Understanding and Improving Psychosocial Services in Long ...

Understanding and Improving Psychosocial Services in

Long­Term Care


Sonya E. Bowen, M.S.W. and Sheryl Zimmerman, Ph.D.

In this issue of the Health Care Financing life in LTC is variably defined, it can be
Review, we present research that speaks to understood to include emotional health,
the importance of psychosocial care and its social function, and self­worth, in addition
relationship to the overall well-being and to physical health and function (Sloane
quality of life for people receiving long-term et al., 2005). These domains fit within the
care (LTC) services in nursing homes and purview of psychosocial assessment, care
community-based settings. The articles ad­ planning, and care. More specifically, psy­
dress numerous psychosocial processes of chosocial services are those that enhance
care and outcomes within the LTC service mental, social, and emotional well­being to
spectrum. This overview discusses the ratio­ promote quality of life. In this context, psy­
nale for examining psychosocial services in chosocial providers address psychological,
the context of quality of life in LTC; summa­ social and environmental stressors that
rizes the focus of the articles in this issue; negatively affect quality of life outcomes.
and highlights current CMS initiatives rele­
vant to psychosocial needs in LTC including Not only must LTC address psychoso­
national data sources that measure psycho­ cial needs, but outcome data must indi­
social services and outcomes of care and can cate whether this care results in improved
be used to develop programs to improve care quality of life. Given our historic focus on
and outcomes. medical indicators of quality care (e.g., bed
sores) and easily observable processes of
intrODUCtiOn care (e.g., restraint use), a significant gap
exists in our knowledge regarding the pro­
The LTC system serves people with di­ vision of psychosocial care and quality of
verse needs, including those with recent life. That is, psychosocial indicators, such
impairment in activities of daily living af­ as promoting patient dignity or assess­
ter an acute event or surgery; those with ing and providing services to maintain
LTC disabilities or advanced chronic con­ social engagement or lessen symptoms of
ditions including dementia; and people depression, have been deemed less impor­
who are approaching the end of life. The tant and are generally more complex and
needs of these individuals extend beyond time­consuming to measure and target for
assistance with function and medical care, quality improvement. However, LTC pro­
and as a society we have come to recognize viders and administrators, payers, regu­
the importance of quality of life regard­ lators, and policymakers stand to benefit
less of one’s limitations. While quality of from research findings that inform psycho­
social care and outcomes, especially given
Sonya E. Bowen is with the Centers for Medicare & Medicaid the rapid growth and associated costs in
Services (CMS). Sheryl Zimmerman is with the University of this health care sector.
North Carolina at Chapel Hill. The statements expressed in this
article are those of the authors and do not necessarily reflect the CMS is committed to improving the
views or policies of the University of North Carolina or CMS. quality of care in LTC. Consistent with the

HealtH Care FinanCing review/winter 2008-2009/Volume 30, Number 2 1

culture change transformation being pro­ home reform enacted by the Omnibus
moted in these settings, CMS’ vision for Budget Reconciliation Act of 1987; it also
LTC is person­centered, meaning that it is indicated that the evidence regarding home
individualized and responsive to an indi­ based care is sparse and tends to measure
vidual’s choice. An example of this vision satisfaction and unmet need, as opposed
is CMS’ revision to the federally man­ to quality of care. This issue of the Health
dated Minimum Data Set (MDS) 2.0 of the Care Financing Review provides a glimpse
nursing home Resident Assessment Instru­ of how LTC research is making progress
ment, which is scheduled for implemen­ to promote better psychosocial care, and
tation as MDS 3.0 in fall 2009. The MDS also conveys systemic and programmatic
contains standardized items that measure challenges to evaluating psychosocial care
comprehensive physical and psychosocial in different types of LTC settings.
functioning for all residents in Medicare
and/or Medicaid­certified long­term care The four articles in this issue contain
facilities (Centers for Medicare & Medicaid findings on psychosocial outcomes of care
Services, 2008a). One advance in MDS 3.0 in various LTC settings from the perspec­
gives nursing home residents a voice in tives of consumers, family members, and
reporting on their status rather than hav­ social service providers. The volume is
ing staff do so, which has the potential to organized conceptually into three sec­
improve resident care and outcomes. tions: (1) quality of care in traditional nurs­
ing homes, (2) quality of care in a newer
The person­centered approach to LTC model of nursing home, and (3) commu­
is also reflected in CMS’ Home and Com­ nity based services outcomes. In addition,
munity Based Services (HCBS) Waiver, data highlights from the Medicare Current
Real Choice Systems Change Grant, and Beneficiary Survey (MCBS) are presented
Money Follows the Person Grant pro­ on psychosocial data captured by the
grams. The HCBS waiver programs, admin­ facility­based component of the survey.
istered by States, facilitate the delivery of
LTC services in community settings as an In a study on psychosocial care quality in
alternative to nursing home care (Centers certified nursing homes, Zang, Gammonly,
for Medicare & Medicaid Services, Paek, and Frahm analyzed Online Survey
2008b). The Real Choice Systems Change Certification and Reporting (OSCAR) data
Grants and Money Follows the Person for Medicare and Medicaid certified facili­
Demonstration Grants under the New ties to explore the association between
Freedom Initiative both provide funding to the stringency of State requirements com­
assist States in implementing changes to pared to Federal minimum regulations
their LTC support systems to better serve for qualified social services staffing and
frail elderly and individuals with disabili­ six psychosocial service related deficiency
ties in their setting of choice (Centers for measures. Numerous nursing home demo­
Medicare & Medicaid Services, 2008c). graphic characteristics (e.g., ownership,
payer status, Medicaid concentration) ex­
COntent OF iSSUe tracted from the national Area Resource
File (ARF) were also evaluated to measure
In 2001, the Institute of Medicine issued their relationships with psychosocial care
a report of findings reflecting that nursing quality. Bonifas analyzed a different aspect
home residents had experienced limited of nursing home quality, using OSCAR
gains in quality of life following the nursing data to evaluate how the work environment
in skilled nursing facilities in Washington

