Although it took effect a little later, 1987 was the year that OBRA, the Omnibus Budget Reconciliation Act (which included the Federal Nursing Home Reform Act), was enacted. For me personally, it was the year I started my first permanent job in long-term care. I have worked in long-term care ever since. It has been a career that’s been sometimes frustrating, but almost always challenging and rewarding. It seems an opportune time to look back and examine how long-term care has changed since OBRA, and also to look forward to see where we still need to go.

In a recent article by Jeff Smoker in Provider, “Key Players Assess State of Long Term Care” (July, 2007), representatives from long-term care (providers, consumers, politicians, and regulators) were asked to comment on these issues. Most agreed on some common themes regarding changes over the last 20 years. There are many more choices available today – CCR’s, Assisted Living, Hospice, and many options for home-based care. The typical LTC resident has more complex medical needs, and many more people are using nursing facilities for short-term rehab after an acute health problem or injury. The use of restraints has dropped dramatically. OBRA contained the first principles of “culture change”, and there has been a move toward a more person-centered approach, with focus on individual needs, in many facilities. The assessment process became standardized with the advent of the MDS, but paperwork increased along with this. OBRA changed the nursing care requirements and the survey process for assessing compliance, also introducing new sanctions for facilities that failed to comply with the standards.

While there have been positive steps forward resulting from OBRA, it is generally agreed that the gains are not what we had hoped, and we still have a long way to go. There is great disparity in nursing home care, with some facilities adopting culture change models, and others stuck in an institutional, medical-model approach. Key players feel that the funding structure is a mess and most facilities lack adequate numbers of well-trained and well-supervised staff to provide the care needed by residents (Provider reports that 2000 & 2001 government studies indicated that 90% of nursing homes do not have enough nursing staff). While the federal regulations are good, the enforcement is subjective and inconsistent, which undermines the integrity of the process. Key obstacles to moving forward to improve the quality of nursing home care are adequate financing, consistent regulatory oversight, and the ability to recruit and maintain competent employees who can meet the demands of a higher skill level in the populations we serve.

So – where do social workers stand in all of this? Obviously, we hold as a core value the person-centered model , which focuses on resident rights, individuality, and self determination. I believe social workers have been key players in advances made in this area. I also believe that overall, social work is a much more valued and integral part of the provision of LTC than it used to be. We can continue to effect positive change through advocacy efforts for individual residents, facility-wide policy change, and by sharing our knowledge and opinions on a federal policy and legislative level. We cannot get so mired in the day to day that we forget the social work mission of social justice and positive change for those who cannot advocate for themselves.

Twenty years ago, on a typical day, I walked down the hall of my facility and saw several patients clustered at the nurse’s station. About half had on hospital gowns and were wearing part of their breakfast. Two had posey restraints, and another two were too medicated to say hello. I noticed several more patients enjoying a bingo game in the dining room. The nurse called out to me to ask if I found Mr. J’s dentures and if I called the family to get new bras for Mrs. M. Today, on a typical day, there are two residents at the nurse’s station anxiously asking for their meds, but they are dressed in casual, clean clothes. One, who has frequent falls, has a self-releasing seat belt. There is a table-gardening activity going on in the living room. The nurse calls out to ask me to talk to Mrs. B’s family, who doesn’t want to follow her living will regarding tube feeding… and asks whether I found Mr. T’s glasses.