N A T I O N A L A S S O C I A T I O N O F S O C I A L W O R K E R S

National Association of Social Workers

Gary Bailey, MSW

NASW President (2003–2005)

Elizabeth J. Clark, PhD, ACSW, MPH

Executive Director

Aging Section

Steering Committee (2002–2003)

Len Kaye, DSW, ACSW, Chair

Suzanne Cross, PhD, ACSW

Patricia Nagle, ACSW, LCSW

Cynthia Stuen, DSW, ACSW

Joe Torres, MSW

Long-Term Care Facilities

Standards Task Force

Patricia A. Nagle, ACSW, LCSW, Chair

Mary Avery-Edwards, MA, MSW

Laurie Frank, MSW

Phyllis A. Hall, MSW, LCSW-C

Arlene Kleinman, MSW, LCSW-C

William L. Miller, MSW, LISW

Carmen Morano, PhD, LCSW-C

Susan Dishler Shubin, JD, LCSW

Sharon Hines Smith, PhD, ACSW

NASW Staff

Toby Weismiller, ACSW

Tracy Whitaker, ACSW

Lisa Yagoda, ACSW, LICSW

©2003 National Association of Social WorkersAll rights reserved

Contents

5 Introduction

7 Definitions

9 Guiding Principles

10 Standards

10 Standard 1. Ethics and Values

10 Standard 2. Service Plan

12 Standard 3. Responsibilities of the

Social Work Department

13 Standard 4. Program Functions

15 Standard 5. Staffing

16 Standard 6. Professional Development

17 Standard 7. Personnel Policies and Procedures

17 Standard 8. Documentation

18 Standard 9. Work Environment

19 Standard 10. Cultural Competence

19 Standard 11. Interdisciplinary Collaboration

20 References

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Introduction

Long-term care is an increasingly important andrapidly changing component of today’s socialservices delivery system. The need for long-termcare services is expected to increase dramaticallyin the United States as the population ages.Changing demographics have continued to affectthe demand for long-term care services and theavailability of social workers to provide care tothe most vulnerable members of our society. Asthe number of individuals in need of long-termcare services rises, new issues surrounding staffing,family involvement, quality of life, the role ofspirituality, end-of-life care, medical management,program development, and overall service deliveryare emerging.

The principal components of social work servicesin long-term care settings are designed to provideassessment, treatment, rehabilitation, and supportive care, and to preserve and enhancesocial functioning. Service provision requires aunique combination of physical, psychological,and social interventions and family support, thegoal of which is to promote an optimal level ofpsychological, physical, and social functioning.

There have been significant changes in themanner in which long-term care services aredelivered across the long-term care spectrum.Long-term care services and programs haveevolved into a variety of institutional and noninstitutional modalities. Because long-termcare encompasses a wide array of services, manydefinitions of long-term care exist. The need forlong-term care services most often arises amongolder people, but some people need long-termcare services because of physical, mental, or

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developmental limitations that occur at birth orat any point across the life span. Long-term careservices can be provided in a person’s own home,in the community, or in a facility. However, evenwith changing patterns of care, long-term carefacilities, as temporary or permanent providers ofcare, are still a major resource for those whoreceive social work services in this country.

In 1981 the National Association of SocialWorkers (NASW) developed Standards for SocialWork Services in Long-Term Care Facilities thathave served as an initial effort to formulatestandards in this important and continuallyevolving area of practice. Because it is essentialthat standards reflect and promote sound socialwork practice, these standards have been revisedto reflect changing practices and policies. Thestandards may be regarded as a basic tool forsocial work practice in long-term care facilities,although practice priorities may vary amongsettings.

NASW recognizes the need to integrate knowledgeof long-term care services into social workpractice. The standards outlined in this documentare the results of that recognition.

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Definitions

For the purposes of these standards, the termresident is used instead of patient, client, or consumer. A resident is defined as the recipient ofcare who resides in a long-term care facility.

Long-Term Care Facility

As used in these standards the term long-termcare facility includes skilled nursing facilities,intermediate or heath-related care facilities, andresidential care facilities such as assisted living,congregate, domiciliary, or propriety adulthomes. When these facilities have programs suchas day care, home care, and so forth, these socialwork standards for long-term care shall apply.

Family

The reference throughout these standards to“family” refers to family of origin, extendedfamily, domestic partners, friends, or healthcare surrogates, all of whom must be designatedby the competent resident, or in the case of aresident deemed incompetent, a legal guardian orsurrogate.

Social Worker

A social worker has, at minimum, a bachelor’sdegree from an accredited school or program of social work; has two years of postgraduateexperience in long-term care or related programs;and meets equivalent state requirements forsocial work practice, or, in jurisdictions nothaving such legal regulation, holds certificationor credentialing from the National Association ofSocial Workers. In no instance shall a socialworker have less than a baccalaureate degree froman accredited school or program of social work.

