, and Discharge

 

The nature of social work in a long-term care facility brings the social worker into extensive contact with current and potential clients. The practice of social work requires sensitivity to people’s needs and an understanding of the problems and issues that people may face when they have to live within social systems that can be large and complex. Hence, dealing with residents’ psychosocial concerns is at the heart of good nursing home social work (Bern-Klug et al., 2010). The term psychosocial refers to a constellation of social and emotional needs and the care provided to meet those needs (Vourlekis et al., 2005). When psychosocial issues remain unaddressed, they can lead to depression, anxiety, and physical illness. Eventually, the person may lose touch with reality as a means of coping and may even lessen the will to live (Bern-Klug et al., 2010). Because many complex social issues cannot be resolved in the best interest of everyone, the focus of social services is on supporting the coping and adaptive capacities of individuals (Dubois & Miley, 1999, p. 44). Social services are an essential component of long-term care from preadmission planning through a patient’s stay in the nursing facility to the time of discharge. The social worker performs key planning and coordinating functions through these stages of change in a person’s life.

 

Social Services Department

 

Staffing

 

In an average-sized facility of 100 to 120 beds, the social services department typically consists of one full-time social worker, who holds the position of department head and reports to the nursing home administrator. Larger facilities generally have a director of social services, who is in charge of one or more assistant social workers in the department. A facility of 120 beds or more may also have an additional position of director of admissions, admissions coordinator, or director of admissions and marketing, who may report to the administrator or to the director of social services.

 

Federal regulations mandate a full-time social worker for facilities that have more than 120 beds. Facilities with 120 or fewer beds must still provide social services, even though a full-time social worker is not required by regulations. Apart from these minimum requirements, however, staffing considerations should be based on the overall scope of responsibilities assigned to the social services department. A national study found that a full-time social worker was typically employed to serve 80 to 90 residents, but there were considerable variations among facilities. Social services directors, on the other hand, indicated that a full-time social worker could address the needs of 60 or fewer long-stay residents or 20 or fewer subacute care residents (Bern-Klug et al., 2010).

 

Qualifications

 

Qualifications of social workers are specified by state nursing home licensure regulations. Depending on what a state requires, social workers may or may not have to be licensed professionals. Typically, a bachelor’s degree in social work (BSW) is the minimum academic preparation necessary. In addition to the bachelor’s degree, individuals who have less than a specified amount of experience—typically 1 year—must receive regular consultation from someone who holds a master’s degree in social work (MSW). Not all states require education in the social work field. Some states allow facilities to have the position of social work designee, someone who has a related degree but not a BSW, in which case consultation from someone with an MSW is required. Evidence, however, suggests that better qualified social workers are better prepared to meet the residents’ psychosocial needs (Simons, 2006).

 

In addition to academic qualifications, social workers in a geriatric setting must have an understanding of the physical and psychosocial changes that accompany the aging process. They must understand the unique needs of the elderly and demonstrate a desire to work with the problems and issues confronting clients in nursing facilities.

 

The client population in nursing homes will continue to become increasingly diverse in race and ethnicity. This is particularly true in geographic areas where there are sizable numbers of ethnic groups. Working with these clients requires an understanding of and sensitivity to cultural differences.

 

Social workers should also possess certain personality traits such as trustworthiness, compassion, patience, thoughtfulness, and ability to listen. They must be knowledgeable of community resources, and they need to establish linkages with various external agencies in order to obtain needed services for patients and their families.

 

Knowledge of Aging and the Elderly

 

An understanding of aging and the special needs of the aged is essential for anyone working in a long-term care setting. Caregivers’ attitudes regarding older people can influence how the elderly are treated. The social worker is often called upon to assist other staff members in the facility with aging-related issues. Social workers also generally provide staff training on issues pertaining to gerontology—an area of knowledge that deals with the understanding of the aging process, the changes accompanying aging, and the special problems associated with aging.

 

Understanding Aging

 

In our society, people are generally considered elderly or a “senior” when they are in their mid-60s. At this age, people frequently take formal retirement from work, become eligible for Social Security and Medicare, and start paying more attention to some of the symptoms that naturally accompany advancing age. However, age itself merely provides a chronological context. In fact, different people age differently. Attitudes toward one’s own aging, and behaviors associated with the issues of aging, differ from person to person. From this perspective, the elderly are a very heterogeneous group.

 

Categorizing every elderly person according to a stereotype is a gross error. The need to avoid stereotyping is one reason that assessments, plans of care, and interventions require individualized attention. Attitudes and behaviors also differ among diverse cultural and ethnic groups. Family support, values and expectations, level of trust, and reaction to nursing home placement may be associated with a resident’s cultural orientation.

 

Aging is loosely regarded as the culmination of a life cycle that started at birth. Although aging may be the final stage of life, this stage can last a long time, and, as further changes occur, substages within this stage manifest themselves. Hence, a person’s background and social history—upbringing, education, hobbies and interests, marriage, divorce, death of spouse, children, siblings, major illnesses, occupation, economic achievement, dysfunctions, and recent occurrences—provide meaningful information that should be used for planning strategies to help the individual cope, adapt to new circumstances, and get the best out of life despite current illness and declining physical functioning.

 

Theories of Aging

 

During the past 40 years or so, a number of theories have been proposed in an effort to understand behaviors associated with aging. Each theory has its limitations, and even together all the theories do not account for every possible situation. Of the several theories, three are considered most useful for their application in nursing home settings:

 

•  Activity and disengagement theories

 

•  Continuity theory

 

•  Labeling theory

 

Activity and Disengagement Theories

 

According to activity theory, people in their old age seek to remain active in meaningful ways. Older adults are capable of using their own skills and have an inherent potential to engage in vital and successful growth across the life span (Mallers et al., 2013). This theory counters the “rocking chair” stereotype, according to which the elderly are often visualized as sitting passively in a rocking chair and dozing off because of inactivity. Satisfaction in old age depends on a person’s ability to substitute new roles and activities for those that the individual pursued during preretirement years. A career postal worker, for example, may enjoy distributing mail to other nursing home residents. Many elderly women still enjoy baking, cooking, knitting, and other activities that should be incorporated into the facility’s recreational planning. Many elderly maintain or improve their self-esteem when they feel they are engaged in doing something useful.

 

Engagement in activities, however, varies among the elderly. For example, many elderly regard television viewing to be a far from passive activity (Östlund, 2010). Instead, it contributes to structuring their daily lives and to achieving satisfaction by meeting some of their mental and emotional needs. TV viewing is a way of maintaining routines and habits developed over prior years. Some people simply seek disengagement from social interactions for at least part of their daily routines.

 

Disengagement theory questions the belief that activity creates satisfaction for everyone. Hence, it is important to realize that not everyone wants to remain socially active and that the notion of what constitutes satisfying activity can differ significantly from one person to another.

