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Sarah Wright: Keeping patients first in nursing homes

Just as doctors run hospitals, nurses run nursing homes. True, every nursing home has a medical director and an administrator, but the fact is that nursing facilities have become an increasingly significant part of our health care system. We see sicker and frailer people than we did 20 years ago, and we also see younger patients.

To be sure, nurses do not run nursing homes by fiat or without their interdisciplinary teams’ input. However, the nursing home of today is nothing like the one of yesteryear. Nowadays, most residential centers provide both short-term rehabilitation and long-term care.

Post-acute care typically occurs after a brief hospitalization when a patient requires ongoing medical management and/or rehabilitation. It is not a coincidence that some skilled nursing facilities are still located within the hospital setting, where they are known as transitional care units. Still, the more common trend is that people leave the hospital and go to the rehab center, usually for two to four weeks.

It costs Medicare much less to care for someone in the rehab center than it does in the acute care setting. It costs Medicare even less to provide home health services through a visiting nurse agency. However, going straight home after a serious operation or disease flare-up can be risky, and this is what makes nursing home care so crucial.

The magnitude of the current need for memory support and dementia care is also relatively new, which is affecting the need for long-term care. Long-term care is not just for people with dementia, though. It is for people who are unable to live safely at home and need help with things like medication management, eating, toileting, bathing, and dressing. Ironically, Medicaid supports the bulk of long-term care costs in the United States, something it was not intended to do.

I have spent the better part of the last 20 years in the skilled nursing facility environment as a social worker. I can tell you that for all the talk about patient-centered care, we desperately need to enlarge our focus to become more family-centered as well. This will take conscious effort on the part of the entire industry.

In many ways, this discussion is already happening, but it needs to continue and develop into something more substantive. The interdisciplinary team presumes the patient’s participation; it would benefit from stronger family involvement as well. Of course, this may be easier when the patient is admitted for short-term rehab and expects to return home.

Family support is critical here. At the same time, the reality of long-term care includes things like functional decline, advance directives and end of life care. Facing these realities by taking an active role in a family member’s home, health and support is equally essential to quality care.

A greater social work presence would make the nursing home environment more family-friendly. A recent blog post in the industry’s major trade publication made this argument, calling a solid social work department a facility’s best competitive advantage. Part of the analysis relates directly to the role that social work plays in conducting family education sessions as well as alerting nursing supervisors to team issues that need to be addressed.

Family education can be as basic as explaining the discharge planning process or how to complete a health care proxy. Likewise, team issues run the gamut from sending out care plan meeting invitations to facilitating room transfers when a resident’s clinical needs change.

Social workers are trained to see the world from a person-in-environment perspective. Whether a loved one arrives at the front door for short-term rehab or long-term care, many will quickly come to view their relationships with staff in familial terms, a credit to the many nurses’ aides, dietary technicians and housekeepers who are also part of the continuum of care.

Ultimately, a strong social work team will actively encourage the ways all nursing home staff can contribute to the resident’s and family’s satisfaction with care, which is what nursing homes are for.

Sarah Wright, a former Northampton resident, consults to The Overlook in Northampton and is president of Social Work in Progress of Dedham.

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