Employment of a Qualified Social Worker and Residents' Health in Nursing Homes: A National Longitudinal Data Analysis

Background and Purpose: Nursing homes (NHs) provide 24-hour care for individuals—primarily older adults—with significant health or functional needs. With over 15,000 NHs serving approximately 1.2 million residents in the U.S., concerns about care quality remain despite high costs. Social workers play a vital role assessing residents, creating care plans, and supporting person-centered environments. A systematic review found that NHs with social work-led services had higher quality ratings, better health outcomes, and cost savings. However, many NHs face staffing shortages, including limited social work coverage, and high staff turnover further strains care delivery. Rigorous evidence on the effectiveness of social workers is needed to inform policies and funding decisions. This study examined the relationship between social worker employment in NHs and resident’s health using national longitudinal data.

Methods: We used facility-level data from the Long-Term Care (LTC) Focus database and the Payroll-Based Journal (PBJ) non-nursing staff files from the Centers for Medicare & Medicaid Services, spanning 2017 to 2021. The dependent variable was residents’ health measured by successful discharge rates from hospital, hospitalizations per resident-year, rehospitalization rates, and use of physical restraints in NHs. The independent variable was employment of a qualified social worker (QSW). To account for non-random QSW employment, we applied a Synthetic Difference-in-Differences approach with staggered adoption to estimate causal impact of QSW employment on resident outcomes, controlling for NHs and year fixed effects. Specifically, we compared NHs that began employing a QSW after 2017 to those that never employed one. Our final sample included 2,507 NHs, with 1,423 never employing a QSW during the study period.

Results: We found that the estimated effects on successful discharge rates from hospital (–0.002, p = 0.624) and hospitalizations per resident-year (0.012, p = 0.306) were not statistically significant. However, NHs that employed a QSW saw a 0.3 percentage point reduction in physical restraint use in NHs (p = 0.059) and a 0.4 percentage point decrease in rehospitalization rates (p = 0.119), compared to those without a QSW. Subgroup analysis focused on facilities with a higher proportion of residents with related dementias (AD/ADRD), defined as those above the 50th percentile in ADRD prevalence. The results showed a 0.5 percentage point reduction in restraint use in these facilities (p = 0.019), suggesting that QSW employment has a particularly strong impact in NHs with more residents experiencing cognitive impairment.

Conclusions and Implications: The findings showed that QSW employment was linked to a modest reduction in physical restraint use and rehospitalization rates, with stronger effects in NHs serving more residents with AD/ADRD. The significant decline in restraint use in these facilities underscores the critical role QSWs play in promoting person-centered, less restrictive care for residents with dementia. These results highlight the value of targeted social work interventions in improving care quality, particularly for cognitively impaired populations. The findings also provide insights for policymakers, healthcare administrators, and stakeholders on the role of social workers in enhancing care delivery in NHs.