Social Workers Critical to Honoring Commitments to Residents and Families in Long-Term Care.

Social workers have been at the forefront of research and advocacy to improve nursing home care for several decades. However, United States (U.S.) regulations have not kept pace with professional standards, as nursing home social services workers are still not required to have a degree in social work and many are assigned caseloads that are untenable for providing quality psychosocial and behavioral health care. The National Academies of Sciences, Engineering, and Medicine (NASEM)'s recently published interdisciplinary consensus report, The National Imperative to Improve Nursing Home Quality: Honoring our Commitment to Residents, Families, and Staff (NASEM, 2022) makes recommendations for changing these regulations, reflecting years of social work scholarship and policy advocacy. In this commentary, we highlight the NASEM report recommendations for social work and chart a course for continuing scholarship and policy advocacy to improve resident outcomes.

Barriers to Psychosocial Care in Nursing Homes as Reported by Social Services Directors.

This study identifies social services directors' perceptions of major barriers to psychosocial care and examines the structural factors associated with these barriers. Data were merged from the 2019 National Nursing Home Social Services Directors Survey and CMS's Nursing Home Compare. A hierarchical linear regression predicts overall barriers. Nine binary logistic regressions predict specific barriers. Common major barriers include "insufficient number of nurse aide staff" (31%), and "having to do things other people could do" (30%). Overall barriers to psychosocial care decreased as directors' years of experience increased, the number of staff members in social services increased, and less time was spent on short-stay residents. Departments with one staff member (compared to 3+) have a 300% greater likelihood of perceiving a major barrier in social services staffing, pressured discharge of short-stay residents, and residents' socioemotional needs are treated as less important than medical/nursing needs. Directors had a 59%-239% greater likelihood of perceiving a major barrier across six of the nine barriers when 50% or more of social services staffing is devoted to short-stay residents. To improve psychosocial care, federal guidelines should ensure adequate staffing levels differentiated by resident needs across short- and long-term care.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes.

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

About a Third of Nursing Home Social Services Directors Have Earned a Social Work Degree and License.

Nursing home (NH) residents have high psychosocial needs related to illness, disability, and changing life circumstances. The staff member with the most expertise in addressing psychosocial needs is the social worker. However, federal regulations indicate that only NHs with 120+ beds need hire a social services staff member and that a "qualified social worker" need not have a social work degree. Therefore, two-thirds of NHs are not required to employ a social services staff member and none are required to hire a degreed social worker. This is in stark contrast to NASW professional standards. Reporting findings from this nationally representative sample of 924 social services directors, we describe the NH social services workforce and document that most NHs do hire social services staff, although 42% of social services directors are not social work educated. 37% of NHs have a degreed and licensed social worker at the helm of social services. The odds of hiring a degreed and licensed social workers are higher for larger NHs, especially if not-for-profit and not part of a chain. NH residents deserve psychosocial care planned by staff with such expertise. Quality of psychosocial care impacts quality of life.

Older Adults' Experiences with Audiovisual Virtual Reality: Perceived Usefulness and Other Factors Influencing Technology Acceptance.

OBJECTIVE: This study explores how older adults respond to audiovisual virtual reality (VR) and perceive its usefulness to their lives. METHOD: Focus groups were conducted with residents of a retirement community after they viewed two audiovisual VR simulations (n = 41). Thematic analysis was used to identify patterns in responses. RESULTS: Older adults described positive and negative emotional reactions to aspects of the VR experience, articulated content preferences, shared ideas to improve the usability of the equipment, and identified facilitators and barriers that influenced perceived usefulness. Recommendations for improving this technology include maximizing the positive aspects of VR through increasing interactivity, facilitating socializing with friends or family, and enhancing older adults' ease of use. Desired content of simulations involved travel, continuing education, reminiscence, and self-care/therapy. CONCLUSION: Virtual reality was reviewed positively, yet modifications are necessary to facilitate optimal user experience and potential benefit for this population. CLINICAL IMPLICATIONS: As older adults are interested in using VR, especially if poor health prevents the continuation of desirable activities or new experiences, it is important to respond to older adults' preferences and remove barriers that limit use and enjoyment.

Secondhand Smoke and Women's Cognitive Function in China.

