Long-Term Solutions for Long-Term Care
Social Work Today
By David Surface
Vol. 4 No. 5 p. 22

Quality care begins with education and awareness. Staff training and development programs are making a difference at all levels in long-term care.

Recent news stories of negligence in our nation’s nursing homes have spotlighted the long-term care industry and turned quality improvement from an abstract concept into an urgent necessity.

While some look to the government for better monitoring of long-term care facilities, more substantive ideas for rehabilitating the long-term care industry are coming from social workers on the front lines.

Long-Term Care Lags in Staff Development
In any industry, the importance of staff training and development may seem like a no-brainer—if you want your organization to thrive and provide excellent service, you train and develop your staff. But in many long-term care settings, staff training and development seems to be a foreign concept.

According to Carol J. Grubba, MSN, RN, C, education director of the Michigan Public Health Institute (MPHI) Center for Long Term Care (CLTC), the long-term care industry is far behind other healthcare sectors in terms of staff development.

“When I first started, it was evident that the staff in long-term care did not have the knowledge base, first in gerontology, to really be able to adequately assess and plan for a geriatric person,” says Grubba. “Standards of practice and standards of care were not adhered to in all cases. The industry has been slow to pick up on that. The OBRA [Omnibus Budget Reconciliation Act] federal regulations in 1987 are what gave the impetus to change.”

For Sheldon Lewin, LCSW, MBA, director of staff development and training at Glenview Terrace Nursing Center, Illinois, his early impressions of the long-term care industry were similar to Grubba’s.

Lewin began his career as a social worker in long-term care 15 years ago. “I could see there was a need back then,” says Lewin. “At the first nursing facility where I set up a social services department, the CNAs [certified nurse assistants] all lacked basic customer service skills, such as how to introduce yourself to a patient and family. A simple thing like eye contact is immensely important—if you introduce yourself to a patient or family without looking them in the eye, they think you’ve got something to hide. You may lose credibility. These really basic skills just weren’t there.”

Is It All About Money?
Lewin points out the grim financial realities behind the lack of staff development in the long-term care industry.

“Training and development is costly,” says Lewin. “One video can cost $500. These facilities are underfunded. Many of the customers are on public aid. It used to be that more residents paid privately, but that’s now virtually nonexistent. The reimbursement rates from the government are very low. You barely have money to hire your nursing staff, let alone someone specially hired to do training.”

MaryAnne Benedict, MSN, RN, chairperson, advisory committee of the New England School of Whole Health Education (NESWHE), explains how lack of funding combined with overworked staff has led to the current situation. “What happens is that the number of hours required for staff to care for the long-term care population and the intensity of those hours frequently doesn’t allow for opportunities for staff development because we need the caregivers at the bedside,” says Benedict. “To take them away from the bedside to do any sort of formal development, there’s no budget for that.”

But for Carl A. Gibson, PhD, program director of the MPHI CLTC, there are factors other than funding that may be equally important.

“The industry as a whole is very quality-focused but often believes they don’t have enough resources to develop quality staff,” says Gibson. As for what’s behind the lack of staff development, “The industry would say that it’s financial resources—I’d say just resources, including effective administration and management, collaboration with other providers within the community. It’s not just having enough dollars.”

Grubba believes the administration of long-term care facilities have other resources at their disposal for developing staff, even when funding is low.

“How management supports and respects the staff is a big issue in long-term care,” says Grubba. “It’s difficult work for the caregivers and burnout is high. But even though the financial benefits aren’t tremendous, research shows that there are other factors that come into play. The good homes respect and support the staff in different ways, basically by respecting them as a people, involving them in management issues, rewarding them in positive ways so they’ll respect who they’re working for.”

Grubba cites a LEAP (Learn, Empower, Achieve, and Produce) training program in Michigan recently sponsored by the CLTC. “The purpose of the LEAP program is to develop and train nursing staff in long-term care and is an example of how management can show staff that they are supported and valued,” says Grubba. “Organizations that have implemented LEAP training have reduced costs by significantly decreasing turnover; improved relationships and communication among nursing staff, residents, and families; and increased job satisfaction and work productivity through team building.”

Gibson points to the results of a recent survey of more than 800 direct care staff in Michigan. “Among some of the reasons they’d left their facilities, pay was an issue, but also having too many patients, not being valued by administration and supervisors, lack of opportunity to advance—all these rated almost equally.”

