Nursing Home Social Services and Post-Acute Care: Does More Qualified Staff Improve Behavioral Symptoms and Reduce Antipsychotic Drug Use?

Published:September 20, 2019DOI:



      An increasing number of post-acute care patients are admitted to skilled nursing facilities (SNFs) with behavioral symptoms such as wandering and rejecting care, which can interfere with care and place a patient at risk of social isolation or injury. This study examines whether increasing the qualifications of social service staff through using a greater proportion of qualified social workers (QSWs) instead of paraprofessionals improves patients' behavioral symptoms and reduces the use of antipsychotic medications.


      Secondary data analysis of national data drawn from the Minimum Data Set, Medicare Beneficiary Summary File, and Certification and Survey Provider Enhanced Reporting surveys.

      Setting and participants

      Newly admitted, Medicare fee-for-service patients aged ≥65 years who received post-acute care after a hospitalization from 2011-2015 (1,201,096 patient admissions in 5383 unique SNFs).


      A regression discontinuity approach is used to identify how changes in the qualifications of social service staffing affect changes in patient outcomes, through exploiting a federal regulation that requires 1 full-time QSW for SNFs with at least 121 beds.


      SNFs with a greater proportion of QSWs improved behavioral symptoms that affected residents or others and reduced the use of antipsychotic medications. Marginally significant improvements were also found in patients' rejecting care, wandering, and having any behavioral symptoms. There was no statistically significant change in delusions.

      Conclusions and implications

      Although the focus of most research and effects on improving patient outcomes in SNFs has focused on nursing staff, our results underscore the importance of staffing in social services. Specifically, social service staff with higher qualifications are integral to improving care through reducing patients' behavioral symptoms and avoiding the use of antipsychotic medications. It may be time for SNFs to revisit efforts to improve staffing in social services.


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        • Centers for Medicare & Medicaid Services
        Medicare program; prospective payment system and consolidated billing for skilled nursing facilities (SNFs) for FY 2016, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, and staffing data collection; final rule.
        (Available at:)
        Date: 2015
        Date accessed: December 19, 2018
        • Hughes C.M.
        • Lapane K.L.
        • Mor V.
        Impact of legislation on nursing home care in the United States: Lessons for the United Kingdom.
        BMJ. 1999; 319: 1060-1063
        • Roberts A.R.
        • Bowblis J.R.
        Who hires social workers? Structural and contextual determinants of social service staff in nursing homes.
        Health Soc Work. 2017; 42: 15-23
        • Rahman M.
        • Grabowski D.C.
        • Mor V.
        • Norton E.C.
        Is a skilled nursing facility’s rehospitalization rate a valid quality measure?.
        Health Serv Res. 2016; 51: 2158-2175
        • Reus V.I.
        • Fochtmann L.J.
        • Eyler A.E.
        • et al.
        The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia.
        Am J Psychiatry. 2016; 173: 543-546
        • Bowblis J.R.
        • Lucas J.
        • Brunt C.S.
        The effects of antipsychotic quality reporting on antipsychotic and psychoactive medication use.
        Health Serv Res. 2015; 50: 1069-1087
        • Coon J.T.
        • Abbott R.
        • Rogers M.
        • et al.
        Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: A systematic review.
        J Am Med Dir Assoc. 2014; 15: 706-718
        • Gilmore-Bykovski A.L.
        • Roberts T.J.
        • Bowers B.J.
        • Brown R.L.
        Caregiver person-centeredness and behavioral symptoms in nursing home residents with dementia: A timed-event sequential analysis.
        Gerontologist. 2015; 55: S61-S66
        • Scales K.
        • Zimmerman S.
        • Miller S.J.
        Evidence-based nonpharmacological practices to address behavioral and psychological symptoms of dementia.
        Gerontologist. 2018; 58: S88-S102
        • Bern-Klug M.
        • Kramer K.W.O.
        Core functions of nursing home social service departments in the United States.
        J Am Med Dir Assoc. 2013; 14: 75.e1-75.e7
        • National Association of Social Workers
        Standards for Social Work Services in Long-term Care Facilities.
        NASW Press, Washington, DC2003: 1-24
        • Simons K.
        • Bern-Klug M.
        • An S.
        Envisioning quality psychosocial care in nursing homes: The role of social work.
        J Am Med Dir Assoc. 2012; 13: 800-805
        • Vourlekis B.
        • Zlotnik J.L.
        • Simons K.
        Evaluating Social Work Services in Nursing Homes: Toward Quality Psychosocial Care and Its Measurement—A Report to the Profession and Blueprint for Action.
        Institute for the Advancement of Social Work Research, Washington, DC2005: 1-44
        • Hyer K.
        • Babcock C.
        • Lucas A.H.
        • et al.
        Multi-professional Team Care Case-Based Geriatrics: A Global Approach.
        McGraw-Hill Medical, New York2010
        • Sehrawat S.
        The omission of comprehensive care: An analysis of the Nursing Home Reform Act of 1987.
        J Gerontol Soc Work. 2010; 53: 64-76
        • Bern-Klug M.
        • Kramer K.W.O.
        • Chan G.
        • et al.
        Characteristics of nursing home social service directors: How common is a degree in social work?.
        J Am Med Dir Assoc. 2009; 10: 36-44
        • Bowblis J.R.
        • Smith A.C.
        Occupational Licensing of Social Services and Nursing Home Quality: A Regression Discontinuity Approach.
        ILR Rev. 25 Jun 2019; ([Epub ahead of print])
        • Bowblis J.R.
        • Roberts A.R.
        Cost-effective adjustments to nursing home staffing to improve quality.
        Med Care Res Rev. 2018; 1077558718778081
        • Calonico S.
        • Cattaneo M.D.
        • Titiunik R.
        Robust nonparametric confidence intervals for regression-discontinuity designs.
        Econometrica. 2014; 82: 2295-2326
        • Joyce N.R.
        • McGuire T.G.
        • Bartels S.J.
        • et al.
        The impact of dementia special care units on quality of care: An instrumental variables analysis.
        Health Serv Res. 2018; 53: 3657-3679
        • Lucas J.A.
        • Chakravarty S.
        • Bowblis J.R.
        • et al.
        Antipsychotic medication use in nursing homes: A proposed measure of quality.
        Int J Geriatr Psych. 2014; 29: 1049-1061
        • Imbens G.W.
        • Lemieux T.
        Regression discontinuity designs: A guide to practice.
        J Econometr. 2008; 142: 615-635
        • Lee D.S.
        • Card D.
        Regression discontinuity inference with specification error.
        J Econometr. 2008; 142: 655-674
        • Barreca A.I.
        • Lindo J.M.
        • Waddell G.R.
        Heaping-induced bias in regression-discontinuity designs.
        Econ Inq. 2016; 54: 268-293
        • Dellefield M.E.
        • Castle N.G.
        • McGilton K.S.
        • Spilsbury K.
        The relationship between registered nurses and nursing home quality: An integrative review (2008-2014).
        Nurs Econ. 2015; 33: 95-108
        • Harrington C.
        • Zimmerman D.
        • Karon S.L.
        • et al.
        Nursing home staffing and its relationship to deficiencies.
        J Gerontol B Psychol Sci Soc Sci. 2000; 55: S278-S287