Occupational Licensing and Patient Outcomes: Do qualified social workers improve post-acute care discharge outcomes?

By requiring a minimum level of educational attainment, a demonstrated mastery of knowledge through passing a formal exam, and in some cases, continuing education requirements, proponents of occupational licensing argue that it assures an adequate level of service quality. While theoretically valid, few studies empirically test whether occupational licensing leads to better quality because there are very few occupations in which individuals with and without licenses offer the same services in a similar setting.

In this paper, we examine the quality of post-acute care provided by skilled nursing facilities (SNFs) because certain services can be provided by licensed or unlicensed individuals. SNFs are a type of nursing home which provide rehabilitative services, called post-acute care after a patient has experienced a hospitalization. The main goal of post-acute care is help the patient regain functioning and return to their home.

A key aspect of post-acute care is the provision of social services, which involves helping the patient adjust to transitions in care settings. Social services are an integral part of the care planning process to help the patient meet their goals, and connect the patient and their family with resources in the community that will allow the patient to return home. All SNFs are required to provide social services, however, facilities may provide social services by staffing either unlicensed paraprofessionals or qualified social workers who often hold licenses and are required to have higher levels of education and training than paraprofessionals. In addition, there is an important provision of the Omnibus Reconciliation Act of 1987 that requires all SNFs with 121 or more beds to staff their social services department with at least one full-time equivalent qualified social worker. This provision creates a discontinuity in social services staffing at 121 beds because SNFs are required to increase the use of qualified social workers above this threshold.

Using the Minimum Data Set and CASPER data from 2011 through 2015, we build a dataset which allows us to first determine whether SNFs are responsive to the staffing provision. Using a regression discontinuity approach, we find that SNFs that are just above the 121 bed threshold are more likely to employ at least one qualified social worker, and that the overall staffing levels in social service departments does not materially change. This implies that when we examine quality outcomes, we are identifying a change in the composition of the qualifications of the social service department and not a change in staffing level.

Next, we construct a sample of fee-for-service Medicare patients that were newly admitted to a SNF for post-acute care. Our primary measure of quality was whether a patient was discharged to their home within 30 days of being admitted to SNF. While the statistical significance of the results varied with the model specification, the results generally provide supportive evidence that the use of qualified social workers improves the probability that a patient will be able to return to their home in the community.