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.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors.

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.

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.

Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition.

OBJECTIVES: Previous research suggests black nursing home (NH) residents are more likely to receive inappropriate antipsychotics. Our aim was to examine how NH characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics. DESIGN: This study used a longitudinal approach to examine national data from Long-Term Care: Facts on Care in the US (LTCFocUS.org) between 2000 and 2015. We used a multivariate linear regression model with year and state fixed effects to estimate the prevalence of inappropriate antipsychotic use at the NH level. SETTING: Free-standing NHs in the United States. PARTICIPANTS: The sample consisted of 12 964 NHs. MEASUREMENTS: The outcome variable was inappropriate antipsychotic use at the facility level. The primary indicator variables were whether a facility had high proportions of black residents and the percentage of residents with Medicaid as their primary payer. RESULTS: NHs with high and low proportions of blacks had similar rates of antipsychotic use in the unadjusted analyses. NHs with high proportions of black residents had significantly lower rates of inappropriate antipsychotic use (ß = -2; P < .001) in the adjusted analyses. Facilities with high proportions of Medicaid-reliant residents had higher proportions of inappropriate use (ß = .04; P < .001). CONCLUSION: Findings from this study indicate a decline in the use of antipsychotics. Although findings from this study indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among NHs. Policy interventions that focus on reimbursement need to be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant NHs. J Am Geriatr Soc 68:630-636, 2020.

Civil Money Penalty Enforcement Actions for Quality Deficiencies in Nursing Homes.

BACKGROUND AND OBJECTIVES: Civil money penalties (CMP) are fines collected by CMS and then redistributed to states for the sole purpose of improving resident care and quality of life through reinvestment in quality improvement projects. This study examined state variation in civil money penalty enforcement actions for quality of life (QOL) and quality of care (QOC) deficiencies in nursing homes. RESEARCH DESIGN AND METHODS: 2015-2016 cross-sectional CASPER nursing home survey data obtained from the CMS QCOR database were used to explore the pattern of enforcement actions for QOL and QOC deficiencies across states. Fixed effects regression models examined relationships between state-level characteristics, quality deficiencies, and enforcement actions imposed by states. RESULTS: State enforcement actions resulting in a CMP were more likely for QOC deficiencies (M = 0.143, SD = 0.097) than for QOL deficiencies (M = 0.070, SD = 0.056) and states exhibited variability in imposing enforcement actions. The presence of severe QOC deficiencies resulting in actual resident harm contributed to CMP enforcement actions for both QOL and QOC deficiencies. States with primarily for-profit status providers had more enforcement actions. DISCUSSION AND IMPLICATIONS: The variability noted in state enforcement for quality deficiencies actions parallels inconsistencies in state regulatory oversight of nursing homes.

Post-hospitalization experiences of older adults diagnosed with diabetes: "It was daunting!"

Multimorbidity combined with geriatric syndromes in older adults with diabetes exacerbate their risks for poor post-discharge outcomes. The purpose of this study was to examine self-described hospital-to-home transition challenges encountered by older adults with a diagnosis of diabetes within the first 30 days following discharge. The qualitative responses for this paper emerged from a larger mixed methods study (n = 96) in which participants provided free responses specifying transition challenges during follow-up telephone interviews on the 7th day (n = 67) and 30th day (n = 55) post-discharge. Using inductive content analysis techniques four major themes emerged: a) "The daily stuff is difficult"; b) engineering care at home is complex; c) "life is very difficult"; and d) managing complex health problems is difficult. Findings suggest existing system-level metrics such as readmission rates fail to capture the complex and dynamic interplay of personal, family and social factors which complicate hospital-to-home transitions of older adults with pre-existing diabetes.

The Challenges of Developing a Participatory Arts Intervention for Caregivers of Persons with Dementia.

OBJECTIVE: We describe the development and challenges in implementing a web-based participatory art intervention specifically designed for caregivers of persons with dementia to use at home with their loved one.   Method: An interprofessional team, including an experienced national panel of artists, developed a participatory arts toolkit consisting of seven web-based modules involving a combination of music, singing, dancing, poetry, and painting. Participants completed a survey of demographics, caregiver needs, and caregiver burden.  Results: Thirty caregivers with high caregiver needs and a high caregiver burden volunteered to pilot the intervention. Difficulties with caregiver recruitment and compliance with lesson plans were noted. Caregivers provided positive and negative qualitative feedback.   Discussion: The challenges and possible solutions to the problems identified in the implementation and assessment of this participatory arts intervention will provide important insights for future studies linking the arts and dementia care.

A Home-Based Palliative Care Consult Service for Veterans.