Exposure to secondhand smoke (SHS) is known to be harmful to health. However, the association between household SHS and cognitive function among middle-aged and older women in China is understudied. Lagged dependent variable regression was used to examine the association between household SHS exposure and the cognitive function of married women who had been exposed to SHS, using data from 2 waves of the China Health and Retirement Longitudinal Study (CHARLS, 2011-2013). Controlling for age, educational attainment, geographic residence, household expenditures, and chronic conditions (i.e., hypertension, diabetes, and depressive symptoms), the results indicated that longer SHS exposure was associated with a greater decline in memory over 2 years. After comparing differences across age groups, this pattern was significant for women aged 55-64 years. Furthermore, those who were illiterate, lived in rural areas, and reported depressive symptoms had a greater decline in memory. With evidence linking household SHS exposure with a higher risk of cognitive decline, effective education and public health intervention programs are urgently needed. Stronger tobacco control regulations and education about the dangers of household SHS are viable strategies to reduce the impending dementia epidemic in China.

Marital Quality and Alcohol Use among Couples in Mid- and Later-Life.

Spouses influence one another's drinking behavior, but little research has explored how relationship quality may impact older couples' alcohol use. Using data from the 2014-2018 waves of the Health and Retirement Study (HRS) and actor-partner interdependence models, we examined how marital quality is related to total alcohol consumption and risk of heavy drinking for married couples over age 50. Neither husbands' nor wives' perceptions of negative marital quality were related to changes in heavy drinking or number of drinks consumed over the observation period. However, wives' positive marital quality was associated with increased risk of heavy alcohol use for both wives and husbands, and with an increase in the number of drinks wives consume over time. Couples over age 50 do not appear to use alcohol as a way of coping with negative marital relationships, but rather may increase their drinking in the context of positive relationships.

Reported coping strategies and depressive symptoms among African American and white residents of congregate housing.

Chronic health conditions and living in congregate housing, both stressors and losses, are risk factors for late life depressive symptoms. We examined self-reported coping strategies and their associations with depressive symptoms among residents of congregate living facilities. Despite demographic differences between the African American and the White participants, reported coping for the 2 groups was similar, though more African Americans reported spiritual coping. Participants who reported coping through either positive attitude and adaptations or activity participation had fewer depressive symptoms, after controlling for demographics, health, functioning, and other types of coping.

Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality.

Health care providers face fixed reimbursement rates from government sources and need to carefully adjust staffing to achieve the highest quality within a given cost structure. With data from the Certification and Survey Provider Enhanced Reports (1999-2015), this study holistically examined how staffing levels affect two publicly reported measures of quality in the nursing home industry, the number of deficiency citations and the deficiency score. While higher staffing consistently yielded better quality, the largest quality improvements resulted from increasing administrative registered nurses and social service staffing. After adjusting for wages, the most cost-effective investment for improving overall deficiency outcomes was increasing social services. Deficiencies related to quality of care were improved most by increasing administrative nursing and social service staff. Quality of life deficiencies were improved most by increasing social service and activities staff. Approaches to improve quality through staffing adjustments should target specific types of staff to maximize return on investment.

The Predictors of and Motivations for Increased Family Involvement in Nursing Homes.

BACKGROUND AND OBJECTIVES: Quantitative and qualitative data from a statewide survey of family members of nursing home residents were analyzed to determine the predictors of, and motivations for, family involvement. RESEARCH DESIGN AND METHODS: We examined 3 types of involvement: visiting, providing personal care, and family-staff communication. Our mixed methods approach used (a) multilevel regression models to examine predictors of family involvement, including family member perceptions and resident, family member, and facility characteristics, and (b) a thematic analysis of qualitative data regarding the experiences of family members and their motivations for involvement. RESULTS: Families were more involved when a short-term stay (<3 months) was expected, and when residents were in poorer physical condition. Spouses and female family members were more involved than others, yet the effect of gender varied by relationship type. At the facility level, families of residents in rural facilities reported less family involvement. Aside from these commonalities, predictors of each type of involvement varied. Themes from the qualitative data identify unique motivations for each type of involvement-to enhance residents' identity, care, or quality of life. DISCUSSION: Families visit more and provide more hands-on assistance when they are not confident in the care being provided or the well-being and stability of their resident loved one. Receiving adequate information, perceiving staff as friendly, and residents as looking well cared for promote greater family-staff communication. IMPLICATIONS: Findings can inform strategies to increase meaningful family involvement in nursing homes.

