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The number of nursing home residents with either primary or comorbid substance use disorders (SUDs) is on the rise — while the average age upon admission is getting younger — according to a consultant tasked with training medical professionals and paraprofessionals to meet the needs of this growing demographic.
“We are seeing in our work and in the available data that some nursing homes are definitely caring for younger folks than in the past and that they have a higher incidence rate of behavioral health concerns,” Gail Patry, RN, CPEHR, chief program officer at Health Centric Advisors in Providence, RI, told Caring. The reasons for the change, according to Ms. Patry, include a rise in the number of homeless individuals with chronic health conditions and comorbid SUDs and the overall increase in the number of individuals in the general population with mental and behavioral health conditions who are developing other chronic medical conditions as they age.
“The average age of a nursing home resident, at least in Rhode Island, used to be in the 80s. But we are now seeing a growing number of residents aged between 45 and 65. Many of these individuals have co-occurring substance use and mental disorders with other chronic medical conditions that require care in skilled nursing facilities.”
Ms. Patry is overseeing the implementation of a Centers for Medicare & Medicaid Services Special Innovation Project to offer comprehensive training on aspects of delivering mental and behavioral health care in the nursing home setting. “We’ve had many conversations with the leadership of many nursing homes in the region,” Ms. Patry said. “Between that and the internal data we are seeing, and our observation that poor behavioral health care is a driver of poor care transitions, we believed this would be something CMS would be interested in.”
The 2-year pilot innovation project, which is one of 14 such national CMS special innovation project awards focused on finding patient- and family-centered solutions to health care concerns, includes 13 Rhode Island nursing homes. Some of these facilities are corporately owned, and some are locally owned, with the number of beds ranging from less than 50 to more than 150. In each of the participating facilities, one or more mental or behavioral health conditions has been diagnosed in at least half of the residents, according to data from the most recent Certification and Survey Provider Enhanced Reports (CASPER).
The grant is being applied to partnerships with Rhode Island College, which is providing training for the paraprofessionals employed in the participating facilities, and with the Substance Use and Mental Health Leadership Council of Rhode Island, which is training the professional medical staff.
Ms. Patry said that when she and her team approached nursing home administrators with the opportunity to participate in the project, most of them were eager. “They were saying how this is so important. They were thanking us, saying it was hard to believe some of the situations they were finding themselves in.”
Although few data exist at present on the SUD trend, according to Marianne Raimondo, MSW, LICSW, PhD, assistant professor and executive director of the college’s Institute for Education in Healthcare, the paraprofessionals who form the frontline in confronting it typically receive the least training. If patients who are using drugs attack staff or other residents — or, in one case Dr. Raimondo shared with Caring, overdose in the nursing home — training in how to avoid sarcopenia or use dialysis would be of no use.
“Certified nursing assistants are being asked to deal with people with SUDs, but they’re not familiar with how to recognize the signs and symptoms of mental and behavioral health issues,” Dr. Raimondo said. “Yet it’s the CNAs who spend the most time with these patients. We need to support them.”
The institute’s comprehensive 30-hour curriculum for currently employed paraprofessionals, taught at the college by members of the psychology and social work faculty, covers concepts in behavioral and mental health and communication techniques such as active listening, self-reflection, and crisis management and de-escalation. It also reviews the most common disorders, the variety of contexts in which behavioral health issues arise — including the specific needs of patients who are in recovery, and SBIRT training (Screening, Brief Intervention, and Referral to Treatment). The course concludes with simulated situations and peer review of the participants’ projects based on the materials they’ve learned.
Dr. Raimondo said the course is especially important for paraprofessionals who work on weekends and evening and night shifts, when there are no physicians on site and few if any nurses on the premises. To facilitate this cohort’s access to the training, the college, which currently offers the training only on campus, is considering other ways to deliver the content, including online. Although there are already pre- and post-evaluations of the material, Dr. Raimondo said the pilot program will also help develop measures to determine how the training affects job performance, particularly how paraprofessionals interact with patients.
In addition to developing measures for how training impacts job performance, Ms. Patry said she and her team also will evaluate whether homes are seeing lower emergency department utilization rates and better de-escalation of crisis situations.
“In the last year our resident population has seen an increase in substance abuse and psychological disorders. Many of the residents are homeless or unable to safely return to the community,” Linda Wheeler-Omiunu, RN, NHA, administrator of the for-profit, 185-bed Trinity Health and Rehab in Woonsocket, RI, told Caring. Ms. Wheeler-Omiunu’s facility is participating in the pilot project. “The hope is that this program will assist the staff with handling and managing behaviors using nonpharmacological interventions prior to use of traditional pharmacological interventions. This would result in a positive impact on the life of our residents.”
Health Centric Advisors serves the entire New England region and is a designated CMS quality improvement organization, something Ms. Patry said has helped her appreciate the disproportionate supply and demand for mental and behavioral health services in the nursing home setting. And she believes the situation will get worse before it gets better.
“I am a former nursing home nurse. Something very different is happening out there right now. Many homes today are caring for a very different population than we saw 10 or 15 years ago,” Ms. Patry said. “It’s probably due to a whole host of reasons, not just one thing, but maybe a perfect storm of many things.”
Whitney McKnight is a Washington, DC–area freelance medical writer.