 

Continuity Theory

 

The major assumption of continuity theory is that the experiences of one’s earlier years prepare an individual to adapt to and cope with the demands of aging, which may help explain why some people adapt to new situations better than others. For example, Atchley (1995) suggested that the elderly use their religious and spiritual experiences to guide their current patterns of living and how they relate to others and to find meaning in the current circumstances. In general, current behaviors of elderly individuals can be best understood by examining their behaviors in earlier stages of life, such as past habits, goals, preferences, hobbies, and leisure pursuits. Understanding the patient’s past can enable facility personnel to assist the individual in adjusting to the new environment. This understanding can also help facility personnel think about ways in which routines can be made more flexible to accommodate certain past practices, which would help the person better adapt to a new setting.

 

Labeling Theory

 

Labeling theory helps one understand how a person’s self-concept is molded by the labels others use for that person. It strikes at the negative stereotypes of the elderly because the elderly may believe these stereotypes to be true, and they may assimilate those stereotypes into their behavior. For example, the belief that once people become old, they become dependent may actually promote dependency in elders (Harrigan & Farmer, 1992).

 

Inaccurate Views of Aging

 

Myths and distorted views about aging encourage stereotyping, which results in treating the elderly in ways that are detrimental to their self-esteem, independence, and psychosocial as well as physical health. Prejudicial treatment of the elderly based on stereotypes is called ageism. Ignorance is the main cause of ageism, which creates barriers for adequate delivery of health care and social services to the elderly.

 

Certain changes—such as sensory decline in vision, hearing, tactile feeling, smelling, and tasting—occur naturally as a person ages. Sleep disorders may also become more common. But getting old does not necessarily mean becoming ill and disabled. Many biological and psychological changes that are commonly associated with aging actually start occurring at a much younger age. These changes do not take place uniformly in all people. Earlier life choices and unforeseen accidents have an effect on health in later years. Hence, chronological age is a poor indicator of health and vigor (Harrigan & Farmer, 1992). Although some elders succumb to illness and disability and require assistance, most continue to live healthy and fulfilling lives. However, the risk of functional impairment increases with age as chronic conditions and comorbidities set in. But in spite of the heightened risk, only a small percentage of the elderly will require institutional care over a long period.

 

Old age does not necessarily mean that people lose the desire to remain physically attractive. Economic and physical constraints may interfere with one’s ability to maintain proper grooming. Assuming that inactivity results from old age is also wrong. Because of sleep disorders, some elderly individuals may compensate for lack of sleep at night by taking naps during the day, or they may fall asleep while sitting because of boredom and inactivity. Presuming that physical exertion is harmful for older people is also inaccurate. Within the parameters of physical limitations, most elderly people can engage in various types of physical activities under proper medical supervision. Although sexual functioning declines naturally, particularly in males, most elders retain the desire to express their sexuality.

 

Another area in which the elderly are quite heterogeneous is whether they are set in their ways or whether they can learn new things. Many older adults can successfully adapt to changes and learn new skills, such as those demanded by new hobbies, crafts, or using the computer. Older people generally also have their long-term memory quite intact.

 

It is erroneous to think that the elderly like being dependent on others. To the contrary, older adults like to have control over their life decisions, and to the extent they can, they wish to take care of their own needs. Independence is closely related to self-esteem. The concept of interdependence may provide a more appropriate way for addressing the needs of the elderly (Harrigan & Farmer, 1992). Interdependence can be defined as a state of living together (symbiosis) in a mutually beneficial relationship. In most cases, people are in nursing homes because of impairments, and to that extent, their dependent position cannot be helped. However, although being dependent in some ways, residents may be able to make a contribution to the community in other ways. A sense of being useful, competent, and needed must be preserved as much as possible. Interdependence often develops mutual bonds with other residents and pets in the nursing home.

 

Contrary to popular opinion, the elderly in America are not alienated, ignored, or abandoned by their families. Adult children and their elderly parents generally prefer to live separately—in many other countries, a lack of resources and housing often make it necessary for older parents to live with their grown-up children and grandchildren. At the same time, most long-term care and assistance with activities of daily living (ADLs) are provided to elders by family members on an informal basis. The family continues to play a vital role in delaying or preventing institutionalization of elders. On the other hand, intergenerational conflicts in families do arise. Abuse and neglect, including verbal abuse and psychological mistreatment, exist at all socioeconomic levels of society and in all racial and ethnic groups (Harrigan & Farmer, 1992).

 

Diversity and Cultural Competence

 

In the United States, by 2020, the proportion of ethnic minorities is projected to reach 23% among the 65 and older population group. This is a substantial increase from 13% in 1990 (Pandya, 2005). There is some evidence that nursing home utilization rates among Hispanics, Asians, and Native Americans are much lower than those for whites and African Americans (Himes et al., 1996). The extent of informal caregiving by family members is the highest among Asians, followed by Hispanics, African Americans, and whites. These differences correlate with the extent to which the belief that children are expected to take care of the parents in their old age is prevalent among these ethnic groups (AARP, 2001). However, factors other than culture—such as socioeconomic status, family size, and language barriers—also play a role in molding such expectations. On the other hand, cultural variations exist even among some whites. Hence, delivering long-term care to a diverse population will be a growing challenge.

 

To make matters more complex, people from other cultures go through a process of acculturation. Some people are at the traditional level where they retain beliefs and behaviors of their culture of origin. Others are at the bicultural level where they share the attributes of their culture of origin with those of the dominant culture they live in. Those who reach the assimilation level adopt the values and behaviors of the dominant culture (Valle, 1989). Hence, making accommodations for those from another culture requires more in-depth information than what may be apparent on the surface. On the other hand, people with dementia tend to return to the traditional end of the continuum, requiring cultural accommodation (Valle, 1989).

 

Cultural competence is the term used for an organization’s ability to deliver health care services in accordance with the cultural needs and preferences of the clients. The idea of cultural competence evolved from research that has consistently demonstrated racial and ethnic disparities in health care delivery. In nursing homes, for example, a greater proportion of African American residents was found to be associated with poorer quality (Singh, 1997). Cultural competence initiatives later evolved into eliminating cultural and linguistic barriers that can interfere with the effective delivery of health care. These initiatives are based on the assumption that removal of any type of barrier between patients and caregivers can enhance quality of care. In addition to language barriers, beliefs and values based on a person’s religion and other sociocultural elements define people’s preferences and taboos.

 

Cultural competence begins with respect for the individual. It requires engagement skills that help caregivers understand the differences in another person’s beliefs and values and how those differences can be accommodated. It requires that caregivers honestly assess their personal biases and try to understand cultural differences with a nonjudgmental attitude.

