Multi-level factors related to deficiencies in psychological care in Washington State skilled nursing facilities

Thesis (Ph. D.)--University of Washington, 2007.Persons living in skilled nursing facilities (SNF) have extensive psychosocial needs, yet the services provided to meet those needs appear insufficient. Facility social workers are recognized as the primary providers of psychosocial services in SNFs, but often report barriers interfering with their ability to furnish services to all residents who need them. This study utilizes a three-category quality assessment framework to assess specific factors that either enhance or hinder the provision of effective psychosocial services in Washington State SNFs.A cross-sectional research design was employed merging two sources of data: responses to an investigator-developed questionnaire administered to Social Services Directors (SSDs) in participating SNFs (N= 121) and resident-centered state survey outcomes in psychosocial care-related areas obtained from the Online Survey and Certification Reporting (OSCAR) database. Ordinary least squares regression was utilized to assess the ability of facility structural factors, process factors, and SSD characteristics to predict the frequency of psychosocial services in five diverse service domains: care planning, resource and referral, administration and advocacy, assessment, and intervention. Hierarchical linear regression methods were utilized to assess the ability of structural factors, process factors, and SSD characteristics to predict the scope and severity of survey deficiencies in psychosocial care. Interaction terms were also included in the regression model to determine the potential moderating effect of service delivery on predictive multi-level factors. Results indicate that structural factors, process factors, and SSD characteristics play only a limited role in predicting service frequency, although the size of the SSD's caseload is associated with frequency of care planning and intervention services. Four multi-level factors are associated with positive psychosocial care outcomes: low ownership turnover, more years of SSD experience in SNF social services, stronger SSD identification with the helper role, and paradoxically, lower priority attributed to residents' individualization needs at the facility level. This unexpected finding is possibly explained by a stronger focus on assessment services in lieu of intervention services within facilities that place a high priority on individualization needs. An additional finding is that the frequency of assessment services appears to moderate the impact of both ownership turnover and role identification on outcomes in psychosocial care