Research That Matters (January 17 - 20, 2008)

Background and Purpose: Psychosocial needs such as depression, anxiety, and behavioral symptoms are widespread among persons living in skilled nursing facilities (SNFs), yet the services provided to address these needs appear insufficient. Indeed, substantial evidence indicates SNF residents' psychosocial needs are generally not met (Tirrito, 1996; O'Neill & Rosen, 1998; Parker-Oliver & Kurzejeski, 2003; Department of Health and Human Services (DHHS), 2003). Social workers have been recognized as the primary providers of psychosocial services in SNFs, and both workload and knowledge barriers have been identified as factors impeding their ability to provide necessary services (Tirrito, 1996; O'Neill & Rosen, 1998; DHHS, 2003, Parker-Oliver & Kurzejeski, 2003). However, specific factors that either enable psychosocial care or reduce the barriers to service delivery have yet to be explored. Furthermore, little is known about the connection between service provision and resident-centered psychosocial outcomes. This research project utilized a three-category quality assessment framework to address these gaps in the social work knowledge base, specifically examining the impact of facility structure, facility processes, and social work characteristics on psychosocial outcomes and the frequency of service delivery. Methods: A cross-sectional design was utilized to link primary and secondary data sources. Primary data was derived from a self-administered questionnaire mailed to SNF Social Services Directors (SSDs) across Washington State; secondary data was derived from three-years' worth of resident-centered state inspection results obtained from the federal Online Survey and Certification Reporting database (OSCAR). The questionnaire achieved a 60 percent response rate with 121 SSDs participating. It measured facility process factors (overall priority of psychosocial needs, supportiveness of the work environment, and the frequency of psychosocial service delivery) and SSD characteristics (geriatric mental heath knowledge, interdisciplinary team skills, role identification, SNF social services experience, and educational attainment). The OSCAR provided resident-centered psychosocial outcomes and facility structural measures, including facility ownership, chain affiliation, location, and ownership turnover. Hierarchical linear regression was utilized to determine the independent and combined effects of facility structure, facility processes, and SSD characteristics on the frequency of service delivery and outcomes in psychosocial care. Results: Neither structural factors nor SSD characteristics predict frequency of psychosocial service delivery, but process factors do predict the frequency of services related to administration and advocacy, with the SSD's job autonomy and influence having the greatest impact. In addition, findings pinpoint specific factors in each category that hinder the provision of quality psychosocial services: high ownership turnover, limited SSD psychosocial care experience, minimal SSD identification with the helping role, and frequent assessment services in lieu of intervention services. Conclusions and Implications: Based on these findings, SNF psychosocial care could be enhanced via the following interventions: 1) update state and federal policy to minimize the destabilizing effect of ownership change, 2) identify creative means to increase psychosocial interventions, 3) standardize SNF Social Services functions and areas of responsibility, 4) revise SSD job descriptions to increase focus on the helping role, 5) support SSD involvement in professional networking and educational activities, and 6) promote retention and longevity of SSDs.