Grubba has seen how effective these other measures can be. “I’ve been in homes in downtown Detroit where the Medicaid reimbursement is low but the staff commitment is high and the care that is given to residents is quality care.”

Why Government Cures Are Not Enough
While most people will agree that government has a responsibility to monitor long-term care facilities for quality and safety, those who have seen these government interventions firsthand are all too aware of their shortcomings.

“I’d have to say that the Illinois Department of Public Health inspections are helpful, but they’re only seeing a bird’s-eye view of one moment of care or service,” says Lewin. “They’re here only a couple of days—that doesn’t give them an opportunity to see real patient care and service issues over an extended period of time.”

Gibson agrees with Lewin’s critique of government monitoring of the long-term care industry. “About a month after the initial survey, the facility will be resurveyed,” says Gibson. “That’s not enough time to fix all the systems and put in effective monitoring. That creates a cyclical yo-yo effect in which the same problems continue to arise.”

Long-term care staff may sometimes be resistant to quality improvement measures prescribed by the state. “These things are sometimes viewed with disdain,” says Gibson. “There’s more paperwork involved, and compliance issues are often hard for facilities and staff to understand if they’re not part of the process. When they fail, they don’t know why, they don’t know the principals behind what they’re being asked to do.”

Grubba believes the way out of this cycle of failure is by providing long-term care facilities with the real tools they need for improvement and self-monitoring. “The management at these facilities get requirements, but they don’t know how to implement them,” says Grubba. “They need to update and enhance their skills. If you want to have quality of care that’s not simply dependent on one individual but that’s systemic and continuous, you have to have it come from the top down. You have to have adequate, competent management.”

Some Solutions
To provide long-term care facilities with the ongoing staff development and training they were lacking, Lewin created the People First program.

“When I came to Glenview Terrace Nursing Center, they had gone through a four-year renovation, several leadership changes, and staff resignations resulting in low employee morale and motivation—all of this affecting customer service,” Lewin says.

Lewin completed thorough organizational and cultural assessments and department and service audits; interviewed employees and management; and conducted focus groups with residents, patients, families, and visitors. The program that was the culmination of that research, People First, was intended to develop customer service, provide training, and improve morale and motivation among the staff.

Among the program’s components are sensitizing staff to resident/patient concerns, developing communication and teamwork, and coordinating uniforms for direct care, operations, and customer service staff.

Why don’t more long-term care facilities enact staff development programs such as People First? According to Lewin, it takes a combination of variables. “In my case, I found an owner who’s not only a visionary but a brilliant businessman,” says Lewin. “He has a major competitive advantage within this industry—a full-time training director and department. This is virtually nonexistent in the Chicago area. It really takes someone with a vision, who has resources and is willing to invest time and money. Many private owners in long-term care would rather keep the profit to themselves, getting by with basic in-services. A program such as ours takes commitment, the right energy, and people.”

The MPHI CLTC was created by the bureau of health systems as part of the Resident Protection Initiative in 1997 as an alternative to the state enforcement processes that were in place.

“The traditional remedies are punitive,” Gibson explains. “Civil money penalties and fines, like denial of payments for new admissions—it’s almost like a traffic ticket.”

“Our program was to give help and resources to facilities with education and support from advisors,” says Grubba. “It was not meant to be punitive, like the state’s civil money penalties and fines, but more remedial and collaborative.

“When a facility has a survey and are found deficient in any practice, they’re required to turn in a plan of correction to the state,” continues Grubba. “When they’re found to be in significant need, a directed plan of correction is enforced. It’s more detailed than a regular plan. We come in and work with the facility staff. We include the quality assurance and monitoring part, which is typically weak in the first place.

“Along with that, or as a stand-alone measure, the licensing officer may order a directed in-service training on a number of issues, such as assessment, urinary incontinence, dementia, a variety of clinical issues,” says Grubba. “We go in and train the facility managing staff and ask them to take on the responsibility of training the rest of the staff. These are all multiple visits—we try to come back in and assist.”

“We can provide a continuing service,” says Gibson. “Our focus is to educate the management staff in the nursing homes so they can provide the mentoring.”

