1. Describe your experience with care plan conferences?
► Review the actual care plan during the conference
► Invite participation from resident/family/responsible party
Social work is a professional and academic discipline that seeks to improve the quality of life and subjective well-being of individuals, families, couples, groups, and communities through research, policy, community organizing, direct practice, crisis intervention, and teaching for the benefit of those affected by social disadvantages such as poverty, mental and physical illness or disability, and social injustice, including violations of their civil liberties and human rights. The profession is dedicated to the pursuit of social justice and the well-being of oppressed and marginalized individuals and communities.
► Organize day into related activities to increase efficiency
► Do all related tasks at once, i.e. gather all charts to complete MDS
assessments at one time
► Determine what time the residents will be discharging and ensure
all services are arranged to facilitate a safe d/c plan (all this should
have already been arranged prior to the day of d/c but now it's just
making sure it all falls into place)
► Since care plans are at scheduled times, all other activities must
take place around those
► Save the new admissions for the end of the day unless
intervention is needed sooner
► Remain focused on the task at hand
► Minimize interruptions
Grievance reports are written whenever an issue/complaint cannot be immediately resolved (and sometimes then as well).
5. How do you know when to write a grievance report?
Usually, the social worker is responsible for maintaining the grievance log and reporting issues/trends at the quality meeting.
6. How do you describe risk management?
Risk management is anything related to reducing the possibility of loss or injury; it requires excellent communication and teamwork as well as ongoing training, especially in areas of customer service.
7. Describe the components of a care plan for a resident with depression?
► The Problem Statement needs to be resident specific and describe
How depression impacts his/her quality of life
► The goal should
► Offer positive value to the resident
► Improve his/her life somehow
► Be measurable and realistic
► Address causal factors and not symptoms such as tearfulness or Combativeness.
8. What are the components of a comprehensive biopsychosocial assessment?
► Focus on resident strengths throughout the entire interview and
assessment process
► Identifying information (ethnicity, spirituality, appearance,
payer source, etc.)
► Reason for admission and presenting problems, prior living
arrangements and level of assistance needed with ADLs and
IADLs
► Advance directives and need for advance care planning
► History of physical and/or psychosocial problems
► Mental health and psychological treatment
► Personal and family history
► Support system
► Education and employment history
► Interests/hobbies
► History of substance abuse
► Cognitive functioning
► Discharge plan, if appropriate
► Impression and assessment
9. How do you prepare to interview a new resident/patient?
► Advance directives
► Responsible parties
► Diagnoses and impact on mood/behavior
► Discharge planning issues or placement issues if for long term care
► Issues from the hospital such as mood or behavior challenges
► Review of nursing assessments, especially fall, pain and elopement risks - ensure care plans are started
► Identify areas that the social worker can contribute to an interdisciplinary approach to care plans
► Therapy evaluations to get information on the prior level of functioning and goals
10. How do you explain code status to a resident and/or family member?
► First ask if they have questions regarding advance directives or code status
► Ask them to explain their understanding of the choice, either full code or do not resuscitate (DNR)
► Ensure accuracy of understanding
► If education is needed, explain full code in the same way that any other treatment or procedure is explained which includes discussion of risks (broken ribs, punctured lungs, probably decreased quality of life). Inform that Full Code includes many procedures, i.e. intubation, cardiac compression, artificial ventilation, etc.,
► Take the orange card to the meeting as a visual aid
► If education is needed for DNR, explain that comfort care is always provided, i.e. oxygen, pain management
► If code status is changed, must communicate with the charge nurse to get appropriate orders and follow facility procedures.
11. Do you facilitate the meetings?
Facilitate conference calls if family/responsible party unable to attend, schedule conferences at bedside if resident is unable to get out of bed.
12. How do you keep them on track?
Keep group focused - if conference turns into a "complaint session" schedule a separate meeting with necessary staff.
13. What information do social worker report on?
Social worker reports on: mood, behaviors, room changes, roommate changes, how resident is adapting to facility life or if admitted for a rehab stay, the discharge plan, advance directives, emergency contact and relationship.