We describe the development and implementation of a home-based palliative care consult service for Veterans with advanced illness. A retrospective chart review was performed on 73 Veterans who received a home-based palliative care consult. Nearly one-third were 80 years of age or older, and nearly one-third had a palliative diagnosis of cancer. The most common interventions of the consult team included discussion of advance directives, completion of a "do not resuscitate" form, reduction/stoppage of at least 1 medication, explanation of diagnosis, referral to home-based primary care program, referral to hospice, and assessment/support for caregiver stress. The home-based consult service was therefore able to address clinical and psychosocial issues that can demonstrate a direct benefit to Veterans, families, and referring clinicians.

Using life history narratives to educate staff members about personhood in assisted living.

Oral life history narratives are a promising method to promote person-centered values of personhood and belonging. This project used resident oral history interviews to educate staff members in an assisted-living setting about personhood. A single group pre-post test design evaluated impacts on 37 staff members to assess their use of resident videotaped oral history interviews and impacts on their perceived knowledge of residents. Perceived knowledge of residents declined (p = .003) between pretest and posttest. Older staff members were less likely to view a video. Staff members are interested in resident oral history biographies and identify them as helpful for delivering care. Oral history methods might provide an opportunity for staff members to promote personhood by allowing them to expand their understanding of resident preferences, values, and experiences.

The attitudes of graduate healthcare students toward older adults, personal aging, health care reform, and interprofessional collaboration.

Healthcare reform has led to an increased emphasis on interprofessional healthcare models for older adults. Unfortunately, best practice education that focuses on the interprofessional healthcare of the elderly does not yet exist. As a prelude to implementing interprofessional geriatric educational initiatives, we developed a survey to identify potential attitudinal differences among graduate healthcare students regarding personal aging, caring for older adults, healthcare reform and the role of the physician on the interprofessional team. We surveyed third-year medical students, nurse practitioner students and graduate social work students. Attitudes regarding personal aging were similar among the professions. Nurse practitioner and social work students had higher positive attitudes toward the care of older adults. Concerns about the impact of healthcare reform on quality and healthcare costs differed significantly. There was also a significant difference in attitudes concerning the role of the physician as the leader of the interprofessional team. These results provide insights into gerontologic-focused attitudes of graduate healthcare professional students. In an era of dramatic healthcare change, these findings will assist educators in the development and implementation of educational programs to prepare graduate students for the interprofessional care of elderly patients.

Gerontological social workers' perceived efficacy for influencing client outcomes.

Using a sample of practitioners (n = 269) from the 2004 National Study of Licensed Social Workers, this article employs a quality assurance structure-process-outcome model to examine factors at the practitioner, workplace, and service delivery levels that influence the perceived efficacy of licensed gerontological social workers to affect client outcomes in the context of a highly challenging health care environment. A regression model accounted for 33.9% of the variance (adjusted R (2) = .291) in perceived efficacy with 3 aspects of service delivery satisfaction having significant effects: ability to address complex/chronic care, to influence the design of services, and to help clients navigate the system.

Commitment of licensed social workers to aging practice.

This study sought to identify client, professional, and employment characteristics that enhance licensed social workers' commitment to aging practice. A series of binary logistic regressions were performed using data from 181 licensed, full-time social workers who reported aging as their primary specialty area as part of the 2004 NASW's national study of licensed social workers. Several variables were identified as being significant predictors of commitment to aging, including clients' source of insurance, practitioners' years of experience in social work and gerontology, perceived adequacy of training, number of social work colleagues in the work environment, perceived appropriateness of delegated tasks, and annual income. This study illuminates critical areas of need to promote professional commitment to aging practice. Promotion of training and competency-based education and the need for sufficient job challenge and appropriate assignment of roles (that is, those that are consistent with practitioners' skills and abilities) will encourage commitment to working in the field ofgerontology.

Psychological well-being and social support among elders employed as lay helpers.

Impacts on lay helpers of participation in part-time work supporting rural elders with severe mental illness were explored in a group of 17 older adults employed in a demonstration project. Self-rated well-being and social support were assessed over 1 year. Ratings of autonomy and positive relations with others varied over 1 year. Perceptions of the amount of social support provided showed a trend toward improvement at 1 year. Results are considered in the context of role theory and illustrated with an ethnographic case study of the service environment. The lay helper role is a form of productive engagement through paid caregiving, with potential to supplement rural mental health service systems while supporting elders' needs for meaningful civic engagement.

Facility service environments, staffing, and psychosocial care in nursing homes.

Using 2003 Online Survey Certification and Reporting (OSCAR) data for Medicare and Medicaid certified facilities (N = 14, 184) and multinomial logistic regression this study investigated if (1) psychosocial care quality was better in facilities where State requirements for qualified social services staffing exceeded Federal minimum regulations and (2) facility service environments are associated with psychosocial care quality. For-profit status and higher percentage of Medicaid residents are associated with lower quality. Staffing, market demand, and market competition are associated with better quality. Psychosocial care quality is more associated with payer status and market forces and less with regulatory requirements.