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Aging and Social and Economic Justice

Using the Eco-Map and Ecosystems Perspective to Guide Skilled Nursing Facility Discharge Planning

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Pages 504-518 | Received 14 Nov 2016, Accepted 25 Apr 2017, Published online: 01 Jun 2017

References

  • Alzheimer’s Association. (2015). Alzheimer’s disease facts and figures. Chicago, IL: Alzheimer’s Association.
  • Alzheimer’s Association. (2016). Nursing homes/skilled nursing facilities. Chicago, IL: Alzheimer’s Association. Retrieved August 24, 2016, from http://www.alz.org/sewi/documents/SNF_Check_List(2).pdf
  • American Health Care Association (AHCA). (2016). Fast facts, Skilled nursing care centers in the U.S. Retrieved from https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx
  • Bailey, D. B., & Simeonsson, R. J. (1988). Family assessment in early intervention. Columbus, OH: Merrill.
  • Bangerter, L. R., Van Haitsma, K., Heid, A. R., & Abbott, K. (2016). “Make me feel at ease and at home”: Differential care preferences of nursing home residents. The Gerontologist, 56(4), 702–713.
  • Beaulieu, E. M. (2012). A guide for nursing home social workers. New York, NY: Springer Publishing Company.
  • Beckett, J., & Coley, S. (1987). Ecological intervention with the elderly: A case example. Journal of Gerontological Social Work, 11(1/2), 137–157.
  • Berkman, B., Coulton, C., Haikalis, S., Kaplan, K., Keller, S., & Wills, D. (1990). NASW clinical indicators for social work and psychosocial services in the acute care medical hospital. NASW Commission on Health and Mental Health and the Society for Hospital Social Work Directors. Retrieved from http://www.naswdc.org/practice/standards/acute_care_med_hospital.asp
  • Berkowitz, R. E., Fang, Z., Helfand, B. K., Jones, R. N., Schreiber, R., & Paasche-Orlow, M. K. (2013). Project reEngineered discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. Journal of the American Medical Directors Association, 14(10), 736–740.
  • Bern-Klug, M., Connolly, R., Downes, D., Galambos, C., Kusmaul, N., Kane, R., … Beaulieu, E. (2016). Responding to the 2015 CMS proposed rule changes for LTC facilities: A call to redouble efforts to prepare students and practitioners for nursing homes. Journal of Gerontological Social Work, 59(2), 98–127.
  • Bonifas, R. P. (2011). Multilevel factors related to psychosocial care outcomes in Washington state skilled nursing facilities. Journal of Gerontological Social Work, 54(2), 203–223. doi:10.1080/01634372.2010.538817
  • Bronfenbrenner, U. (1992). Ecological systems theory. Philadelphia, PA: Jessica Kingsley Publishers.
  • Calix, A. (2004). Is the ecomap a valid and reliable social work tool to measure social work? ( Masters thesis). Retrieved from ProQuest Dissertations Publishing. (1560467).
  • Center for Aging Research and Educational Services. (2003). A guide to record keeping for adult services social workers. School of Social Work University of North Carolina - Chapel Hill. Retrieved from http://ssw.unc.edu/cares/rk/AppendixB.pdf
  • Centers for Medicare and Medicaid Services. (2010). CH. 3: MDS items. RAI Version 3.0 Manual. Retrieved from https://www.ahcancal.org/facility_operations/Documents/UpdatedFilesRAI3.0/Chapter%203%20-%20Section%20Q%20V1.03%20July%202010.pdf
  • Coleman, E. A., Min, S. J., Chomiak, A., & Kramer, A. M. (2004). Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39(5), 1449–1465.
  • Craig, S., & Muskat, B. (2013). Bouncers, brokers, and glue: The self-described roles of social workers in urban hospitals. Health and Social Work, 38(1), 7–16.
  • Dambaugh, L., & Ecklund, M. (2014). Assuring evidence-based practice in skilled nursing facilities. Clinical Nurse Specialist Journal. doi:10.1097/NUR.0000000000000083
  • Dombrowski, W., Yoos, J., Neufeld, R., & Tarshish, C. (2012). Factors predicting rehospitalization of elderly patients in a postac20baute skilled nursing facility rehabilitation program. American Congress of Rehabilitation Medicine, 93, 1808–1813.
  • Duarte, M. C., Da Costa, S. F., De Albuquerque, K. F., & Costa, M. M. (2016). Family evaluation of hospitalized elderly with encephalic vascular accident under palliative care. International Archives of Medicine, 9(215). doi:10.3823/2086