Nursing Home Social Services and Post-Acute Care: Does More Qualified Staff Improve Behavioral Symptoms and Reduce Antipsychotic Drug Use?

OBJECTIVES: An increasing number of post-acute care patients are admitted to skilled nursing facilities (SNFs) with behavioral symptoms such as wandering and rejecting care, which can interfere with care and place a patient at risk of social isolation or injury. This study examines whether increasing the qualifications of social service staff through using a greater proportion of qualified social workers (QSWs) instead of paraprofessionals improves patients' behavioral symptoms and reduces the use of antipsychotic medications. DESIGN: Secondary data analysis of national data drawn from the Minimum Data Set, Medicare Beneficiary Summary File, and Certification and Survey Provider Enhanced Reporting surveys. SETTING AND PARTICIPANTS: Newly admitted, Medicare fee-for-service patients aged ≥65 years who received post-acute care after a hospitalization from 2011-2015 (1,201,096 patient admissions in 5383 unique SNFs). METHODS: A regression discontinuity approach is used to identify how changes in the qualifications of social service staffing affect changes in patient outcomes, through exploiting a federal regulation that requires 1 full-time QSW for SNFs with at least 121 beds. RESULTS: SNFs with a greater proportion of QSWs improved behavioral symptoms that affected residents or others and reduced the use of antipsychotic medications. Marginally significant improvements were also found in patients' rejecting care, wandering, and having any behavioral symptoms. There was no statistically significant change in delusions. CONCLUSIONS AND IMPLICATIONS: Although the focus of most research and effects on improving patient outcomes in SNFs has focused on nursing staff, our results underscore the importance of staffing in social services. Specifically, social service staff with higher qualifications are integral to improving care through reducing patients' behavioral symptoms and avoiding the use of antipsychotic medications. It may be time for SNFs to revisit efforts to improve staffing in social services.

Family Satisfaction With Nursing Home Care: Findings and Implications From Two State Comparison.

Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Data sources are family satisfaction surveys from Minnesota (MN) and Ohio (OH), linked to facility characteristics from Certification and Survey Provider Enhanced Reports (CASPER) for both states (N = 378 facilities for MN; N = 926 facilities for OH). Activities and food were among lowest rated items in both states. Relationships with staff were the highest rated domain. Higher occupancy rates, smaller facility size, and non-profit ownership consistently predicted better satisfaction in both states. Our findings show consistent organizational factors associated with family satisfaction and provide further evidence to the validity of family satisfaction as a person-centered measure of quality. This lays the foundation for tool development on the national level.

Coping Resources, Loneliness, and Depressive Symptoms of Older Women With Chronic Illness.

Chronic illness with its accompanying physical stressors poses a risk factor for loneliness and depression in later life. Testing a model of stress and coping, we examined the effects of three types of coping resources (religious coping; Selection, Optimization, and Compensation [SOC] adaptive strategies; and perceived social support) on the deleterious effects of chronic illness among older women. Community-dwelling older women (N = 138) with at least one chronic illness (M = 3.9, SD = 2.1) completed mailed questionnaires. Respondents reported multiple morbidities and 90% reported interference with daily life. Social support was associated with less loneliness and depression and mediated the relationship between physical health and loneliness. Our study demonstrates two distinct pathways to depressive symptoms: one through physical symptoms, pain, and disability, and another through the experience of loneliness. Findings support intervention approaches that address disability-related issues and loneliness, and assist older women with chronic illness in identifying and marshaling social support.

Family Involvement in the Nursing Home and Perceived Resident Quality of Life.

Purpose of Study: This study focuses on the relationship between family involvement and family perceptions of nursing home residents' quality of life (QOL). Design and Methods: Resident and family variables from the 2012 Ohio Family Satisfaction Survey were merged with facility information from the Certification and Survey Enhanced Reports (CASPER). Hierarchical linear modeling was used to examine the association between family involvement and other predictors with perceived resident QOL. Results: Although most of the variability in family member perceptions of resident QOL was observed at the individual level (residents and families), characteristics of the facilities were also significantly associated with perceived resident QOL. Family involvement was a strong predictor of perceived resident QOL: Families who visited frequently and provided more help with personal care perceived lower resident QOL, while those who communicated frequently with facility staff had higher perceptions of resident QOL. Interestingly, the negative association between helping with more personal care and perceiving lower resident QOL was attenuated when family members communicated more regularly with facility staff. However, as family member age increased, the positive association between communication with facility staff and resident QOL diminished. Family members who are spouses, older, non-White, and highly educated perceived resident QOL as lower. Implications: Meaningful family involvement is a modifiable factor that can potentially enhance resident QOL. Facilities can become more family-oriented through encouraging communication between staff and families, helping spouses and other family members fulfill their desired caregiving role, and discussing the family's motivations for providing personal care during visits.

