Exploring Capacity for Palliative Care Focused Social Work in Skilled Care Facilities

Background: Skilled nursing facility (SNF) care for older adults accounted for $26.8 billion of health care spending in 2012. While the SNF setting is intended to be a stabilizing transition period, between one-fourth and one-half of Medicare beneficiaries are readmitted from SNF rehabilitation back to the hospital within thirty days, costing $4.34 billion in 2006.  Individuals in SNFs frequently have less than optimal health and well-being outcomes; in fact, 1 in 11 elders die while enrolled in the SNF benefit. Although there is a great need for it, palliative care is often not provided in SNFs. There are indications in some research that having qualified and trained social workers improves resident quality of life. However, there is little to no research examining palliative focused social work in SNF settings. This study explored the current capacity for providing palliative care focused social services across SNFs in the state of Colorado.

Methods: Correct contact information for 135 social services workers was obtained through contacting all 214 Colorado certified Medicare and Medicaid SNFs. In the spring of 2015, invitations to participate in a 20-item, self-administered, anonymous, on-line survey were sent. Questions focused on day to day practice, skills and activities specifically related to palliative care. Mostly descriptive and some bivariate analysis statistics are reported.

Results: Ninety-four respondents participated in the survey (70% response rate). Only 60% of respondents had a degree in social work and only 22% had a master’s degree in social work. Sixty-three percent reported a 1 to 50 worker/patient ratio at their facility (14%, 1 to 75, 5% even higher). Twenty-five percent of time was spent assessing needs for psychosocial support, 23% providing in-person psychosocial support, 22%, discharge planning and 10% assessing insurance eligibility. Forty-four percent stated only 10% of their time with clients/families is spent discussing future goals of care related to life-prolonging treatments versus palliative care.

Less than 30% of facilities required palliative or hospice training. However, respondents rated their knowledge and abilities to provide palliative care services to be moderately high (M=7.09, SD=2.13, scale of 1 to 10). Competence related to 6 palliative care focused activities were also reported. A vast majority (over 75% on all 6) assessed their skills as a 4 or 5 on a scale of 1 to 5. However, respondents rated their availability to actually perform those with clients reported at or below 3 on a scale of 1 to 5 (statistically significantly lower on all, p<.001). A notable portion believe it is difficult to recruit (25%) and retain (39%) social workers in SNFs.

Conclusions and Implications: Considering the fact that SNF residents are some of the highest risk patients for failed advance care planning, poor provider-patient/family communications, poor quality of life, and mortality our survey of SNF social service providers reveals some important opportunities for growth. Recommendations include further exploration into capacity and competence of social workers to expand their scope/ time to include palliative care focused social work and to test social work led palliative care strategies.