What to expect and how to best advocate for your client after they are admitted to a SNF.

Joanne Stiteler, LCSW, NHA, C-ASWCM

Having worked in skilled nursing as a social worker and assistant administrator before beginning my own care management business, the following are some ideas on how to best cope with what may feel like the chaos of a very busy environment.

Over the last decade, nursing homes have seen regulations escalate, and funding decline. This has often resulted in depleted social work staff. What staff remains is often so busy completing tasks related to regulations that communication often suffers. Yet for geriatric care managers, communication is critical to our understanding, and our ability to advocate for our clients.

Persistence is essential. If there is initially a lack of response from SNF staff in your efforts to reach them, do not take offense.

The Care Conference Process

Know that new residents/patients to a SNF need to have a care conference at least within the first twenty-one days. Make it your business to, as soon as possible, get the date and time of the conference. Express your intentions to attend in person or via phone conference. If calls are not returned, combine a visit with your client with insisting on speaking to a care team member –the social worker, his/her supervisor, rehab personnel, or DON – to get the care conference date. Ensure the nursing facility staff knows of your plan to attend.

The care conference is a multidisciplinary meeting (nurse, social worker, rec therapist, rehab personnel, if on rehab, and occasionally a dietician), where the care plans are presented and reviewed. Care plans simply mean what is the staff doing for my client, what are the areas in which they are receiving services.

SNF’s use a three-part format for care plans – usually problem, goal, and interventions to reach the goal, with a projected time frame. Nursing home funding is in part related to care conference schedules and the content of the assessments employed on the resident/patient from which the care plans are designed. What this means is that everyone who resides in a SNF must have regularly scheduled care conferences. They are held every 90 days, though sometimes more frequently. The sheer volume of residents to be care conferenced is why there is little flexibility on when the conference can be held. Facilities are under pressure due to scheduling volume to have conferences be brief. Their time goal for the conference is often no longer than 15 minutes. To stay longer can interfere with the care conferences that follow.

The Care Manager and the Care Conference

As a geriatric care manager, it is important to attend the care conference with focus and prepared with questions. Know that if you have concerns/complaints not related to the specifics of the care plans, the care conference is not the forum to address them. For example, if there are missing clothes, issues regarding housekeeping, or complaints about specific staff members, then ask with whom, and when, these issues can be addressed. It is always important to bring concerns to relevant staff members as soon as possible, to get them addressed, and not wait for the next care conference.

Because of the detail and volume of work in nursing homes, it helps staff if you use two means of communication. Follow phone calls with an email confirming details of what was addressed or is still needed.

A Word About Valuables

It is best to leave valuable jewelry at home. Credit cards and cash are also best kept out of the SNF. Residents with confusion can misplace items, and valuables can disappear. We know that a major disruption in routine like going to a SNF can increase confusion. When items go missing it can be staff who is accused. While dishonest staff is possible, also consider the great number of people walking through the SNF, including other residents, their families and other visitors and vendors. To hear that an heirloom has gone missing is not only very distressful for the resident and family, but also the staff.

Keep Your Focus

As a geriatric care manager, your focus is your client and getting optimum care and service for them. A social worker in the SNF may have 30 to 100+ residents, but they also share your concern that your client has an optimal outcome.

Remember that what you bring to the SNF on behalf of your client helps the staff toward their goal of sustaining a positive environment and ultimately strong customer satisfaction.


This article was first posted on February 5, 2016, and updated on July 26, 2018.