Skilled nursing facilities, which are nursing homes that meet special criteria to be covered by Medicare, often times have many individuals with mental health issues that are not addressed. Many of these facilities are staffed with under-skilled personnel, or just understaffed in general. Much emphasis historically has been placed on how the facility provides for the physical needs of its residents, but an important and often overlooked question is how do they care for mental or behavioral needs?
Recent data indicates that over 20 percent of those aged 65 and older meet criteria for a mental disorder, including dementia. In nursing care and personal care facilities the number increases significantly. Over 50 percent of residents have some form of mental health disorder (some estimates go up to 91%). Dementia, as well as its behavioral and psychiatric symptoms, has long been the most common mental disorder in nursing facilities. However, over the last decade, the proportion of new nursing home admissions with mental illnesses other than dementia, such as major depression and psychotic disorders such as schizophrenia. These disorders are often exacerbated by chronic health problems.
Efforts to address the crippling need have begun only relatively recently. The Nursing Home Reform Act was passed in 1987 to ensure that the residents of nursing homes receive quality care that will contribute to their “highest practicable” physical, mental, and psychosocial well-being. It requires that skilled nursing facility residents be able to receive a full range of services to address their psychosocial needs and behavioral problems.
In 1996, the Inspector General of the US Department of Health and Human Services released a report that in part detailed the failure of Medicaid through the 1987 Nursing Home Reform Act to properly address the mental health needs of nursing facility patients. While the majority of the report focused on how Medicaid was being billed inappropriately by certain sample facilities and therefore wasting money, they also admitted to certain difficulties “in delivering needed mental health services to beneficiaries.” As an example, “some received psychotherapy without being evaluated for medication which may have been helpful,” while others received “erratic, inconsistent services when they need consistent psychotherapy.” Another finding was that often the skill levels of the providers were not adequate.
A study in New York found that out of 1,139 patients in 42 skilled nursing facilities in upstate New York, 64.2% had significant behavioral problems. A cross-state study in 2009 found that of the 1,150,734 new nursing home admissions in the entire U.S., 27.4% indicated schizophrenia, bipolar disorder, depression, or anxiety. Using this data, and based on the Holzer synthetic estimation technique’s estimation that there are over 10.4 million adults in the U.S. with a mental illness, it is estimated that about 3% of the population with mental illness was admitted to a nursing home in just one year (2005).
The latter study is particularly interesting because, while the data averages provide remarkable insight into the problem at large, it also breaks the information down to the state level. They found significant variation in data between states with the lowest rate and the highest rate of nursing home admissions among persons with mental illnesses. While the national average was 3% of the population with mental illness was admitted to a nursing home, the lowest rate was 1.6% (Georgia), and the highest rate was 4.5% (Ohio).
Why is this variation so high? The study ultimately asserts that there’s a need for further research, but does suggest three possible reasons. 1) There is a considerable amount of discretion given to states to determine the method and generosity of Medicaid payments, 2) as part of the Deficit Reduction Act, the DHHS has incentivized states to turn away from nursing home care and toward home- and community-based services (HCBS), and 3) considerable room for discretion by the states as to how to interpret and implement Preadmissions Screening and Resident Reviews (PASRR), which are used to determine serious mental illnesses. For example, Ohio, the state with the highest rate of nursing home admissions indicating a mental illness, uses the hospital exemption method, which allows patients to gain admission to a nursing home straight from the hospital without any screening at all.
Another primary issue that has long been on the health community’s radar is the widespread understaffing of nursing facilities. It is estimated that up to 90% of nursing homes are currently understaffed. In a survey, 46% of nurses said they had missed changes in a patient’s condition because of their excessive workload.
Telebehavioral health may be the answer to these issues. Recently, interest in telehealth has reached an all-time high. Many of the most prestigious health systems in the U.S. have begun to implement the technology within the past couple of years. Delivering medical services virtually enables health systems to better distribute staff throughout their healthcare facilities, thereby relieving the rampant understaffing within many healthcare facilities, and load-balance resources across entire systems, reaching more patients with less strain on specialist resources. A novel approach to health delivery, telehealth is only expected to grow in the years to come.
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