Heidi Splete is a senior writer with Elsevier Global Medical News.
Within his first week at a skilled nursing facility for postacute rehabilitation services, 54-year-old J.P. was disrupting the nursing home's normal routine. It wasn't his stage IV renal failure that was the problem. It was his mental health diagnoses: schizoaffective bipolar disorder and nicotine dependence. The combination led J.P. to demand long stays on the facility's smoking patio, and that required one-on-one supervision, explained Timothy L. Heston, DO, of Stormont-Vail HealthCare, a skilled nursing facility in Topeka, Kan.
J.P. is not an anomaly. The number of individuals admitted to nursing homes with mental illnesses other than dementia has surpassed the dementia admissions, according to nursing home admissions data published recently in the journal Psychiatric Services.
The force most likely driving this trend include the decreasing number of residential psychiatric facilities with the ability to house and care for individuals with dysfunctional and debilitating psychiatric symptoms, while the number of people who need such care is rising, Dr. Heston said in an interview.
Most facilities that normally house psychiatric residents are heavily subsidized through Medicaid, Dr. Heston noted. When Medicaid payments aren't enough to meet the costs of housing and providing CMS-regulated services, these facilities have no choice but to close.
“Also, the need to house the growing number of long-term psychiatric residents increases the resident census, thereby virtually eliminating the number of open skilled beds available for the shorter-term rehab and respite residents,” he said.
To examine recent trends in the admission of mentally ill individuals to nursing homes, Catherine Anne Fullerton, MD, of Harvard Medical School, Boston, and her colleagues collected data from the Centers for Medicare & Medicaid Services national registry of nursing home residents and reviewed information on mental illness from the residents' Minimum Data Set assessments at admission.
The researchers found that the number of individuals admitted to nursing homes with mental illness increased 111%, from 168,721 in 1999 to 187,478 in 2005. “The large increase in admission of persons with mental illness from 1999 to 2005 was primarily due to the increase in residents with a diagnosis of depression,” the researchers wrote. The prevalence of individuals admitted with depression increased from 11% (128,566 individuals) to 15% (154,262) during the study period (Psychiatr. Serv. 2009;60:965-71). The number of residents admitted with bipolar disorder increased slightly (from 0.4% to 0.5%), although this difference was not statistically significant. The percentage of newly admitted residents with anxiety dropped slightly (from 2.5% to 2.3%), and the percentage with schizophrenia remained approximately the same (0.5%).
The question of how far nursing homes should go on the spectrum of managing mental illness remains unclear. The American Association of Homes and Services for the Aging (AAHSA) takes the view that nursing homes aren't the best places for adults with chronic and acute mental illness.
Although the AAHSA supports the role of nursing facilities in developing care plans that meet their residents' needs, including mental health care, the requirements for long-term care facilities don't stipulate that they be capable of providing the intense, specialized services that individuals with chronic mental illness need, said Evvie Munley, a senior health policy analyst for the AAHSA, in an interview.
Because most nursing homes are designed primarily to serve the needs of the frail elderly, they may not have the specialized staffing and resources to serve people who are acutely or chronically mentally ill, Ms. Munley said. Specialization in that area includes managing the behaviors and manifestations common to major mental illnesses and providing care for patients who need long-term, intense psychotherapy, she explained.
The change in nursing home demographics continues to challenge physicians, and strategies to manage this resident population are evolving. “From the physicians' perspective, visit and on-call time has increased due to the need to provide therapies consistent with psychiatric illness,” said Dr. Heston.
AMDA has developed a Web-based, downloadable documentation guide to help medical directors and attending physicians address the issue of mental illness in nursing home residents and document those actions, as required by law.
The guide's content is organized to walk physicians through five specific stages of mental health documentation: preadmission, admission, times of cognitive/behavioral/mood changes, monitoring processes once an intervention has been implemented, and the clinical and regulatory documentation necessary when residents are placed on psychoactive medications.
The guide provides sample data-gathering tools and templates, as well as sample forms to record decisions on and monitoring use of psychoactive medications.
“The most significant change is the need for [skilled nursing facility] staff education for the purpose of increased coping and resident-management skills,” Dr. Heston said.