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Transforming Palliative Care in the Nursing Home: The Social Work Role Mercedes Bern-Klug, PhD MSW

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Title: Transforming Palliative Care in the Nursing Home: The Social Work Role Mercedes Bern-Klug, PhD MSW


1
Transforming Palliative Care in the Nursing Home
The Social Work Role Mercedes Bern-Klug, PhD
MSW

2
Home of Wild Bills Coffee Shop Creative
Writing for Social Workers- Annual Summer 4-day
workshop
Mercedes Bern-Klug, PhD, MSW Associate Professor,
School of Social Work Director, The UI Aging
Studies Program
3
Objectives
  • Nursing Homes in US
  • Role of Social Workers in NH
  • Palliative Care
  • SW Striving Toward Palliative Care

4
Nursing Homes in the U.S.
  • Part of the Long-Term Care System
  • Assisted Living
  • Sheltered Housing
  • Private home

5
U.S. Nursing Homes
  • 16,000 NH 2/3 lt 120 beds
  • Most (78) NH have a hospice contract.
  • 1.5 million residents/ 3 million
  • 98 of res are in NH Medicare and/or Medicaid
    certified
  • 2/3 res are in for-profit NH
  • About half in a chain NH
  • 2/3 res in NH with 100 beds
  • Source NCHS, 2004 National Nursing Home Survey.

6
Place of NH-resident
  • When I first came here (4 years ago) I felt
    like Id been put in a penitentiary for life. NO
    chance to get out. Here til I die. Of course I
    would never say that to someone who just came
    inbut I am saying that to you so you know what
    it is like. To someone new Id say, How lucky
    you are to be here. You have a nice place to
    spend your last days. Its a nice place to be
    if you cant be anywhere else.

7
  • NH Relief for Some
  • Mr. L had fallen at home.
  • Former fire fighter said.
  • Mrs. N and local drug store

8
Nursing Home Residents
  • 70 are women
  • 53 widowed 15 single or NM
  • 12 under age 65 45, 85
  • Half receive 9 meds per day
  • 43 incontinent of BOTH b and b
  • 23 in pain over last 7 days
  • 11 pressure ulcer
  • Source NCHS National Nursing Home Survey of 2004.

9
Kanes 5 Types of NH Residents
  • Post hospital rehabweeks/months
  • Chronic physical impairments alert
  • People with cognitive impairment
  • People in permanent vegetative state
  • People considered terminally ill

Source Kane, R.L. (1996). The evolution of the
American nursing home, in Binstock, Cluff Von
Mering (eds), The future of long-term care
Social and public policy. Baltimore, MD Johns
Hopkins Press.
10
Role of Social Workers in NH
11
Federal Regs
  • Nursing homes that receive Medicare and/or
    Medicaid funding are required to
  • Provide medically-related social services to
    attain or maintain the highest practicable
    physical, mental, and psychosocial well-being of
    each resident.
  • Code of Federal Regulations

12
Federal Regs
  • Nursing homes with more than 120 beds must employ
    a full-time qualified social worker.
  • Qualified Bachelors degree in social work or
    in a human service field and one year of
    supervised sw experience in a health care setting
    working directly with individuals.

13
SW Role
  • According to the STATE OPERATIONS MANUAL
  • Medically related social services might include
  • Arrangements for adaptive equipment
  • Participate in care planning
  • Make referrals for outside services (talking
    books)
  • Financial and legal matters
  • Discharge planning
  • Provide or arrange for counseling
  • Support residents individual needs
  • Promote actions by staff toward resident dignity
  • Help residents determine how health care
    decisions to be made
  • Meet needs of grieving residents.

14
Working with Residents Metaphors from
interviews
  • Advocate Liaison Mediator
  • Cheerleader
  • All the in-betweens (ss preferred)
  • Get everybody on the same page
  • Troubleshooter and problem solver
  • Gentle watchdog
  • I work on anything a pill cant fix!
  • Im somebody who doesnt do something TO them
    and just for a moment they can forget they are in
    a nursing home. Iowa Social service director
    2005

15
Education Level
  • Less than 4 yr degree 20
  • BA 25
  • BSW 31
  • MA 6.4 (non BSW)
  • MSW 18 (includes some BSW)
  • 49 of NH SS Directors are SW educated

16
Implication It is difficult for residents,
staff, physicians, and families to know what they
can count on from SW, if there is no common
educational background or common ethic of
professional service.
17
Maslows Hierarchy
2 types of esteem needs
18
Abraham Maslow
  • 1908 1970
  • Esteem needs
  • Respect of others
  • Attention
  • Recognition
  • Reputation
  • Fame Glory
  • Self-respect
  • Confidence
  • Competence
  • Freedom
  • Mastery
  • Independence
  • Achievement

19
Advanced age/Illness Psychosocial Issues
  • Depression anxiety dementia
  • Lossmultiple and profound
  • Function and fluids
  • People/relationships
  • Possessions
  • Social Role who am I now?
  • Meaning making/existential crisis
  • Dealing with NH living
  • Transitions Hope and the New Normal

20
Psychosocial Unmet Needs
  • Can be life threatening
  • Can effect how people experience pain.
  • Can affect a residents willingness to trust
    staff.
  • Can interfere with relationships
  • Can zap the joy out of life
  • Can affect a residents will to live

21
Palliative Care
22
Social/ Health Roles
  • Sick
  • Chronically Ill
  • Dying
  • Where does palliative care fit?

23
What would you have said?
  • Mrs. R., you know you are getting up there in
    age. You are 95. Well you know Mrs. R., your
    eyes are 95 too. Your eyes are deteriorating
    right along side the rest of youget the
    picture.
  • As long as there is life there is hope. You
    dont bury a person until they are dead..honey,
    I dont fight death, but as long as Im living I
    want to be happy and not be in pain.