14. What is your experience in discharge planning?
► Referrals to community resources - must demonstrate knowledge of most common resources, i.e. home health, medical equipment, Title 19, Meals-on-Wheels, mental health services.
► Discharge planning starts with the pre-admission process
► Comprehensive documentation of all activities related to discharge planning, including name and time of any phone calls, meetings or interactions.
► Communication with interdisciplinary team, resident and family
► Coordination of home health and equipment to coincide on day of discharge or earlier if training is necessary on a new piece of equipment, i.e. 4-wheeled walker, glucometer, etc.
15. How do you give report to a health plan case manager?
► Be prepared with updates from all disciplines (nursing, rehab, dietary)
Focus on progress to justify skilled stay
► Keep conversation short and focused on patient issues
► Keep case manager updated on all discharge planning barriers/challenges
► If not sure how to answer a question, get someone to help
Assess reason(s) why resident is declining therapy, i.e. depression, confusion, pain
Identify possible interventions to facilitate participation
Explain insurance benefits and skilled stay requirements
Involve family if appropriate
Consider writing a care plan for "refusal of care"
Communicate with staff at PPS or stand-up meeting
17. What do you do if two roommates are not getting along?
► Interviewee must demonstrate knowledge of resident rights and roommate regulations
► Talk to both residents, individually and possibly together
► Help them generate creative solutions
► If a solution is not possible and a room change is necessary, the
resident that initiated the "complaint" is the one who must make the room change
► Document in both residents' medical records all interventions attempted as well as the outcomes
► Make sure families are kept informed as appropriate
18. What is the role of the social worker with pain management?
► Be familiar with the Federal regulations for pain management in F309 Quality of Life
► Assessment using tools like the "faces" scale, the "number scale 1-10" or scales for advanced dementia
► Assessment by asking about: aggravating and alleviating factors, impact of pain, meaning of pain, and most importantly, the resident's goals for pain management
► Education regarding: misconceptions related to pain, challenges to achieve adequate pain management, the relation of pain to behaviors/mood, definitions of tolerance, addiction and dependence
► Identification of non-drug interventions and techniques to relieve anxiety (guided imagery, visualization, muscle relaxation)
► Invite her to sit down
► Shut the door to ensure privacy,
► Put phone on Do Not Disturb
► Start where the daughter is - if she needs to cry, let her cry; if she needs to talk, let her talk (about topics she feels necessary)
► Encourage her to share her feelings, concern, worries
► Do not offer false hope or meaningless comments like "I'm sure things will be just fine" or "At least she won't be suffering."
► If she is receptive, talk about ways staff focuses on her mom's comfort
► Determine if any action is necessary
► Ask if there is anything else she would like staff to do
► In some circumstances, suicide assessment might be necessary
► Start with very general discussion and ask her what she knows about her medical condition or why she is in the facility
► Determine if she needs more information or to have information repeated and then facilitate getting the information to her
► Involve other members of the IDT as necessary, i.e. physician, nurse
► Use active listening techniques
► Initiate or update the care plan with social work interventions such as 1:1 visits to allow resident to share feelings r/t diagnosis and prognosis
21. Tell me about your communication skills?
► Communication is vital to a successful facility
► Must be comfortable speaking up in a group, being assertive even if the group does not agree with the content, i.e. room change conflicts, patient discharge decisions
22. How do you employ them in the interdisciplinary team?
Ability to listen to other peoples' points-of-view and use reflective statements, i.e. "What I hear you saying is" or "It's important to you that"
23. What is one of the most challenging situations you have dealt with?
► Interviewee must be able to describe a complicated situation and demonstrate skill and critical thinking in achieving resolution.
24. What is something you have failed at?
Must demonstrate ability to learn from mistakes and to use the knowledge positively.
25. What areas would you like more education?
► Ability and willingness to be honest about areas that need work or that the person wants to become more proficient
► Of concern would be the interviewee who does not feel additional education is necessary