  • Fabbre, V. D., Buffington, A. S., Altfeld, S. J., Shier, G. E., & Golden, R. L. (2011). Social work and transitions of care: Observations from an intervention for older adults. Journal of Gerontological Social Work, 54(6), 615–626. doi:10.1080/01634372.2011.589100
  • Fields, N. L., Anderson, K. A., & Dabelko-Schoeny, H. (2011). Ready or not: Transitioning from institutional care to community care. Journal of Housing for the Elderly, 25(1), 3–17.
  • Fort, M., Castro, M., Peña, L., Hernandez, S., Camacho, G., Ramirez-Zea, M., & Martinez, H. (2015). Opportunities for involving men and families in chronic disease management: A qualitative study from Chiapas, Mexico. BMC Public Health, 15, 1019. doi:10.1186/s12889-015-2361-6
  • Germain, C. (1973). An ecological perspective in casework practice. Social Casework, 54, 323–330.
  • Germain, C., & Gitterman, A. (1996). The life model of social work practice, advances in theory & practice (2nd ed.). New York, NY: Columbia University Press.
  • Germain, C. B., & Gitterman, A. (1995). Ecological perspective. Encyclopedia of Social Work, 1, 816–824.
  • Gitterman, A., & Germain, C. B. (1981). Education for practice: Teaching about the environment. Journal of Education for Social Work, 17(3), 44–51.
  • Gorina, Y., Pratt, L., Kramarow, E., & Elgaddal, N. (2015). Hospitalization, readmission, and death experience of noninstitutionalized medicare fee-for-service beneficiaries aged 65 and older. National Health Statistics Reports, 84. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr084.pdf
  • Grebla, R. C., Keohane, L., Lee, Y., Lipsitz, L. A., Rahman, M., & Trivedi, A. N. (2015). Waiving the three-day rule: Admissions and length-of-stay at hospitals and skilled nursing facilities did not increase. Health Affairs, 34(8), 1324–1330.
  • Harrington, C., Carrillo, H., & Garfield, R., & Kaiser Family Foundation. (2015). Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2014. The Kaiser Commission on Medicaid and the Uninsured. Retrieved from http://ltcombudsman.org/uploads/files/library/deficiencies-09-14.pdf
  • Hartman, A. (1978). Diagrammatic assessment of family relationships. Social Casework, 59, 465–476.
  • Hartman, A. (1995). Diagrammatic assessment of family relationships. Families in Society: The Journal of Contemporary Human Services, 1, 111–122.
  • Hartman, A., & Laird, J. (1983). Family-centered social work practice. New York: Free Press.
  • Hearn, G. (Ed). (1969). The general systems approach: Contributions toward an wholistic conception of social work. New York, NY: Council on Social Work Education.
  • Huber, D., Milne, S., & Hyde, K. (2016). Biographical research methods and their use in the study of senior tourism. International Journal of Tourism Research. doi:10.1002/jtr.2081
  • Hunter, T., & Birmingham, J. (2013). Preventing readmissions through comprehensive discharge planning. Professional Case Management, 18(2), 56–63.
  • Kemp, S. P., Whittaker, J. K., & Tracy, E. M. (1997). Person-environment practice: The social ecology of interpersonal helping. New York, NY: Aldine De Gruyter.
  • Kennedy, V. (2010). Ecomaps. MAI Review. Retrieved from www.review.mai.ac.nz/index.php/MR/article/download/371/546
  • Levinson, D. (2013). Skilled nursing facilities often fail to meet care planning and discharge planning requirements. U.S. Department of Health and Human Services. Retrieved from https://oig.hhs.gov/oei/reports/oei-02-09-00201.pdf
  • Lusignan, K. A. (2003). “Give us your tired, your poor”… an analysis of postmodern medical use of underpriviledged individuals from the Albany county almshouse skeletal sample. American Journal of Physical Anthropology, 150(1), 142.
  • Mattaini, M. (1995). Visualizing practice with children and families. Early Child Development and Care, 106, 59–74.
  • McCarthy, J. F., Szymanski, B. R., Karlin, B. E., & Katz, I. (2013). Suicide mortality following nursing home discharge in the department of veterans affairs health system. American Journal of Public Health, 103, 2261–2266.
  • McCormick, K. M., Stricklin, S., Nowak, T. M., & Rous, B. (2008). Using eco-mapping to understand family strengths and resources. Young Exceptional Children, 11(2), 17–28.