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Social Work Director

The term social work director is defined in thesestandards as a social worker who is the staffmember responsible for the social work programin the facility. It is preferable that the socialwork director be a graduate of a master’s degreeprogram from an accredited school or programof social work, have a minimum of two yearspostgraduate experience in long-term care orrelated programs, and meet equivalent staterequirements for social work practice or, injurisdictions not having such legal regulation, is amember of the Academy of Certified SocialWorkers.

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Guiding Principles

Social work services in long-term care settingsfocus on several key areas, including the socialand emotional impact of physical or mental illnessor disability, the preservation and enhancementof physical and social functioning, the promotionof the conditions essential to ensure maximumbenefits from long-term health care services, theprevention of physical and mental illness andincreased disability, and the promotion andmaintenance of physical and mental health andan optimal quality of life.

Objectives include the following:

■ providing direct social services to residentsand their families by professionally trainedsocial workers

■ assisting residents and families to use andreceive maximum benefit from the facilityand community-based social and healthresources on a continuum throughout the stayof each resident

■ strengthening communications among residents,families, and the program or facility staff

■ assisting the facility to achieve and maintain atherapeutic environment essential to the optimalquality of life and independent functioning ofeach resident and to provide for maximumparticipation of residents in planning activitiesand policies

■ promoting facility–community interaction byencouraging community involvement in thefacility along with resident and staff involvementin the community, developing linkages with awide range of community resources, andparticipating in the assessment of and theneed for planning related to other long-termsocial and health care resources.

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Standards for Social Work Services in Long-Term Care Facilities

Standard 1. Ethics and Values

Social workers in long-term care facilities shalldemonstrate a commitment to the values andethics of the social work profession, emphasizingresident empowerment and self-determination,and shall use NASW’s Code of Ethics (2000) as aguide to ethical decision making.

Interpretation

Social workers shall demonstrate a recognitionof basic human rights, including the right ofresidents to receive an optimal level of socialservices and medical care. Social workers shalldemonstrate a willingness to act on professionaljudgment and convictions, which are informed bythe NASW Code of Ethics.

With the recognition that change in long-termcare settings is constant, social workers shallremain current by regularly evaluating and contributing to social work theory, policy, andpractice. Social workers have a responsibility toknow and comply with federal, state, and locallegislation, regulations, and policies. In the eventconflicts arise among competing expectations,social workers should use the NASW Code ofEthics as a guide in their decision making.

Standard 2. Service Plan

The long-term care facility shall maintain a writtenplan for defining social work services designed toensure their availability to all residents and theirfamilies. The plan for social work services shall beguided by a written statement of philosophy,objectives, and policies.

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Interpretation

An organized department under the leadershipof a social work director is the preferableapproach to providing social work services inlong-term care facilities. The plan shall ensurethat a professionally directed program will beprovided. The plan shall document the philosophy,objectives, goals, policies, procedures, and scopeof services provided. The plan shall provide foraccess to services for all residents and forprospective residents from preadmission untildischarge or end-of-life. All services and programsshall be directed toward the following: creating atherapeutic environment to promote independentfunctioning; maintaining residents at or restoringresidents to an optimal level of functioning; providingfor the highest level of well-being; and allowingfor maximum participation by the resident, thefamily, and staff involved with residents’ care.

The plan shall include, but not necessarily belimited to, the following:■ assurance of the selection of appropriately

trained, educated, and licensed or credentialedsocial work staff

■ communication and collaboration with thecare plan team and others involved with residents’ care

■ collaboration with colleagues, communityagencies, volunteers, and consultants

■ development and implementation of servicesand special programs

■ compliance with laws and regulations mandatedby federal, state, and local governing bodies

■ requirements for professional developmentand continuing education of social work staff

■ maintenance of residents’ medical records andreports mandated by federal, state, and locallaws and the facility.

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The social work director, in collaboration withother clinical and administrative representatives,is responsible for ensuring that the social workplan is implemented. The plan of the socialwork department shall provide procedures toensure that all federal, state, and local laws areimplemented and adhered to and shall be consistentwith the facility’s policies and regulations.

Standard 3. Responsibilities of

Social Work Department

The social work director shall carry primaryresponsibility for social work services, includingthe development of organizational plans andadministrative policies and procedures andcoordination of services.