 

Cultural stereotyping can be just as detrimental as ageism. Another type of bias is ethnocentrism—a belief that one’s way of life and view of the world are inherently superior to those of others and that those views are desirable for others to acquire. It involves judging another’s culture as inferior to one’s own (Barger, 2004). According to Barger, “Addressing ethnocentrism is not a matter of trying not to be ethnocentric. This is an impossible task, since we will never experience every life situation of everyone around the world. We will always have our assumptions about life based on our existing limited experience. So a much more productive approach is to catch ourselves when we are being ethnocentric and to control for this bias as we seek to develop better understandings.” Associates working with ethnically diverse populations should be trained in dealing with their ethnocentric biases.

 

Cultural Accommodations

 

Certain types of accommodations are relatively simple to make. These include choice of apparel, preference for either male or female attendants, dietary restrictions from a cultural standpoint, and ability to follow certain religious practices. Other restrictions, particularly those that may have implications for a person’s health and well-being or that may be disruptive to other residents, require a more careful approach. In some situations, it would be wise to obtain legal counsel because they may have implications for a person’s civil rights under Title VI of the Civil Rights Act of 1964. There are other issues that a social worker may be called upon to address. For example, conflicts based on ethnic diversity can arise between residents or between residents and visitors.

 

Soliciting information from someone of a different ethnic origin requires tact. For instance, an outright inquiry about a person’s religion is generally not appropriate. It may also be inappropriate to ask someone, “Do you understand English?” Many immigrants from other countries speak and understand English quite well and may perceive such a question as an insult. Instead, it would be appropriate to pose exploratory questions, such as, “Do you have any particular needs that we should be aware of? We want you to feel very comfortable in our facility.”

 

Learning about some common beliefs and customs is important to gain an understanding about other cultures. But caution must be exercised in how such learning is applied: there are many subcultures that often differentiate among people from the same general background. For example, not everyone from Vietnam is a Buddhist, not everyone from the Middle East is a Muslim or a Jew, and not everyone from India is a Hindu. Hence, broad assumptions should not be made. Also, people from the same ethnic or religious background often have individual differences; some are orthodox, others are liberal, most are likely to be somewhere in between. Many westernized Hindus eat beef, many unorthodox Muslims use alcohol, and many nonobservant Jews consume pork products. Hence, it is critical to ascertain individual needs and preferences.

 

It is almost impossible to furnish accurate details on all different cultures and subcultures found in the United States today. However, some main cultural differences in the areas of religious observances, dietary restrictions, and health care preferences are summarized here:

 

•  Observances. Catholics and most Christian denominations observe Sunday as a day of religious observance. Orthodox Jews and Seventh-day Adventists (members of a Christian denomination) observe Saturday as a holy day. More specifically, they observe the Sabbath from sundown on Friday evening to sundown on Saturday evening. Muslims observe Friday as a day for prayers. Christmas, on December 25, is the most widely celebrated Christian holiday; however, some Christians regard the holiday as anti-Christian and pagan. On the other hand, social celebrations associated with Christmas are not offensive to most people. Hanukkah is the most widely celebrated Jewish holiday, which falls in November or December, according to the Hebrew calendar. Other major Jewish observances are the Passover, which occurs in the spring, and Yom Kippur (day of atonement), considered as the holiest of all Jewish observances, comes in the fall. Most observant Jews fast during Yom Kippur. Ramadan, the month of fasting, is observed by devout Muslims during the daylight hours. Catholics and some other Christians observe the season of Lent, which begins with Ash Wednesday and culminates with Easter Sunday. Catholics particularly refrain from eating meat (a practice called “abstinence”) on Fridays during Lent. Other devout Catholics observe abstinence on all Fridays of the year. By many Christians, Good Friday and Easter are considered more important than Christmas in remembrance of the death and resurrection of Jesus Christ. Many Christians, such as the Amish and the Mennonites, observe Thanksgiving and New Year’s Day as religious holidays. Many Christians say a short prayer before a meal; many Jews pray both before and after a meal.

 

•  Dietary restrictions. Most Christians do not have any faith-based dietary restrictions, but many do. Among Seventh-day Adventists, for example, about half are strict vegetarians. Those who consume meat, poultry, and fish confine themselves to foods considered biblically clean, which are listed in Leviticus, chapter 11 of the Bible. Some of the unclean meats include pork, rabbit, frog, squid, shellfish, and fish that do not have scales. Most Seventh-day Adventists do not drink caffeinated beverages. They also shun tobacco in all its forms and the use of any kind of alcohol, and consider such practices to be offensive. The Mormon church also prohibits use of tobacco, alcohol, and caffeinated beverages. For Jehovah’s Witnesses, tobacco and alcohol are forbidden. They also do not eat certain meats such as sausages because they may contain blood. Jewish dietary practices are also based on Leviticus, except that meat and milk may not be served together. To be considered kosher, animals and poultry must be slaughtered in accordance with Jewish law. A similar practice of ritual killing is followed by Muslims for meat or poultry to be considered halal. Muslims also do not eat pork. Many Buddhists and Hindus are vegetarians. Those who eat meat generally prefer chicken or fish over beef, or they may shun beef and veal altogether.

 

•  Health care preferences. Nontraditional or alternative medical treatments, such as use of herbs, acupuncture, and rites and rituals are historically embedded in many cultures. People from these cultures accept Western medicine, but may also insist on using alternative remedies. Patients have the legal right to follow or not to follow treatments prescribed by a physician. For example, Jehovah’s Witnesses refuse blood transfusion on religious grounds. In other cultures, immunization, such as flu shots, is refused. Treatment such as artificial prolongation of life may be refused by some. Religion may also govern certain ritualistic practices that can vary considerably among cultures. For example, various forms of prayers, singing of hymns, sacraments for the sick, anointing with oil, and so forth, may be practiced according to different belief systems.

 

Making cultural accommodations does not require a faith-based organization to compromise its religious philosophies and values. Many nursing homes in the United States are operated by various Christian denominations and Jewish congregations. They accept patients regardless of their religious affiliations but do not compromise their own principles. A nursing home run by the Catholic church, for example, will hold regular Mass services; but attendance will be optional. A Jewish nursing home will serve only kosher meals. A Seventh-day Adventist nursing facility will not serve pork or other meats considered biblically unclean but may allow family members to bring in such products for individual consumption.

 

Skills and Competencies

 

As discussed later in this chapter, social workers serve in a variety of roles. To carry out these roles effectively, social workers must learn and develop skills in at least six main areas:

 

•  Engagement skills

 

•  Assessment skills

 

•  Communication skills

 

•  Conflict resolution skills

 

•  Interviewing skills

 

•  Documentation skills

 

Engagement Skills

 

This skill is basic to all social work practice because it entails recognizing client needs, demonstrating sensitivity and concern, and being committed to addressing client needs. Effective engagement with the elderly client is built on respect. Engagement requires building rapport with patients and their families.

 

Young adults may tend to treat older adults as children, a process called infantilization. It is not uncommon for nursing home staff members to address patients by their first names, which may be taken as demeaning, even though the patient is not likely to openly protest about it. Similarly, addressing patients as “cutie,” “sweetie,” “baby,” or “honey” is regarded as condescending. Patients are already dependent upon the caregivers; infantilization further strips away the patients’ self-respect and dignity.