  • McCoyd, J., & Schwaber Kerson, T. (2016). Social work in health settings: Practice in context (4th ed.). New York, NY: Routledge.
  • Medicare.gov. (n.d.) Skilled nursing facility (SNF) care. Retrieved from https://www.medicare.gov/coverage/skilled-nursing-facility-care.html
  • Meehan, J. (2015). A culturally competent approach to engagement, assessment, intervention, and evaluation with LGBT elders: A case example. Advanced Generalist: Social Work Research Journal, 1(3/4), 1–17.
  • Mor, V., Intrator, O., Feng, Z., & Gambrowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs (Millwood), 29(1), 57–64. doi:10.1377/hlthaff.2009.0629
  • National Institutes of Health (NIH). (2013). The dementias: Hope through research. Retrieved August 24, 2016, from https://www.nia.nih.gov/alzheimers/publication/dementias/types-dementia
  • Omnibus Budget Reconciliation Act of 1987. Pub. L. No. 42, CFR § 483.20(l)
  • Orr, N. M., Boxer, R. S., Dolansky, M. A., Allen, L. A., & Forman, D. E. (2016). Skilled nursing facility care for patients with heart failure: Can we make it “heart failure ready?” Journal of Cardiac Failure. doi:10.1016/j.cardfail.2016.10.009
  • Parsons, T. (1949). The structure of social action (Vol. 491). New York, NY: Free Press.
  • Ray, R., & Street, A. (2005). Ecomapping: An innovative research tool for nurses. Journal of Advanced Nursing, 50(5), 545–552.
  • Reidt, S., Sibicky, S., & Yarabinec, A. (2016). Transitional care units: Expanding the role of pharmacists providing patient care. The Consultant Pharmacist®, 31(1), 44–48.
  • Rowe Kaakinen, J., Padgett Coehlo, D., Steele, R., Tabacco, A., & Harmon Hanson, S. M. (2014). Family health care nursing: Theory, practice, and research. Philadelphia, PA: F. A. Davis.
  • Scarlatt Oliveira, P., Santos Fagundes, L., Andrade Barbosa, H., Soares Santos, A., Costa Lopes, M., & Santos Vilasboas, F. (2016). Care of a fragile elderly by the family. Journal of Nursing UFPE, 10(1), 273–283.
  • Sherry, J., & Cruz, Y. (2014). Knowledge, stigma, and attitudes about Alzheimer’s disease among Hispanic older adults and their caregivers. Alzheimer’s & Dementia, 10(4), P294–P295.
  • Social Security Act of 1935. §1919. [42 U.S.C. 1396r]
  • Teno, J. M., Mitchell, S. L., Skinner, J., Kuo, S., Fisher, E., Intrator, O., & …Mor, V. (2009). Churning: The association between health care transitions and feeding tube insertion for nursing home residents with advanced cognitive impairment. Journal of Palliative Medicine, 12(4):359–62.
  • Toles, M., Anderson, R. A., Massing, M., Naylor, M. D., Jackson, E., Peacock‐Hinton, S., & Colón‐Emeric, C. (2014). Restarting the cycle: Incidence and predictors of first acute care use after nursing home discharge. Journal of the American Geriatrics Society, 62(1), 79–85.
  • U.S. Department of Health and Human Services. (2016). Aging statistics, Administration on Aging. Administration for Community Living. Retrieved from http://www.aoa.acl.gov/Aging_Statistics/index.aspx
  • Von Bertalanffy, L. (1950). An outline of general system theory. British Journal for the Philosophy of Science, 1(2), 134–165.
  • Wakefield, J. (1996). Does social work need the ecological perspective? Reply to Alex Gitterman. The Social Service Review, 70(3), 476–481.
  • World Health Organization (WHO). (2016). Dementia fact sheets. Retrieved August 24, 2016, from http://www.who.int/mediacentre/factsheets/fs362/en/
  • Xiao-Ling, L., Hu, N., Meng-Shan, T., Jin-Tai, Y., & Tan, L. (2014). Behavioral and psychological symptoms in Alzheimer’s disease. Biomed Research International, 2014. doi:10.1155/2014/927804
  • Ye, Y., Efeovbokhan, U., & Parker, R. (2011). Identifying patterns of skilled nursing facility readmission. Journal of American Medical Directors Association, 12(3), B13–B14.
  • Yoo, J. W., Jabeen, S., Bajwa, T., Kim, S., Leander, D., Hasan, L., … Khan, A. (2015). Hospital readmission of skilled nursing facility residents, a systematic review. Research in Gerontological Nursing, 8(3), 148–156.
  • Zimmerman, S., Connolly, R., Zlotnik, J. L., Bern-Klug, M., & Cohen, L. W. (2012). Psychosocial care in nursing homes in the era of the MDS 3.0: Perspectives of the experts. Journal of Gerontological Social Work, 55(5), 444–461.

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