24
Palliative Care
  • Relief from pain symptoms
  • Affirms life dying is normal
  • Neither hastens nor postpones death
  • Integrates psychosocial spiritual
  • Support to live actively until death
  • Supports familymore.
  • www.nationalconsensusproject.org/AboutGuidelines.a
    sp

25
Palliative Care
  • Team approach
  • Enhance QoL
  • Is applicable early in illness
  • Investigates complications
  • WHO

26
Palliative Care is Consistent with other Care
Initiatives in NH
  • Person-centered care
  • (google Pioneer Network in NH)
  • Quality of life emphasis
  • OBRA 1987
  • Setting as a home

27
Palliative Care
  • Relief from pain symptoms
  • Affirms life dying is normal
  • Neither hastens nor postpones death
  • Integrates psychosocial spiritual
  • Support to live actively til death
  • Supports familymore.

28
Palliative Care is Consistent with other
Initiatives in NH
  • Person-centered care
  • Pioneer Network in NH
  • Achieving Excellence Campaign
  • Quality of life emphasis
  • OBRA 1987
  • Setting as a home

29
Hospice
  • One method of providing palliative care for
    persons considered to be at the end of life.

30
Medicare Hospice benefits
  • RN provided (or supervised) nursing care
  • Medical social services (social workerMSW)
  • Physician services
  • Counseling (dietary, emotional- loss) for res
    and/or family)
  • Medical appliances and supplies and pain drugs
  • PT, OT, speech.
  • Bereavement counseling
  • Short-term in-patient care (hospice, hospital,
    NH) to control pain and symptoms respite for
    caregivers.
  • other

31

Effects of Hospice in Nursing Homes
  • Reduce hospitalizations
  • Improve pain management
  • Have positive effects on non-hospice residents
  • http//www.nhpco.org/files/public/regulatory/JPSM_
    NurHome_review_Sept2009.pdf Stevenson Bramsons
    2009 article Hospice Care in the NH A Review of
    the Literature

32
Hospice in NH
  • Better resident outcomes
  • More staff to provide care (more baths ?
    possibly more confusion ?)
  • NH staff knows the resident hospice knows pain
    and comfort issues
  • NH staff appreciates hospice help with
    challenging family dynamics.

33
Medicare Hospice Benefit in NH
  • Medicare pays for the pain-control and comfort
    needs.
  • Resident/patient is responsible for room and
    other costs
  • Medicaid may cover
  • Private insurance may cover
  • Out of pocket

34
Social Workers Transforming Nursing Homes
  • Anticipate
  • Identify
  • Address
  • Evaluate interventions
  • Common psychological and social issues at key
    times (with residents, family and staff)
  • Admission
  • Room change/roommate change
  • Health changes
  • Setting of care changes
  • Death of friend

35
SW Can Assist in Transforming NH Through
Palliative Care Philosophy
  • Social
  • Interactions with residents, family, staff,
    community solitude!
  • Spiritual
  • Meaning making
  • Higher Power
  • Self worth purpose
  • Systems/Advocacy
  • Admissions
  • Transitions
  • Resident Rights
  • MH Referrals
  • Comm Connections
  • Physical
  • Roommates
  • Environment
  • Emotional
  • Coping skills
  • Grief/Loss
  • Growth
  • Healing
  • Dignity
  • Mental
  • Depression
  • Anxiety
  • Dementia
  • Adjustment

36
Social Work Role
  • Psycho Educational Series Coordinator
  • Socialization roles
  • Advocacy
  • Emotional support
  • Advance care planning process
  • Connecting with community resources for resident
    and family
  • Transitions and Triggers Coach
  • Care Plan Meeting Coordinator and Group Leader
    (GoC)

37
Family Stress too!
  • When I first put momma in a nursing home I sat
    down and cried for two hoursmy brother said to
    me, there is an unwritten law that daughters
    take care of mothersnow you take her to your
    home and you add a room to your houseand you
    take care of her! I told him, I know about
    that law but I cant do it anymore.

38
SW Helping NH Families
  • Adjustment
  • Loss
  • Seeing the family member decline
  • Depression and anxiety
  • Guilt
  • Conflicted or torn
  • Meaning making
  • Relationship continuity and growth

39
SW Involving Residents and Families in Goals of
Care discussions
  • Conversations
  • 5-Wishes document
  • Respecting Choices - La Crosse
  • Include families in care plan meetings

40
Summary
  • Role of NHs changing
  • Culture of NH changing
  • Palliative care is appropriate throughout the
    life span, and especially in advanced chronic
    illness, especially in NH setting.
  • SW have much to contribute to enhancing
    palliative care!
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