When the Centers for Medicare & Medicaid Services describes the mission of nursing homes, it notes that “each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being” (42 CFR § 483.40). The majority of residents living in post-acute and long-term care communities have one or more psychiatric diagnoses, and all are by definition contending with a major life transition. This makes PALTC a behavioral health care environment, not just a medical care environment as has been the traditional service model.
As co-chairs of the new Behavioral Health Council of AMDA – The Society for Post-Acute and Long-Term Care Medicine, we are eager to bring behavioral health expertise, training, and care delivery models from the sidelines into the center of care, where Society members get more of what they need to succeed. We plan to accomplish this with an interdisciplinary council focused on promoting integration of behavioral health with medical health, eliminating the false dichotomy, and supporting person-centered well-being.
Integrating Behavioral and Medical Health
The post-acute arena has struggled with the mission of consistently providing the kind of care that residents need to maximize their “whole emotional and mental well-being.” How can we ensure that residents have the opportunity to achieve their highest level of mental health and personal integrity despite the losses they have shouldered and the challenges they face? Do we view the residents’ emotional well-being as coequal with their medical status? When we prescribe treatments, do we always ask ourselves first if the side effects of the treatment, particularly with respect to a resident’s mood, energy level, cognition, and behavior, outweigh any potential benefit? Before we prescribe psychotropics for unwanted behavior, do we ensure that we have done whatever can be done nonpharmacologically to manage the situation?
An objective assessment of the industry’s progress toward providing this kind of care would conclude that we are not yet, collectively, achieving our goals. As a rule, we do not yet view emotional and psychological well-being as coequal to medical status. We often prioritize medical issues over psychiatric and emotional issues. Some of the medical treatments we provide — while well-intended and evidence-based for the conditions they are prescribed for — have extremely deleterious effects on our residents’ mood and cognition. All of this is true despite the fact that psychiatric illness in PALTC is the norm, rather than the exception.
Cognitively impaired residents with behavioral disturbances and psychiatrically compromised residents are now the norm in nursing homes. PALTC is being asked to care for large numbers of these residents, but the staffing patterns, staff training, and professional expertise required have not kept pace with the change in our populations. Staff members who have not received adequate training in behavioral health are frequently overwhelmed by the challenges that residents may present, particularly with respect to behavioral issues.
This chasm between the goals we aspire to as an industry, which CMS continuously encourages us to meet, and the reality of current practice is what led to the creation of the Behavioral Health Council.
A New Model is Needed
PALTC is a behavioral health environment. Residents often present with new mood or anxiety disorders, dementia-related behavioral issues, or all of the above. Many other residents have preexisting diagnoses of significant and persistent mental illness or substance use disorders. Given that the majority of PALTC residents have at least one significant psychiatric issue, it is incumbent upon providers to ensure that residents have access to evidence-based psychiatric and psychological services.
But our thinking should go farther by recognizing that for many of these residents the behavioral health care that is provided is more central to their overall adjustment and well-being than the medical services. For these residents, treatments for behavior, mood, trauma, substance use, and other issues — the “psychosocial” aspects of the “biopsychosocial framework” — are the most critical part of their care.
Models of skilled nursing care that view behavioral health care as an “ancillary” specialty service can do disservice to both residents and the facilities themselves. In contrast, a model that views behavioral health as coequal to medical health will benefit both residents and the facilities in which they reside. Residents with predominantly behavioral and psychiatric issues will find a better fit between their needs and the care they receive. Facilities that adopt such a model will be much better able to provide the person-centered, trauma-informed care that is rewarded through the Five Star rating system and during state surveys.
Behavioral health care should be construed as an essential element of the interdisciplinary care rendered to most residents. It is crucial to recognize that simply providing access to behavioral health clinicians is not sufficient. In PALTC settings, just as the connection between medical and behavioral disorders is complex and interrelated, the way that care is provided must mirror that complexity.
Psychiatric, psychological, and medical services must be organized and rendered through a communicative, connected team of interdisciplinary clinicians in order to achieve outcomes that improve on similar care provided by disconnected clinicians, each working in their own silo. In a connected framework, these professional clinicians must work in concert, not only with each other but with the direct care staff in the facilities and with involved family members.
The individual tasks performed by behavioral health clinicians in the PALTC setting — psychotropic medication management, psychotherapy, and other services — are not by themselves sufficient to provide optimal behavioral health care. Clinicians must go beyond the provision of individual interventions by ensuring that their understanding of the residents and their behaviors informs the entire interdisciplinary approach to care. An individual clinician’s contact with any individual resident will typically represent less than 45 minutes per week. To be optimally impactful, the behavioral health clinician’s contribution to the care of the resident must be augmented by communication across the interdisciplinary framework so that insights, understandings, and recommendations for best-practice strategies filter down through the care that the resident receives on a daily, 24/7 basis.
At minimum, every person admitted to post-acute care finds him or herself in an extremely challenging and stressful situation. Beyond that, each new resident is likely to suffer from a preexisting psychiatric disorder or present with behavioral and mood challenges resulting from the admission itself or from a diagnosis of significant cognitive impairment. In many cases, the behavioral issues may prove more pressing to both resident and facility. In this context, construing behavioral health care as an “ancillary” service does a disservice to all involved.
By contrast, regarding PALTC as truly a biopsychosocial system of care establishes a model in which residents can more easily obtain their highest level of functioning. The Society’s new Behavioral Health Council is committed to helping the Society move continuously toward this true integration of care.
Dr. Juman is the Director of Behavioral Health Policy and Regulation for TeamHealth, which provides behavioral health services in post-acute facilities nationwide.
Dr. Watson is a geriatric psychiatrist and leader in safe prescribing practices. Her job is helping interdisciplinary teams integrate and optimize behavioral health care in nursing homes. She can be found at www.leawatsonmd.com.