The NESWHE takes an aggressively holistic approach to staff development. “No. 1, we need to develop the staff of long-term care facilities—all staff,” says Benedict. “What we have at the New England School of Whole Health Education is a Whole Person Care program, which is a model of staff education and is meant for integration into all aspects of a long-term care facility. We also offer in-person and distance learning-based educational programs for social workers. Our programs consist of a relationship-centered curriculum, which integrates current scientific and medical research, with the wisdom of various spiritual teachings and a natural outlook on healing. It combines one-to-one equity-based mindful listening with respectful, compassionate presence, which is critical to the success of a long-term care facility.”

Benedict understands that the kind of changes advocated by the NESWHE may take time to be widely accepted. “The whole idea of a culture change within an institution or organization is the ultimate goal. That’s not an easy thing to do,” she says.

Is There an Increased Interest in Long-Term Care Quality?
Gibson points to changes in federal regulations in 1989 as the turning point in quality of care for the long-term care industry. “For about four or five years, there was a steady, gradual increase in the quality of care—decreased use of restraints and certain meds. Then there was a period of time when things were at a standoff. After people became proficient with the new federal requirements and the new quality indicators, there was a focus on what the quality indicators really meant, how to measure them and attain good numbers. Now there is much more focus on quality.”

How widespread is interest in quality and staff development among long-term care facilities today? “I would have to say that it depends on the individual ownership,” says Lewin. “Most long-term care facilities are privately owned, so it depends on the owners in terms of what they see as being important. There is no training program like this in the Midwest, nothing that addresses all levels of staff and management. When we teach sensitivity training at our facility, it is a lesson no less significant for dietary, housekeeping, and maintenance than it is for our nursing and management staff.

“Training and development is a relatively new concept to this industry,” continues Lewin. “One other facility in Illinois, Mather Pavilion, does the LEAP program, which focuses primarily on training nursing staff—we train all 300 of our employees and do this consistently every month. Our curriculum includes specialized long-term management training, customer service, and patient care training.”

The CLTC at MPHI sponsors an annual two-day training specific to issues in long-term care for all interdisciplinary team members. “The focus of this training is to offer clinical information on a variety of topics, updates on standards of practice and standards of care, and tools and resources to expand the team member’s gerontological knowledge base,” says Grubba.

“Certainly there’s an increased interest,” says Benedict. “If nothing else, the media has helped create that with articles and exposes written on some of these issues.” Benedict predicts more interest in quality of care for the future. “What’s happened is that as we see our population aging, people are understanding that we’re going to need more staff, more healthcare providers who are able to care for those patients as they age and have chronic illnesses because our lives are much longer.”

— David Surface is a freelance writer and editor based in Brooklyn, NY.

New Career Direction for Social Workers?

Sheldon Lewin, LCSW, MBA, director of staff development and training at Glenview Terrace Nursing Center, believes there’s a real role for social workers today to address issues around training of healthcare professionals.

“Social workers need to reposition themselves in today’s job market,” says Lewin. “The days of traditional social work counseling in healthcare organizations is changing. I’d recommend that if social workers are interested in getting into this area, there may be growing opportunities for them to present ideas about training to long-term care and other healthcare organizations. Social workers, because of their background and experience, may have the needed skill set to thrive in the area of training and development or more broadly human resources.”

However, Lewin cautions social workers considering going into training consultancy to focus on areas in which they have experience. “Any social worker who’s planning to go into the area of training and development of human resources should first make certain they have ripe experience in the area they want to train in or they won’t have the credibility they need to be taken seriously. If I came into Glenview Terrace and tried to put together a corporate training program and talk about emotional intelligence, situational leadership, and other abstract concepts, I’d be laughed right out of the boardroom. Our training is practical, basic, and vital.”

Lewin clearly enjoys his role as consultant to the long-term care industry. But does he miss working with clients? “I feel accomplished after a day’s work because I know I’m making a difference. I may not be working directly with clients anymore, but I’m working with the people who take care of the clients and they too need attention. In addition, I like being able to put my knowledge to work in the classroom setting.”

Lewin notes that some of the things he teaches need to be retaught in acute care. Then does he have plans for branching out into the acute care industry? “Probably not. Actually, I’ll be rolling out this program to three other facilities in our network. My passion has always been in the long-term care industry.”

— DS