Interpretation

The social work director’s responsibilities mayinclude the following:■ development and implementation of all social

health programs in the setting■ participation in budget planning, defining space

and material requirements, and establishingqualifications and staffing patterns of socialwork personnel to ensure that appropriateand adequate services are provided consistentwith stated goals and objectives

■ implementation and oversight of proceduresto ensure that adequate documentation ofsocial work services is provided in each resident’s medical record and that legal, ethical, and professional standards areobserved in written recordings

■ establishment and administration of a socialwork program that provides high-quality careand services reflective of professional standardsof practice and in compliance with all federal,state, and local laws

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■ establishment and administration of qualityassurance procedures and modification ofthese procedures where appropriate

■ encouraging participation where appropriatein the education of social work interns, as wellas other health care personnel and studentsand in the development, implementation, andreview of research in which social workers cancontribute

■ ensuring that social work staff are knowledgeableabout residents’ rights in accordance with allfederal, state, and local laws.

Standard 4. Program Functions

The functions of the social work program shall include, but not be limited to, direct servicesto residents, families, and other individualsinvolved with residents’ care; advocacy; careplanning, discharge planning and documentation;participation in policy and program planning;quality improvement; staff education pertainingto social services; liaison to the community; andconsultation to other staff members.

Interpretation

Social work services should be designed to meet thebiopsychosocial needs of residents, their families,and others involved with the residents’ care andshould be delivered in a manner that ensuresconfidentiality and cultural competence inaccordance with NASW professional standards.

Specific social work functions may include, butare not be limited to, the following:■ preadmission services, including biopsychosocial

assessments and participation in interdisciplinaryevaluation of the individual’s need for institutional care and preparation of theincoming resident

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■ identification of needs and coordination ofservices to ensure that the biopsychosocialneeds of each resident are met

■ participation in the development andreassessment, as needed, of individualizedsocial service and interdisciplinary care plansdesigned to meet the biopsychosocial needsof each resident

■ assisting residents and families in locating andusing financial, legal, mental health, and othercommunity resources

■ provision of individual, family, and groupservices focused on the maintenance orenhancement of the resident’s biopsychosocialfunctioning and understanding of the resident’splacement and health status; services mayinclude assistance with the following: concernsrelated to the resident’s illness, disability,treatment, financial and medical decisionmaking; placement and expectations of care;inter- or intrafacility transfers; interpersonalrelationships; re-establishing community living; and coping with separation, loss, dying,and death

■ advocacy of appropriate care and treatment ofresidents through the development andimplementation of policies, and the educationof residents, staff, and family regarding residents’rights, as well as consultation with the long-term care ombudsperson

■ ensuring that health and mental health socialwork services are available to residents to assistwith attaining or maintaining the highestpractical mental and psychosocial well-being,while helping residents who display mental orpsychosocial difficulty receive appropriatetreatment and services

■ acting as a resource to staff participating inbehavioral interventions

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■ facilitating residents’ safe integration into the community through interdisciplinarydischarge planning and follow-up services

■ participation in planning and policy developmentfor the facility, including collaboration withother members of the staff in the identificationof biopsychosocial, cultural, and environmentalfactors essential to the delivery of quality careto residents and families, participation inorientation of all new employees, and in-servicetraining of facility personnel

■ participation in resident and family councildevelopment, as needed or requested

■ participation with medical personnel andfacility staff in discussing with competentresidents and families advance directives andfinancial powers of attorney; for incompetentresidents, participation in discussions ofguardianship and surrogate decision making

■ orientation and supervision of volunteers■ contribution to the development of community

resources by participating with communitygroups to initiate, plan, and carry out programsconcerned with the health, mental health, andother welfare needs of the residents

■ supervision of fieldwork for social work students in affiliation with an accreditedschool or program of social work

■ participation in research and demonstrationprojects that may be conducted either independently or collaboratively.

Standard 5. Staffing

A sufficient number of appropriately trainedlicensed or credentialed and experienced socialwork and supportive personnel shall be availableto plan, provide, evaluate, and modify all socialwork services.

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Interpretation

The number and qualifications of the social workstaff and the level of consultation needed shall bebased on criteria related to the type, scope, andcomplexity of the social work program, the size ofthe facility, and the biopsychosocial needs andcharacteristics of the population served.

All social work services shall be provided by socialworkers with experience in long-term care and amaster’s degree in social work or a baccalaureatedegree in social work from an accredited schoolof social work.

All social work staff and consultants shall belicensed, certified, or registered as mandated byspecific state licensing agency requirements inthe state in which the social worker practices.

The social work program shall have a sufficientnumber of appropriately trained or experiencedsupport personnel to enable the provision ofsocial work services that ensure each residentmaintains or attains the highest practicable levelof well-being.

Standard 6. Professional Development

Social workers in long-term care settings shallassume personal responsibility for their continuedprofessional development in accordance with theNASW Standards for Continuing ProfessionalEducation (NASW, 2002) and state requirements.