 

Deficiencies in human relations skills can severely hamper a social worker’s effectiveness. Skilled social workers can play an especially important role in training other staff members in effective ways to interact with the elderly, and social workers can periodically reinforce the need for appropriate staff–resident relations. Caregiving relationships are often characterized by intimacy, meaning closeness or proximity of the caregiver to the dependent elder; intimacy goes beyond mere familiarity (Agich, 1995). Without conscious thought, intimacy can lead to infantilization and reinforce a resident’s sense of dependency, which is the antithesis of autonomy.

 

Assessment Skills

 

Assessment is akin to an exploratory study that forms the basis for decision making and action (Coulshed, 1991, p. 25). It is a systematic investigation of all basic and special needs of the individual, including the patient’s own perspective as well as that of his or her family or surrogates. Special attention is paid to the person’s biophysical functioning in relation to psychological and social processes, such as the patient’s attitudes about being in the nursing facility, economic needs, family support, and race or cultural issues. An initial assessment is generally quite comprehensive, but because needs change over time, assessment should be an ongoing process. The information gathered from the assessment is used to determine how the facility’s resources and services will be deployed to best address the needs of the patient as well as the needs of family or surrogates. Such a plan of action takes into account any limitations in resources the nursing facility may have. When a facility is unable to furnish the resources necessary to address all the identified needs of a patient, services from outside the facility must be procured or the patient should be moved to a more appropriate setting.

 

Communication Skills

 

Communicating with the elderly requires special skills apart from speaking, listening, writing, and presentation skills. Particular attention must be paid to language use with older adults. Use of technical jargon is commonplace among nursing home associates, but such jargon should be avoided when communicating with clients and their families. For example, associates should use the term “food service” instead of “dietary,” “recreation” instead of “activities,” and “evaluation” instead of “assessment.” Kropf and Hutchison (1992) make several practical suggestions to improve communication. Simple and straightforward language is the most effective method of verbal communication. A handshake or touch adds warmth to the communication process. Sitting in close proximity to an older client aids understanding of what is being said and is also taken as a sign of acceptance. Active listening, repeating, and feedback are essential techniques for communicating with the elderly to ensure understanding. Because hearing impairment is a common problem among nursing home clients, clear diction and a slow pace of talking are important. Another good strategy is to use the patients’ names frequently, so they know that they are being addressed.

 

Conflict Resolution Skills

 

Conflict occurs in various types of human interactions. It occurs when one party perceives that its interests are blocked by another (Allen et al., 2007). Conflicts can be attributed to several sources, such as disagreement or differences in values, attitudes, needs, and expectations. Conflict can also arise from miscommunication (Conerly & Tripathi, 2004). The results can be residents who withdraw and get depressed, residents who lash out at other residents or staff, or irate family members. Social workers are commonly asked to intervene in such situations, but they may themselves experience resistance when, for example, the social worker decides to do what is best for the resident but the resident insists on having his or her own way.

 

A four-dimensional conflict-resolution model can be helpful in addressing certain types of conflicts. According to this model, the social worker should evaluate four main factors (Allen et al., 2007): (1) needs of the resident; (2) evidence of the urgency of the resident’s need; (3) legal and ethical implications; and (4) likelihood of resistance from some entity—such as associates, management, or family—to what the social worker may propose. A simultaneous review of these four factors can lead to one of five possible resolutions according to the Thomas-Kilmann Conflict Model: avoiding, compromising, accommodating, collaborating (or problem solving), and forcing (or confronting).

 

Avoiding. The social worker would work on improving the situation through education, subtle suggestions, or better relationships (Allen et al., 2007), but the conflict is not dealt with directly. For example, a family member may insist that caregivers help the patient dress even though the patient may be able to dress herself given adequate time. This family member may require some education about why it is important for the resident to do such tasks independently to the extent possible. Avoiding can also be accomplished by separating two individuals who cannot get along. For example, two roommates may be assigned to different rooms. In most other instances, however, avoiding is not a good strategy. When left unresolved, the underlying issue may fester and create an explosive situation later on. For example, avoiding a family member who routinely complains about the services is likely to make this person more irritable as time goes on.

 

Compromising. This involves bargaining (each party gives up something to get something) and taking a middle ground. This approach is used when the four factors play a moderate role. Allen et al. (2007) provide example of a situation in which a resident insists on smoking as a social release, even though there are contraindications on medical grounds and the facility has a nonsmoking environment. Through compromise, the resident may be allowed to smoke occasionally outside the facility in the presence of a staff member.

 

Accommodating. Here, the social worker can help the resident best by smoothing relationships, repairing trust, and reopening lines of communication (Nelson, 2000). It requires low assertiveness. This strategy is valuable when it is important to appease the other party because the facility is wrong on the issue and the issue may not be very important. As an example, a resident’s nightgown did not get returned from the laundry and could not be located despite a thorough search. The social worker may ask the administrator to authorize the small amount of money it would cost to replace the gown.

 

Collaborating (or problem solving). This approach requires a careful definition of the problem, alternative solutions, evaluation of costs and effectiveness of each solution, and choosing a solution that best accommodates the needs of those involved. It is based on the input from several interested parties. This approach is useful when resident needs are high and low resistance from associates or management is expected (Allen et al. 2007). For example, a resident with severe dementia may have a chronic shortage of appropriate clothes to wear and the associates may be constantly running out of clothes to dress this person appropriately. A meeting with the family may involve the social worker and one or two caregivers to discuss alternatives. If the family is not interested, the social worker and other associates may discuss alternatives such as using the resident’s personal funds to buy new clothing, asking a faith-based organization to donate clothing, or purchasing used clothing.

 

Forcing (or confronting). When faced with a high degree of resistance, forcing may become necessary when the resident’s needs present urgency and high legal or ethical stakes are involved. Examples include flagrant violation of patient rights, negligence, or abuse. Confrontation would require that the social worker present clear and convincing evidence of the resident’s compelling need (Allen et al., 2007).

 

Interviewing Skills

 

Interviewing is commonly used for gathering facts about individual situations. As an interactive tool that is generally used when dealing with specific issues, interviewing involves communicating in a more focused way than usual. Effective interviewing generally requires some prior preparation, such as gathering background or other preliminary information that is used as the basis for further probing to obtain more pertinent and detailed information. When preparing for the interview, the social worker needs to think through what specific questions to ask.

 

The actual interview requires a private and quiet place and adequate uninterrupted time. Effective interviewing employs the skills of engagement and communication just described. But it goes beyond a mere use of those skills. An interview should get to the main point of the issue and begin with a summary of the issue and the purpose of the interview. It is important to pose questions that get to facts and feelings. Questions posed accusingly or in a suspicious manner would only make the person erect defensive barriers. During the interview, particular attention must be paid to special cues that may require further probing. For example, the individual may try to dodge an issue or may be hesitant to respond to a question. A victim of abuse may be reluctant to discuss it because of embarrassment or fear of retaliation. The interview should conclude with a summary that puts the total interview in perspective for the client, who should then be asked if any information has been misrepresented or omitted (Kropf & Hutchison, 1992). The social worker should also explain what follow up will take place.

