A majority (60% to 80%) of nursing home residents have one or more psychiatric diagnoses, including dementia (Med Care Res Rev 2010;67:627–656). And post-acute and long-term care (PALTC) residents take an astonishing number of psychoactive medications, most prescribed by nonpsychiatrists for a variety of indications (J Gerontol Soc Work 2012;55:444–461). Finding the best model to provide meaningful psychiatric services in PALTC, however, is a perennial struggle (Psychiatr Serv 2002;53:1390–1396). Psychiatric symptoms and requests for help to manage them with medications are widespread in the industry, yet practical solutions are seldom available due to the shortage of psychiatry-trained prescribers and the scarcity of geriatric psychiatrists working in the PALTC space.
The traditional model of sending patients out to limited community resources is fraught with barriers and prone to miscommunication, and still only touches a small minority of patients in need — often this option is available only in large urban areas. Although psychotherapists have found success in delivering on-site talk therapy, models of psychiatry prescribers coming into communities are harder to come by.
My observations over many years as a geriatric psychiatrist and consultant in this space are that we can only meet the need by systematically extending the reach of expertise, by training and empowering the primary care providers to address common psychiatric issues. Above all, we must provide care where people want it — and deserve to have it — in service of the whole person by eliminating the false dichotomy of “medical” and “psychiatric” care. Enter Behavioral Health Integration (BHI).
BHI is not a new concept. Fortunately, a model of BHI already exists in outpatient primary care and has a strong evidence base for improving health outcomes and patient satisfaction because patients prefer being treated seamlessly in the primary care clinic, alongside their other medical appointments (JAMA 2002;288:2836–2845).
BHI is an endorsed model of care by the Centers for Medicare & Medicaid Services (see Medicare Learning Network, “Behavioral Health Integration Services,” CMS, 2022; https://go.cms.gov/3O4tklL
), which inspired us to try the model in nursing homes. The medical complexity of the population required creativity and flexibility. And, most importantly, it required several visionary large practices who were willing to partner in a novel model not driven by fee for service and who recognized the importance of access to psychiatric expertise.
The Key Components of BHI
The key components of BHI are systematic assessment and monitoring using validated measures, care navigation to support the treating (billing) practitioner, and oversight by a psychiatric consultant. By using a registry for all residents with psychiatric diagnoses, organized by designated care navigators (who can be clinical or nonclinical staff) and populated with objective measures such as the Patient Health Questionnaire (PHQ-9) and Brief Interview for Mental Status (BIMS), we can oversee a large population of patients systematically.
This population health approach includes regular review of data, with prompts to address changes in status and ongoing support (through the electronic health record and secure texting) to the primary care providers for prescribing guidance. Importantly, there are monthly and as-needed meetings with the entire team to discuss difficult cases and care plans. Patients can still be referred for specialty psychiatry care and other services.
Feasibility and Outcomes
The BHI program is like Chronic Care Management and can be billed as such for eligible patients, thus creating a revenue stream that adds to the sustainability of the model. Billing occurs monthly by the main practitioner.
In collaboration with several large provider groups across several states, we currently have over 2,000 residents enrolled in the BHI program. Practice directors report that the program has been feasible and well-received, reducing the number of referrals outside the building and transfers to inpatient psychiatry. Monthly psychopharmacology reviews have shown a dramatic reduction in polypharmacy and an increase in the willingness to stop medications that are no longer helpful.
It was clear from the beginning of translating BHI to the PALTC space that training would need to be a key addition to the model. Unlike general adult outpatient clinics (where BHI has its roots), nursing homes have a significantly higher prevalence and acuity of psychiatric disorders. We focused on the providers closest to the patients — most often advanced practice providers and some physicians — because they hold the most responsibility for the day-to-day care in PALTC settings. Most have had little to no training in psychiatry, yet often they are the main prescribers for these diagnoses.
Tailoring the program to the individual practice, we created a rolling curriculum of nine sessions on the fundamentals of nursing home psychiatry. This includes topics such as serious mental illness, regulatory requirements for psychotropics to personality disorders, and multiple sessions devoted to dementia and behaviors. The sessions are in-person or live video format with cameras on and interactive. We routinely address current cases from the participants. A favorite based on evaluations is “med list day,” where participants look at scores of actual medication administration records to learn about potentially dangerous prescribing patterns with psychotropics, pitfalls, and opportunities to deprescribe.
Over time, the facility culture began to anticipate the new prescribing culture, creating an essential realignment. This initially has been a barrier; nursing staff may have been used to requesting and receiving orders for medications automatically without a discussion or interaction with a BHI team. However, the providers earned the support of facility leadership to work with frontline staff while receiving expert consultation on cases. Providers are also encouraged to pursue any additional behavioral health support that may be indicated, such as psychotherapy or referral for inpatient care. This synergy has been a fundamental aspect of our success, building trust by listening to and valuing all team members.
We have trained over 100 primary care providers who work directly in PALTC. Data from our training programs show that the participants are highly satisfied with the content and process of training. All of them have said they are more confident in psychotropic prescribing, they have gained new knowledge, and, most encouraging, they can apply their new knowledge immediately in their day-to-day practice to effect positive change. Most said they would recommend the program to a peer. Posttests show an average score of 90%, reflecting an objective measure of essential psychiatric knowledge for the nursing home.
Looking to the Future
Several constructs hold in our work. The ongoing BHI registry and care navigation serve as a core backdrop and complement to the training program. The providers were clear that they already had felt the responsibility (and burden) of managing psychiatric medications; the BHI program and training have provided them with the support they needed to do so more confidently. They were also more willing to address their community barriers — such as inappropriate requests from staff for sedating medications — because they had the backing of a BHI “system” that included a team approach to decision-making.
Those of us dedicated to PALTC know that without high-quality behavioral health care we can never achieve optimal well-being for our patients. The combination of BHI and training of primary care providers is helping to realize that ideal in a growing number of communities. Future directions include replication and dissemination of the model and collection of key outcome measures such as meeting the highest-level dementia care standards, preventing unnecessary transfers to hospitals, and meeting the needs of those living with chronic psychotic illnesses.
Dr. Watson is principal at Lea Watson MD, MPH, LLC, and lives in Denver, Colorado. She is the co-chair of AMDA’s Behavioral Health Advisory Council.
September 1, 2022
In this episode Karl Steinberg and Elizabeth Galik discuss the unfolding research on long COVID in older adults and long-term care residents, a model for behavioral health integration, human-animal interactions and intergenerational programs in nursing homes, and the link between breakfast protein quality and sarcopenia.