How Does Rurality Influence the Staffing of Social Service Departments in Nursing Homes?

PURPOSE OF THE STUDY: Social service departments in nursing homes (NHs) are staffed by qualified social workers (QSWs) and paraprofessionals. Due to greater workforce challenges in rural areas, this article aims to describe the staffing levels and composition of these departments by rurality. DESIGN AND METHODS: Certification and Survey Provider Enhanced Reports data from 2009 to 2015 are used to examine the effect of rurality on social service staffing using random-effects linear panel regressions. RESULTS: The average NH employed 1.8 full-time equivalents (FTEs), with approximately two thirds of social services staffed by QSWs. Large NHs had more staff, but employed fewer staff hours per resident day. Staffing levels were lower and QSWs made up a smaller percentage of staff in rural areas. IMPLICATIONS: National trends indicate variability in staffing by NH size and degree of rurality. Very low staffing within rural NHs is a concern, as staff may have less time to respond to residents' needs and these NHs may utilize fewer QSWs.

Quality of Life Trajectories of Older Adults Living in Senior Housing.

Quality of life (QoL) in the face of declining health, mobility, and social losses is a central issue for older adults. Our study examined changes in QoL over time for older adults residing in independent senior housing within continuing care retirement communities (CCRCs) and estimated how residents' social engagement during their first year influenced QoL over the next 4 years. Data were drawn from a 5-year panel study of 267 older adults who moved into senior housing within four CCRCs. Although initial QoL varied between individuals, QoL declined for the group over time. One component of early social engagement-participating in a greater number of formal social activities organized by the CCRC-significantly slowed the rate of decline in QoL. Findings suggest that senior housing residents may benefit from early participation in organized social and leisure activities soon after move-in to forestall declines in QoL over the long term.

Who Hires Social Workers? Structural and Contextual Determinants of Social Service Staffing in Nursing Homes.

Although nurse staffing has been extensively studied within nursing homes (NHs), social services has received less attention. The study describes how social service departments are organized in NHs and examines the structural characteristics of NHs and other macro-focused contextual factors that explain differences in social service staffing patterns using longitudinal national data (Certification and Survey Provider Enhanced Reports, 2009-2012). NHs have three patterns of staffing for social services, using qualified social workers (QSWs); paraprofessional social service staff; and interprofessional teams, consisting of both QSWs and paraprofessionals. Although most NHs employ a QSW (89 percent), nearly half provide social services through interprofessional teams, and 11 percent rely exclusively on paraprofessionals. Along with state and federal regulations that depend on facility size, other contextual and structural factors within NHs also influence staffing. NHs most likely to hire QSWs are large facilities in urban areas within a health care complex, owned by nonprofit organizations, with more payer mixes associated with more profitable reimbursement. QSWs are least likely to be hired in small facilities in rural areas. The influence of policy in supporting the professionalization of social service staff and the need for QSWs with expertise in gerontology, especially in rural NHs, are discussed.

Changes in activity and interest in the third and fourth age: associations with health, functioning and depressive symptoms.

This study examines the changes in activity investment among older adults and the role of these changes in the relationship between health limitations and depression. Residents of six senior living facilities (N = 178) completed questionnaires including the Geriatric Depression Scale, health and functioning measures and the Revised Change in Activity and Interest Index (CAII-R) which measures self-perceived changes in the level of investment in social and leisure activities among older adults. Respondents indicated more disengagement from CAII-R subscales Active Instrumental (AI) and Active Social (AS) and increased engagement in Passive Social Spiritual. Fourth Age adults (age 80+) reported greater reductions in AI than Third Age adults (age 64-79). Reduced AS investment had the strongest association with depression and mediated the relationship between poor health or functioning and depression. These categories of activity may guide occupational therapy practitioners and other health providers in selecting the focus of intervention for older clients according to their identified life stage. The study provides evidence of distinct differences in interests within the parameters of normal aging and a baseline from which to assess the impact of illness and disability on the activity choices for clients in different life stages.