Interpretation

To practice effectively, social workers in long-termcare settings must remain knowledgeable aboutreforms in long-term care and best practice modelsin the social work profession. Opportunities forenhancing professional identity and development

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include participation and leadership in NASWand other professional organizations and coalitionsat local, state, and national levels; participation inand contribution to professional conferences,training events, and other activities; and assistingin the ongoing development of the social workknowledge base by contributing to and promotingprofessional publications.

Standard 7. Personnel Policies and Procedures

A written statement of the personnel policies andprocedures of the facility for the social workdepartment, the NASW Code of Ethics, and allother relevant NASW practice standards shall beavailable to each staff member.

Interpretation

Personnel policies that relate to the social workprogram and those of the facility shall be availableto all staff. There shall be current written positiondescriptions and statement of qualifications withinthe specifications for each position. All staff,including social workers, shall have knowledge ofand access to the personnel policies. These policiesand procedures shall be periodically reviewed,communicated, and implemented.

Standard 8. Documentation

Documentation of social work services providedto residents, family members, and other individualsinvolved with the resident’s care must be recordedin the medical record.

Interpretation

Progress notes and other social work entries inthe medical record shall be recorded to permitand encourage regular and ongoing communicationwith physicians and other professionals involvedin the resident’s care.

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Entries by social work personnel shall includeinformation related to the social and emotionalfunctioning of the resident; relevant historicalinformation regarding the resident and familyand others involved with the resident’s care;psychosocial assessments; the social work planand specific goals; services provided and outcomes;and a summary of problems and goals attained, aswell as reasons for nonattainment of goals.Referrals to other agencies or resources should bedocumented in the resident’s medical recordand should include any ongoing follow-up orrecommendations by an outside agency or individual. Notes shall be clear and concise.

Progress notes, reports, and summaries of servicesshall be regularly recorded in the medical recordand be consistent with all federal, state, and locallegal and statutory, regulatory, and policyrequirements and with the organization’s orfacility’s policies on reporting, maintenance ofand access to records, and confidentiality.

Policies and procedures shall be developed andimplemented to protect residents’ rights to privacy, including confidentiality of records and procedures for release of information toindividuals, and relevant community agencies.

Standard 9. Work Environment

There should be adequate budget, space, facilities,and equipment to fulfill the professional andadministrative needs of the social work program.

Interpretation

Offices of the social work staff must be readilyaccessible to residents, their families, and facilitystaff. They should provide privacy and confidentialityfor individual, family, and group work; conferences;

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telephone calls; and documentation. Standardoffice equipment that adequately reflects currentoffice technological needs should be provided.

Standard 10. Cultural Competence

Social workers shall provide residents and theirfamilies with social services in the context ofmulticultural understanding and competence.

Interpretation

The increasingly diverse population in theUnited States requires that social workers raisetheir awareness and appreciation of cultural differences. Social workers must develop competencies that include heightened self-awareness,knowledge, and practice skills consistent with theNASW Standards for Cultural Competence in SocialWork Practice (NASW, 2001).

Culturally competent social workers need to beknowledgeable about the deleterious effects ofracism, sexism, ageism, heterosexism or homophobia,anti-Semitism, ethnocentrism, classism, and disability-based discrimination on residents’ livesand the need to advocate for and with residents.

Social workers must recognize racial, ethnic, andcultural differences that may be interpreted asbarriers and develop strategies and skills that helpameliorate such barriers.

Standard 11. Interdisciplinary Collaboration

Social workers should be part of an interdisciplinaryeffort for the comprehensive delivery of long-term care services and should strive to enhanceinterdisciplinary and interorganizational cooperation.Social workers shall work in partnerships thatinclude mutual respect, shared information, andeffective communication.

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Interpretation

As leaders and members of interdisciplinaryteams, social workers must constantly be aware ofthe overall goals, objectives, and tasks of theirpractice area and interpret them to residents,families, and other relevant professions andorganizations so that professional activities andcompetencies are maintained.

Social workers shall have a basic understanding ofthe missions and functions of other relevantprofessions and organizations that promote resident health, mental health, and well-being.Social workers shall be able to communicate,cooperate, and collaborate appropriately withprofessionals from different disciplines andagencies. The social work roles and responsibilitiesin long-term care shall be clearly delineated andcommunicated to other members of interdisciplinary teams.

References

National Association of Social Workers. (2000).Code of ethics of the National Association of SocialWorkers. Washington, DC: Author.

National Association of Social Workers. (2002).NASW standards for continuing professional education. Washington, DC: Author.

National Association of Social Workers. (2001).NASW standards for cultural competence in socialwork practice. Washington, DC: Author.

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