The Rising Importance Of Social Services In Nursing Homes

The role of social services is rapidly becoming more complex and central in nursing homes, as caseloads are increasingly shaped by higher clinical acuity and the growing complexity of residents’ mental health and social circumstances. As a result, staffing needs cannot be based simply on the number of residents.

Also, as operators adopt more integrated approaches to care, social workers – and social services workers – are integral to communication between teams for the care plans, and all this is prompting skilled nursing organizations to seek staff with broader clinical expertise as well as expand their career pathways for licensing.

Heather Brekke, vice president of social services and behavioral health at Monarch Healthcare Management, who herself holds a master’s degree in social work, told Skilled Nursing News that she has seen the role grow more complex during her tenure with Monarch since 2015.

“Our Social Services department requires training in a variety of areas related to health and human development, behavioral health, ethics and more,” Brekke said.

States also have put in place staffing mandates for social workers as a recognition of the rise in severity in behavioral health conditions within skilled nursing facilities (SNFs).

The state of Minnesota requires a licensed social worker in buildings licensed for more than 120 residents, Brekke said.

Monarch’s social workers handle everything from admission to discharge and are key in handling the care plan, she said.  

“Social services serves as an advocate for the residents and their loved ones, helping to create a personalized care plan that best meets their individual needs and goals,” said Brekke. 

Optimal staffing levels vary considerably based on the needs and complexity of the resident population, she noted.

“There is no mathematical equation that determines how many people we need to best support our residents. Strictly relying on the number of residents does not take into account the complexities that things like substance use, mental health, housing insecurity, et cetera, add to the caseload of the department,” Brekke said.

Integrated health and social workers

For integrated health providers in long-term care and skilled nursing, a social services role – which can be fulfilled by non-licensed social workers depending on the size and mix of assets – takes on a higher level of urgency, especially if the facility is small and not required to have a licensed social worker oversee the resident population.

Kimberly Green, CEO of Oklahoma-based Sage Integrated Health and former COO of Diakonos Group, believes social workers and social services staff are crucial in delivering truly integrated care and care plans. While the industry has long recognized the importance of addressing residents’ biological, psychological and social needs, she argues that facilities have historically focused too heavily on physical care while treating mental health and psychosocial care as secondary.

Green said her vision for Sage is to create a highly collaborative, interdisciplinary model in which physicians, nurses, therapists, dietary staff and social services all work from a unified, constantly evolving care plan rather than operating in silos. She believes care planning should be an ongoing conversation among disciplines instead of a compliance exercise.

In long-term care, staff can get increasingly frustrated and burned out as they manage complex mental health needs of residents, including depression, anxiety, dementia and family concerns. When a licensed social worker – often drawn from outside the industry due to a shortage in her state – lacks the expertise to address these issues, the burden falls on nurses and other staff, making effective interdisciplinary communication and support essential, Green said.

Oklahoma regulations only require licensed social workers in skilled nursing facilities above the bed threshold of 118 licensed beds, she said. And, because Sage’s campus also has independent living, assisted living and memory care, the organization is not required to employ a licensed social worker.

Instead, Green retained a newly hired social services employee and is training the individual to take on a broader, more resident-centered role than is typical in long-term care.

Rather than focusing only on required paperwork and assessments, Sage’s social services model emphasizes understanding each resident’s physical, mental and psychosocial needs, identifying what gives residents meaning and purpose, and helping establish a sense of “place” rather than simply occupying “space.” Green said this philosophy is informed by her doctoral research on the psychological impact of long-term care environments, an area she believes has been largely neglected by researchers since the 1970s.

“That care plan that social services should be guiding with nursing, it’s supposed to be a living document. It’s not supposed to be stagnant. It’s not supposed to be a quarterly care plan,” she said. “That information and communication and consultations are free flowing like they’re supposed to be … it’s changing on a constant basis.”

And, this constant change of information can impact care planning, which will be better served if social services is also actively involved.

Green stressed that licensing alone does not ensure effective care. In her experience, many licensed social workers – and other clinicians – enter long-term care without specialized geriatric training. As a result, they may meet regulatory requirements but lack the expertise to counsel families coping with guilt and grief, address dementia-related behaviors or understand the unique psychological needs of older adults in skilled nursing settings.

She noted that the formal responsibilities of licensed social workers and non-licensed social services staff are often nearly identical in practice, with both handling assessments, care planning and family interactions. The difference, she said, should be the depth of clinical expertise and counseling skills, though that expertise is often missing because facilities struggle to recruit qualified professionals and geriatric-specific training remains limited.

All said, Green believes that without knowledgeable social services professionals, nurses often absorb responsibilities such as family counseling, dementia behavior management and emotional support. She sees stronger integration of social services into daily care – and continuous communication among all disciplines – as essential to improving quality of care in skilled nursing facilities.

Promoting internal talent versus hiring brand new

Social services positions are generally easy to fill but harder to retain for for-profit providers like Monarch, according to Dan Strittmater, VP of innovation and bench strength at Monarch.

“Rural employers or nonprofits offer added benefits of loan forgiveness after 10 years. Also, there is lots of competition,” he explained.

And so, while Monarch hires externally, it also supports career development for many social services designees by offering scholarships, supervision and training, he said.

Meanwhile, unlicensed social services staff can be deployed in smaller buildings that meet regulations. However, Monarch is always prioritizing career advancement and clinical expertise for these unlicensed workers given the role’s growing importance, Strittmater said.

“We try to get as many LSW/MSW as possible including hiring new hires … Where it meets the regulation, we have both and sometimes in director roles if the facility is under the size it requires,” Strittmater said. “We have lots of licensed social workers at a regional level or in other support roles so that all of our facilities [benefit from] them.”

As the largest operator in Minnesota, Monarch operates more than 45 nursing homes and caters to a broad spectrum of social service needs.

“Because we have facilities with behavior and chemical dependency needs, we have an extensive LCSW, or Licensed Clinical Social Workers, and similar – it’s amazing to capture someone’s passion for serving others and help them move their career along,” he said.

For nursing homes in rural settings, workforce shortages make hiring difficult across all disciplines, including social services, Green said. And, it would behoove organizations to develop talent internally, particularly by training motivated newcomers instead of relying on experienced workers who may be resistant to changing longstanding practices that don’t facilitate integrated health, she said.

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