 

Documentation Skills

 

Documentation often requires the use of prescribed forms and formats, but much of this work is now computerized. Documentation must be timely, accurate, complete, and descriptive—but concise. In this manner, social service documentation should provide a complete record of the patient’s initial history, assessment, care planning, progress (or lack thereof), interventions, and discharge. A number of documents are also completed upon a patient’s admission to the facility, as discussed later in this chapter.

 

Social Service Roles

 

Social workers perform a variety of different tasks that are too numerous to describe. Most situations that require social work intervention cannot be foreseen and must be dealt with as they arise. The roles discussed in this section paint a general portrait of what a social worker employed in a nursing facility does. These roles also highlight the importance of the social worker’s position in a nursing facility. The various roles and functions can be classified into six main categories:

 

•  Informational role

 

•  Case manager role

 

•  Coordination role

 

•  Enabler role

 

•  Intervention role

 

•  Advocacy role

 

Informational Role

 

The social worker is generally the main source of information on several fronts: the facility and its services, eligibility for public financing and the services covered under programs such as Medicare and Medicaid, resources and services available in the community and their suitability for a particular client, and various issues related to long-term care. A social worker must acquire comprehensive knowledge in all these areas.

 

People who inquire about nursing home placement for a family member or acquaintance are often the primary recipients of information about the facility. But professionals in other health care and social service agencies also need to be educated about nursing home services. One skilled nursing facility can differ substantially from another on the basis of the level of specialization, philosophy of care, socioresidential environment, and so forth. Such differentiating factors should be used in marketing the facility to potential sources of patient referrals.

 

Case Manager Role

 

As a case manager, the social worker generally coordinates external resources to meet the total care needs of each patient. When a resident is admitted to a nursing facility, the facility takes on the responsibility of providing or procuring all appropriate services that the patient may need—a concept called “total care.” Services not provided by the facility are obtained from external sources. For example, a resident may require eyeglasses or dental care or may need a psychiatric evaluation. A referral for such services may require obtaining orders from a physician, involving family or other responsible party, follow up on financing, making an appointment with an appropriate professional, arranging transportation, and follow up to ensure that the patient has actually received the service.

 

Coordination Role

 

The social worker’s coordination role goes beyond case management. Each admission and discharge requires careful coordination with both key staff members within the facility and with relevant parties outside the facility. The social worker is generally the facilitator of the resident council within the facility or a family support group sponsored by the facility. The social worker is also generally called upon to assist the facility administrator in sharing the facility’s expertise with the community through well-coordinated programs on geriatric issues and financing for long-term care. Examples include sponsoring a support group for dementia-related issues or a support group on handling personal guilt and anxiety associated with institutional placement, sponsoring a seminar on Medicare and Medicaid coverage for long-term care, and disseminating information on respite care.

 

Enabler Role

 

In this role the social worker functions as a facilitator. For example, new residents require adjustment to the new surroundings and the unfamiliar routines of the facility. The process and time required for adjustment varies from one patient to another. Social workers help residents adjust by frequently visiting them and by encouraging them to express their fears, anxieties, and feelings. Social adjustment is also facilitated by assessing compatibilities and introducing residents to others to encourage social bonding (Patchner & Patchner, 1991).

 

The resident’s family also requires adjustment. Family members often carry feelings of guilt from putting a close relative in a nursing home. There may be conflict among family members over the decision. The social worker can help family members explore their own feelings, clarify areas of disagreement, and confront the realities of the situation.

 

Intervention Role

 

The social worker is called upon to address a variety of problems that nursing home patients may face. It often requires good communication and conflict resolution skills, discussed earlier. In most instances, the patient has a conflict or lacks the ability to cope with his or her environment. Examples of this type of conflict include a patient repeatedly losing her eyeglasses or not having enough clothes to wear. The conflict may involve other people, such as an associate or family. For instance, the family may find it too expensive to replace lost items and may not favor purchasing new eyeglasses or hearing aids. The family may blame the facility for losing items of clothing and decline to replace them, with the result that the patient has insufficient or inappropriate items to wear. There may be conflict between two residents who may or may not be sharing a room or a dining table. Some conflicts arise from psychosocial problems or dementia and may require therapeutic intervention in the form of reality orientation, validation therapy, or sensory stimulation (Patchner & Patchner, 1991). Activity personnel can be called upon to assist with these therapies.

 

Advocacy Role

 

The social worker is an advocate for the patient. It is the social worker’s responsibility to inform patients of their rights. The social worker also monitors the enforcement of patient rights in the facility and educates the staff on the meaning and importance of patient rights. Many patients cannot express their desires and cannot determine on their own what is best for them. In the advocacy role, the social worker does not try to guess the patient’s wishes; rather he or she is responsible for bringing patient-related issues to the attention of the administration and any other parties whose involvement may be necessary for decision making and initiating action. For instance, a resident may have already lost two hearing aids and may be unable to express whether he or she needs a new one. The family may resist investing money in a third hearing device. This patient needs someone to stand up as an advocate on his or her behalf.

 

Effectively managed nursing homes have ethics committees to address such issues. The social worker brings issues to the attention of the committee for decision and resolution. An ethics committee is a multidisciplinary forum that may include the administrator, a nurse, a physician, social worker, activity director, and others as necessary. Depending on the issue, the committee may also include a member of the clergy, an ethicist, a legal representative, a dietitian, or a therapist. Generally, family members are also invited to attend and to provide their input. The committee’s purpose is to discuss situations and resolve issues in view of what is best for the patient. A multidisciplinary forum allows for different insights and viewpoints. It relieves the social worker of the responsibility for making complex decisions independently. When the consequences of a decision turn out to be negative, blame cannot be assigned to one person. Finally, the decision of a committee is more likely to be accepted by individuals, such as family or staff members, whose action or support is necessary for carrying out that decision.

 

Admission and Discharge

 

Preadmission Inquiry

 

The social worker is generally the one to first meet a prospective client, unless the facility has a separate director of admissions, who would then be the one to take most inquiries. A prospective client or a referral agency may call the facility and make arrangements for a family to visit the facility. In other instances, an inquirer may walk in unannounced. The facility must be prepared at all times to handle either situation promptly and professionally, because in today’s competitive environment an inquiry delayed is an admission lost.

 

Handling an inquiry is akin to making a sale, but using a social service approach. This approach requires the intake worker, who may be the social worker or the admissions coordinator, to function as an information disseminator and case manager. The focus is not simply on finding new patients for admission to the facility but also on determining whether the nursing home is appropriately suited to meet the patient’s needs.