2 HealtH Care FinanCing review/winter 2008-2009/Volume 30, Number 2

State related to social service providers’ the evaluation model they developed could
ability to deliver effective care as measured potentially be tailored for use by other
by resident outcomes. Together, these States’ community based LTC programs.
articles suggest that nursing home demo­
graphic and caseload characteristics are The MCBS Highlight presented in this
good predictors of psychosocial care qual­ issue is one example of CMS data that
ity and warrant further research, because may be used to study quality of care in
they may indicate disparities in care and LTC settings. Other publicly­available data
areas in which more attention is needed. that include rich psychosocial information
are three federally mandated LTC data
Culture change in LTC represents an sources; these include (1) home health
organizational­based approach that has patient outcome measures captured by the
taken root over the past several years to Outcome & Assessment Information Set,
transform nursing homes from medically­ (2) OSCAR, and (3) MDS databases. In
oriented facilities to more resident­cen­ addition, Medicare claims data are available
tered, home­like environments (Ragsdale for skilled nursing facilities, home health,
and McDougal, 2008). As one evaluation and hospice settings. These databases
component of a larger longitudinal study include service and/or outcome informa­
of a small­house nursing home model tion relevant to psychosocial care and qual­
implemented in 2003 in Mississippi, Lum, ity of life. Outside of CMS, the Centers for
Kane, Cutler, and Yu present findings on Disease Control and Prevention also collect
the Green House nursing home program LTC data through the National Nursing
related to family members’ satisfaction and Home Survey. Through the collection of
burden. As this model of LTC is relatively new primary data and the use of these and
new, their study speaks to alternate mod­ other existing databases to understand psy­
els of LTC that address psychosocial well­ chosocial care and outcomes, the future is
being and quality of life. In comparison to being directed toward improved quality of
the traditional nursing home model, find­ life in LTC.
ings are that families prefer the small house
nursing home model, are engaged, and aCKnOwleDgMentS
do not experience increased burden. One
area identified as needing improvement We thank Robert Connolly for his lead­
was social activities, including religious ership in promoting quality psychosocial
obser vances. care through quality measurement in LTC
and post acute care settings, including
In the final article, Glass et al. evaluate a spearheading the MDS initiatives, as well
State waiver program that provides home as his commitment to advancing the field
based and community based personal of geriatric social work.
care services in Virginia. They conducted
a representative statewide consumer sur­ reFerenCeS
vey to collect data on caregiver perfor­
mance and consumer satisfaction, as well Centers for Medicare & Medicaid Services:
as quality of life outcome data. The study Nursing Home Quality Initiatives, 2008a. Internet
found that consumers generally are satis­ address: http://www.cms.hhs.gov/ NursingHome
fied with care received. More importantly, QualityInits (Accessed 2008).
the services provided enable consumers Centers for Medicare & Medicaid Services: Home
to better deal with health problems and and Community Based Services, 2008b. Internet
enjoy an improved quality of life. Further, address:http://www.cms.hhs.gov/HCBS(Accessed
2008.)

HealtH Care FinanCing review/winter 2008-2009/Volume 30, Number 2 3

Centers for Medicare & Medicaid Services: New Sloane, P.D., Zimmerman, S., Williams, C.S., et
Freedom Initiative, 2008c. Internet address: al.: Evaluating the Quality of Life of Long­Term
http://www.cms.hhs.gov/NewFreedomInitiative Care Residents with Dementia. Gerontologist 45(1):
(Accessed 2008.) 37­49, 2005.
Wunderlich, G. and Kohler, P.: Improving the Quality
Ragsdale, V. and McDougal, Jr., G.J.: The Changing of Long-Term Care. Institute of Medicine. National
Face of Long­Term Care: Looking at the Past Academy Press. Washington, DC. 2001.
Decade. Issues in Mental Health Nursing 29(9):992­
1001, 2008. Reprint Requests: Sonya E. Bowen, M.S.W. Centers for Medi­
care & Medicaid Services, 7500 Security Boulevard, C3­24­07,
Baltimore, MD 21244­1850. E­mail: [email protected]

4 HealtH Care FinanCing review/winter 2008-2009/Volume 30, Number 2