 

PASRR Compliance

 

PASRR stands for Preadmission Screening and Resident Review. One of the provisions of the Nursing Home Reform Act (OBRA-87) was to eliminate inappropriate placement of people with mental illness, mental retardation, and developmental disabilities (DD) in Medicaid-certified (NF) nursing homes. The federal law required the states to establish procedures to screen Medicaid-eligible patients before admission to a nursing home. These screening procedures vary from state to state. In some states, the nursing home may have the responsibility to do the PASRR. A review is also required when there is a significant change in the patient’s condition. Nursing facilities should not admit anyone—even a private-pay patient—to an NF bed who has not been through the PASRR. Only when a patient is admitted for less than 30 days based on a physician’s certification is the PASRR not required.

 

There are two levels of PASRR screenings. Level I screening is required before admission. A person with mental illness, mental retardation, or DD may be admitted as long as he or she also requires nursing home care; that is, the patient’s needs cannot be adequately met by community-based services. Level II screening provides for a more detailed assessment and serves as the basis for determining whether the nursing home setting is appropriate for individuals who have a serious mental illness, mental retardation, or related condition; whether their rehabilitative needs can be met in the nursing home setting; and, if so, what specialized rehabilitation services related to their mental illness or mental retardation are necessary.

 

Once the resident is admitted, the nursing facility is obligated to provide the necessary care and services the resident requires to attain or maintain the highest practicable physical, mental, and psychosocial well-being. For example, the facility may have to obtain specialized mental health services while the patient is a resident at the facility.

 

Written Procedure

 

The facility should have a written procedure for handling inquiries. The procedure should include a list, in descending order of preference, of backup personnel in case the primary intake worker is not available. For instance, the list of personnel could start with the director of admissions and include the social worker, a second social worker (if the facility has one), the administrator (or an administrative staff member such as an assistant administrator, if the facility has one), the director of nursing, and the activity director.

 

The point here is that the facility should always have someone to provide complete information, regardless of whether the inquiry is initiated over the phone or in person. The procedure should include the main steps in handling inquiries, in which all personnel assigned to this task must be properly trained. The list of staff members should be available to the receptionist, so each inquiry can be appropriately directed, based on who is available at the time. The facility should also have a plan for handling inquiries after regular business hours and on weekends. For example, many well-run nursing facilities designate a weekend manager. This role is carried out by the primary and secondary intake professionals mentioned earlier, who cover the role of weekend manager in rotation. An evening charge nurse or nurse supervisor should also be trained to handle the occasional inquiry that may come in after regular business hours.

 

Initial Interview

 

The facility should provide an office or other private area for the interview. This setting should be comfortable, inviting, and cheerfully decorated, but not to the point of being distracting. Handling an inquiry is an art, which is perfected with time and practice. A preprinted inquiry checklist can greatly facilitate the interview. Even if the intake process is computerized, making entries during the interview should be avoided because it depersonalizes the process.

 

The objective of the interview is to obtain essential information about the patient, starting with his or her name, age, gender, current location such as hospital or home, name of referring agency (if any), attending physician, when accommodation may be needed, diagnosis, ADL status, hobbies and interests, any special needs, and so forth. The inquiry checklist should also have space for the inquirer’s name, relationship, phone number, and address. Even though all pertinent information is obtained at this time to make a judgment about the patient’s needs, this is not a formal assessment, nor should an attempt be made at this juncture to make one.

 

Once the basic information has been obtained, the interview moves on to a discussion of the facility’s services that can best meet the patient’s needs, according to a preliminary clinical judgment based on the information provided. If necessary, the intake worker—that is, the person handling the interview—can call the referral agency to seek further clarification. The intake worker should also call in the director of nursing, a specialized nurse, a therapist, or the dietitian to provide additional expertise if specific issues arise during the interview. The facility should evaluate the case objectively. Admitting a patient and then not providing adequate services because the facility is not equipped to handle the care that the patient’s condition demands would be a mistake. On the other hand, if a community-based long-term care program or a residential institution is determined to be more suitable for a prospective client, the intake worker should make appropriate referrals. Establishing exchange partnerships with external agencies can result in two-way referrals, creating a win–win situation for both parties.

 

Facility Tour

 

Prospective clients seldom decline to tour the facility, but it can happen if the initial interview turns them off. This phase of the inquiry process consists of a guided tour, during which the inquiring party is accompanied by the intake worker. Well-managed facilities have written procedures for giving an effective guided tour. The written tour plan is also used for training staff members who may be called upon to conduct facility tours in the absence of the primary intake personnel.

 

The tour should highlight the various elements of the internal environment and caregiving philosophy from the standpoint of person-centered care. Some of the main areas of the facility to include in the tour are dining rooms, lounges, social and private spaces, amenities, and the activity room and calendar. Many facilities have a large, wall-size calendar of activities and events. In addition, safety features and practices, comfort factors, privacy aspects of care, and enrichment of the environment and culture change should be emphasized in the conversation while touring the facility. The visitor must be able to observe and feel the caregiving environment to the fullest extent possible without compromising the privacy of patients receiving care. For example, activity sessions and certain therapies, such as gait training, can be observed without compromising privacy. It is inappropriate to take visitors into occupied patient rooms unless permission to see their rooms has been obtained in advance. Some facilities set apart one or two furnished model rooms for visitors to see and to get some ideas about how a room may be personalized by bringing items such as small television sets, memorabilia, plants, personal furniture, and bed accessories (personal pillows, comforters, etc.). Visitors should not be taken into the kitchen because it violates sanitation regulations.

 

Concluding Interview

 

The conclusion of a tour always brings the inquirer back to the place where the initial interview was conducted. The intake worker now continues to judge the client’s reactions and provides an opportunity for questions and answers. At this point, financing should be discussed. If appropriate, the patient accounts manager may join the conversation to answer questions about financing. For instance, the patient may be eligible for Medicare, Medicaid, or both. In some cases, an application may have to be made for Medicaid coverage. If the patient would come in under Medicare, an approximate length of stay and out-of-pocket costs should be discussed. Private-pay rates should be furnished if that is appropriate. If the patient has private insurance or coverage under a managed care plan, all necessary information on the coverage should be obtained. Bed availability, wait-list status, or a tentative date of admission can also be discussed at this time.

 

Information Packet

 

Before the prospective client leaves, he or she must receive an information packet, and the intake worker should briefly go over some of the materials contained in the packet. The information packet should be professionally designed and should contain all relevant information that may be needed for making a decision about placing someone in the facility. If the client has no further questions, the interview is concluded. The client should be courteously escorted to the main lobby and given a personal send-off.

 

Follow Up

 

When different personnel are involved in handling separate inquiries, all inquiries should be channeled to the person who has the primary responsibility for inquiry intake, such as the director of social services or the director of admissions. This individual should follow up on all inquiries, and the final disposition should be noted. If a prospective patient was considered an appropriate client for the facility but was not admitted, an attempt should be made to find out the reason the facility was not selected. Inquiry dispositions should be periodically reviewed with the administrator. Over time, this information can be useful in identifying weak spots and taking appropriate measures to improve operational policies, procedures, and services.

 

Admission and Orientation

 

Nursing home admission trauma is common and affects most patients. But the social worker can take steps to minimize a patient’s fear and anxiety. One source of anxiety for the patient, and of guilt for the family, is stereotyped and unpleasant images of nursing homes. Despite efforts made by industry leaders to change the gloomy portrayal of nursing homes, the effect of these images has not been overcome. Lingering negative perceptions require the industry to do more to change people’s perceptions. The adoption of culture change and incorporating the concepts of enriched environments are likely to overcome the negative perceptions over time.

 

Planning and Preparation

 

Sometimes, it may be possible for the social worker to visit a prospective resident at his or her current location. The purpose of such a visit would be to attempt to allay unfounded fears that the new patient may have. A sizable number of patients are admitted to nursing facilities on a short-term basis for rehabilitation and convalescence. If that is the case, the fact that it will be a short-term stay must be emphasized to the patient, who otherwise may be thinking that admission to the facility may be his or her final living arrangement before death. If a long stay is contemplated, the social worker should emphasize the vibrant living environment of the facility and the opportunity to pursue one’s own interests and to make new friends. Autonomy, privacy, and other features should be highlighted. This is also an appropriate time for the social worker to discuss with the family which personal belongings may or may not be brought to the facility.

 

Any special instructions from the family should be passed on to the staff members who will be involved in the patient’s care. Associates can be better prepared if they know in advance the patient’s requirements, such as assistance with specific ADLs, incontinence, patient’s preferences, or other special needs.

 

Before admission, the patient’s room must be given special attention to ensure that everything is in order. Paying attention to minute details is critical. For example, a corner of the room may need additional cleaning, a wall may need some touch-up paint, or a leaky faucet in the bathroom may need fixing. On the day of admission, a flower arrangement in the room is always a welcoming sign.

 

Admission Records

 

An important part of the admission process is ensuring that all pertinent medical records have been forwarded to the facility at the time of admission. If the patient is coming from the hospital or another nursing facility, the transfer of medical records is arranged with that institution. If the patient is coming from home or a residential facility, medical records must be obtained from the admitting physician’s office. Records must include current physician’s orders certifying the need for admission to the facility and orders for medications, nursing treatments, rehabilitation therapies, therapeutic diets, etc.

 

The social worker should also complete the admission paperwork. The resident or the responsible party must sign an admission agreement, which is a contract between the facility and the patient (or his or her representative). Another important document contains the rights and responsibilities of patients. The patient or the representative must sign this document to acknowledge that they have received it. Other documents should also be completed as required by regulations and facility policies. Generally, facilities have packets of admission forms prepared in advance to ensure that all paperwork gets completed. A monetary deposit may also be required. Besides the admission packet, the social worker completes a social history of the patient. The social history and assessment are incorporated into the patient’s individualized plan of care.

 

Orientation

 

The purpose of orientation is to help new residents adjust to the facility and its routines. On the first day, the new resident should be introduced to a handful of key staff members, such as the unit’s charge nurse, one or two nursing assistants, the activity director, and the dietitian or food service director. The administrator may also stop by for a welcoming handshake. If the admission takes place close to meal time, the family or friends who are accompanying the patient should be invited to dine with the patient in a private area. The patient may, however, express a preference to dine alone in the room or go to the dining room.

 

During the first week, the social worker should contact the resident and staff regularly to find out how the resident is adjusting to his or her new surroundings. Communication with the family should also be maintained to ensure satisfaction with the services or to simply stay in touch. Such ongoing contact can prevent conflicts down the road because it enables the facility to address minor issues as they arise. It also projects a caring attitude and allays family’s anxiety.

 

An integral part of orientation is educating new residents about their rights and the decisions and choices they can make. Patients should be encouraged to participate in decision making so that they do not fall into a pattern of “learned helplessness” because of their dependent position. Staff interactions should be supportive.

 

Within their limitations, patients should be allowed to do for themselves as much as possible.

 

Discharge Planning

 

Discharge planning is a process, not an event. The process includes decisions about when a patient may need to be discharged from the facility and what may be needed to make a smooth transition from one level of care to another or from the facility to living independently. Discharge planning is more appropriately described as continuity-of-care planning (O’Hare, 1988). According to the continuity-of-care model (Figure 8–1), discharge planning begins when a patient is admitted to the nursing facility. Upon admission, assessment and care planning are approached with discharge outcomes in mind. Discharge planning takes a multidisciplinary approach. Associates from various disciplines, such as medical, nursing, dietary, rehabilitation, and social work, provide their input into the clinical and psychosocial progress made by the patient, their reevaluation of the patient’s current status, and the patient’s prognosis for discharge from the facility. Thus, discharge planning becomes a continuous process as illustrated in Figure 8–1. The family also needs to be involved in discharge decisions. The social worker is primarily responsible for coordinating the process.

 

Figure 8–1  Continuity-of-Care Model

 

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Financial considerations, such as coverage under Medicare, are an important consideration in discharge planning. Medicare does not cover long-term stay in a skilled nursing facility. Length of stay depends on the patient’s diagnosis, assessment, and rehabilitation potential. If additional length of stay in the facility is necessary after Medicare benefits have been exhausted, the patient must pay privately or, if he or she is eligible, apply for Medicaid. Otherwise, the multidisciplinary team must prepare for the patient’s discharge from the facility. Facilities that are certified to serve Medicare and Medicaid patients are required to comply with certain discharge planning standards:

 

•  The facility must provide sufficient preparatory time to ensure safe and orderly transfer or discharge from the facility.

 

•  Medical records should contain a final discharge summary that addresses the resident’s postdischarge needs.

 

•  Facilities are to develop a postdischarge plan of care with the participation of the resident and his or her family, that will assist the resident in adjusting to his or her new living environment. This plan should include the assessment of continuing care needs and a plan to ensure that the individual’s needs will be met after discharge from the facility into the community.

 

Ensuring continuity of care after discharge is a primary consideration in the facility’s decision about where the patient will be discharged to and what ongoing services the patient may still need. If a patient will go back to his or her home, the social worker will do a social evaluation to determine whether adequate support services will be available to the patient. The facility may refer the patient to a home health agency, in which case the follow-up tasks are turned over to that agency. The key to successful discharge planning is to make arrangements so that all available resources are used to provide all the appropriate services that a patient needs after discharge. Follow up is often essential to ensure that the arranged services are being delivered (Patchner & Patchner, 1991).

 

Resident Council

 

A resident council is an independent semi-formal body made up of all residents who are able and willing to participate. The purpose of this forum is to empower the residents so they can have a say in the facility’s operations. An active resident council in the nursing facility helps promote resident autonomy and gives the residents a sense of control. This council is also a means of promoting self-esteem among residents who are able to participate in decision making concerning their own quality of life in the nursing home.

 

The social worker generally has the responsibility to assist the residents in organizing a council and to facilitate their regular meetings. For example, the social worker can assist the residents in electing council officers such as a president, a secretary, and a liaison for special events. Space should be designated where regular meetings can be held in privacy. Existence of the council should be publicized, and all residents who are able to participate should be encouraged to do so. Individual involvement, however, is voluntary. In some facilities, primary responsibility for the resident council is delegated to the activity director.

 

Because the resident council is a self-governing forum, the administrator and other associates attend the meetings only when invited. However, the administrator or other associates may ask the president for time when they can address the council on important issues and policies and provide follow-up reports on any previous concerns expressed or recommendations made by the council.

 

Family Management

 

Family management is a proactive approach to minimize dissatisfaction and conflict by addressing family members’ emotions about placing someone in a nursing home. Once a patient has been placed in a nursing facility, the patient’s family becomes a secondary client. Treating the patient’s family as a client and addressing their emotional needs is important for the overall well-being of the patient, who is the primary client. Maintaining the patient’s family ties becomes an important task of social work. The first step in this process is for the facility’s administration to promote a policy of unrestricted visiting hours for family members.

 

Families often do not anticipate placing a loved one in a nursing facility and are not prepared for it. In many instances, admission to a nursing home is preceded by a family crisis such as the death of the patient’s spouse or that of some other informal caregiver, sudden hospitalization for some unforeseen complication, an accident such as a fall that results in a fracture, or the relocation of adult children who may have been providing informal care. Such events can trigger rapid deterioration of a patient’s physical health, mental health, or both. In such situations, families may show signs of desperation, frustration, anger, guilt, or conflict. The social worker’s role is to show acceptance and empathy and to provide a supportive outlet for family members to express their true feelings but also face the realities of institutionalization. Also, some families have had a history of internal dissension and resentment. Such dysfunctional family relationships can greatly complicate the staff’s ability to adequately deal with the patient’s needs, because family members may perpetuate disagreements and interference with the facility’s practices.

 

During and after admission, reemphasizing the family’s responsibility to stay involved is important provided, of course, that the relationship between the patient and the family has been positive. If a family is no longer involved in the patient’s life, the patient may feel rejected. Most families, fortunately, continue to visit, phone, write, and care for the patient following institutionalization.

 

The social worker’s task becomes daunting indeed when bitterness and resentment have been, or remain present between the patient and family members. Trying appropriate interventions and setting reasonable goals and expectations become necessary to attempt mending dysfunctional family relationships, but only if these measures are in accord with the family’s own wishes and their willingness to mend broken relationships (Greene, 1982). Otherwise, facility staff may have to accept the fact that tenuous family relationships exist and that staff members should be prepared for occasional tensions between the staff and family. On such occasions, it is critical for the facility’s associates to remain politely and pleasantly communicative with the family members.

 

The social worker can also assist families with making their visits with the patient more meaningful and enjoyable, especially when the patient is disoriented, confused, or bedridden. Sometimes, family members of long-stay residents may become volunteers or informally adopt some patient who does not have a family.

 

The nursing home can also help families by scheduling support group meetings and educational seminars. Programs and classes about visiting skills, processes of aging, institutionalization procedures, nursing home financing, facility policies, the relative merits of assistance and independence, roles and functions of different departments in the facility, volunteering opportunities, relationships with caregivers, and other topics can be very informative and productive. Such educational programs can also provide an opportunity for families to meet key facility associates, some of whom they would otherwise never get to meet. These events help families better understand the challenges faced by the facility, and they also help family members form more realistic expectations of what the facility can and cannot do. Although family members, on an individual basis, should be encouraged to express their dissatisfactions and complaints, family seminars help focus on more productive issues. When creatively managed, these seminars can prevent family group sessions from turning into gripe sessions.

 

Death and Terminal Illness

 

Death is a reality in health care facilities. Many long-term care patients spend their final days in a nursing facility and die there. Although the association of nursing homes with death is an unfortunate stereotype, how a nursing home addresses end-of-life issues and how it provides appropriate services for dying patients and their families is an important concern. Many patients will experience a natural death and pass away without any forewarning. Others may be terminally ill and may have, according to medical opinion, only a few months to live.

 

Traditionally, death has been determined with the complete cessation of respiration and heartbeat. Brain death is the current criterion for determining death (Knox, 1989). A physician also needs to pronounce or certify that a person has expired; hence, the patient’s attending physician should be notified immediately. In some states, a registered nurse can make the pronouncement of death. It is also more appropriate for a nurse than a social worker to break the news to the family. Unless the family is present in the nursing home at the time of death, a simple but professional approach over the telephone would be, “It is with deep regret that I must inform you that (the patient’s name) just passed away. I would like to extend my deepest sympathy to you and your family” (Geary, 1982). Depending on state laws, the death may also have to be reported to the police and coroner or medical examiner. At the time of admission, many nursing homes obtain information about funeral arrangements in case of death. If such information exists in the patient’s medical record, the funeral home should be contacted to arrange for the removal of the remains.

 

People may perceive death in a nursing home to be a normative event, meaning it is normal for old people to die. Such an over-generalization, however, can become a stereotype. Even for the geriatric patient, death is an individual event. Geriatric patients have the same tensions, fears, and despair as any other age group facing death. Also, the family’s reactions to death are not homogeneous (Kosberg, 1977).

 

Social workers, nurses, and even physicians are not always prepared to react to death and dying. Yet, the social worker must be prepared to lend support to family members who have lost a loved one and also to caregivers who often feel the loss of a patient they have been intimately involved in caring for.

 

Hospice care is an appropriate end-of-life service for many terminally ill patients. However, the decision on whether to accept this alternative is left up to patients and their families. The social worker is generally responsible for counseling the patient and family members about the hospice alternative. If they accept the hospice option, a written consent is required that any attempts to cure terminal illness or active interventions to save life will not be pursued.

 

Social workers can help terminally ill patients and their families by simply being present and using kind words. Terminally ill patients generally go through the stages of denial and isolation as initial defense mechanisms; anger and resentment because of frustration and helplessness; depression emanating from feelings of guilt, failure, and despair; and, finally, acceptance of one’s fate and gradual detachment from the surroundings, including close loved ones. Family members also go through similar stages (Kübler-Ross, 1997). Throughout this process, feelings of fear and anxiety may be expressed. Family members, on the other hand, may carry feelings of guilt. Stress and contention among family members may be observed. Social workers and other associates can do very little to help people overcome these emotions. But they can be supportive and understanding throughout the process.

 

Question-In your OWN words, why should a health facility administrator become familiar with social services? Make a list of the various topics in the chapter that will be helpful to the administrator, and explain how these topics can be helpful.

 

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