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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: Policy Polit Nurs Pract. 2022 Aug 11;23(4):238–248. doi: 10.1177/15271544221118315

Changes in Nursing Home Populations Challenge Practice and Policy

M Barton Laws 1, Aly Beeman 2, Sylvia Haigh 3, Ira B Wilson 1, Renée R Shield 1
PMCID: PMC10155416  NIHMSID: NIHMS1890920  PMID: 35957612

Abstract

U.S. nursing homes (NH) have a growing prevalence of individuals with severe mental illness (SMI) and substance use disorders (SUD), and an associated increasing proportion of people under 65. We explored how Directors of Nursing (DONs) perceive challenges and strategies in caring for these populations. We conducted semi-structured telephone interviews with 32 DONs from diverse facilities around the U.S. Participants reported that people with SUD and SMI often present behavioral challenges requiring resource intensive responses, while regulations constrain optimal medication treatment. Younger individuals are considered more demanding of staff and impatient with traditional NH activities designed for older people. Some NHs report they screen out people with behavioral health disorders; they tend to be concentrated in NHs in economically disadvantaged communities. Individuals may remain in NHs because suitable settings for discharge are unavailable. These developments constitute a back door “re-institutionalization” of people with behavioral health disorders, and a growing crisis.

Keywords: nursing homes, mental illness, substance use disorder, institutionalization

Background

The Nursing Home (NH) population has changed markedly in recent decades, with an increasing proportion with behavioral health disorders, and who are younger than 65. The mental health deinstitutionalization movement of the 1960s and 70s resulted in a trend of people residing in NHs who would previously have been in psychiatric hospitals (Sherwood & Mor, 1980). This trend has continued as the proportion of NH residents with severe mental illness (SMI – operationalized in this case as a diagnosis of schizophrenia or bipolar disorder) increased from 6.4% to 8.3% from 2000 to 2008 (Rahman et al., 2013). A study published in 2011 found that 16% of NH residents aged 22 to 64 had a mental illness diagnosis, using a broader definition. The authors speculated that because of Medicaid policy prohibiting payment for psychiatric hospitalization, some individuals are in NHs who might more appropriately be served elsewhere (Simon et al., 2011).

Much of what we know about NH populations is based on the Minimum Data Set (MDS), a required clinical assessment for all residents in Medicare and Medicaid certified NHs (Mor, 2004). Most recently, it has been found using MDS data that the proportion of people in NHs diagnosed with schizophrenia or bipolar disorder increased from 6.5% in 2000 to 12.4% in 2017. The percentage of the NH population < age 65 increased from 10.6% in 2000 to 16.2% in 2017, while the average age fell from 81.1 years to 78.8 years. The prevalence of these characteristics varies among states. In 2015, prevalence of SMI ranged from 1% in Hawaii to 22% in Illinois. The percentage of the NH population under age 65 ranged from 9% in South Dakota to 22% in Utah. These variables were moderately correlated, r=0.45) (Laws et al., 2021).

A study also found a comparable increase in the prevalence of those with SMI in assisted living, from 7.4% in 2007 to 11.4% in 2017, though it is not clear whether the causes of these trends are similar. At the same time, the proportion of people in NHs under age 65 increased from 9% in 1996 (Agency for Healthcare Research and Quality, 2001) to 15.1% in 2013–2014 (Harris-Kojetin et al., 2016). Substance use disorder (SUD) is not included in the MDS, and was redacted from Medicare and Medicaid claims data prior to 2017. Consequently, information is lacking on temporal trends in SUD prevalence in NHs, but it is known that residents who received alcohol or drug treatment are often under 50 years of age and may have comorbid conditions such as HIV (Buchanan et al., 2003).

Despite the increasing proportion of residents with behavioral health disorders, and relatively young people in the NH population, limited literature exists on the experiences that NHs have with these patients. A qualitative study published in 2002, based on interviews with younger residents of a single NH in the midwestern U.S. found that 87% had a psychiatric diagnosis. In effect, the NH was serving as a psychiatric facility. Residents tended to lack family support and authors reported that the NH environment was unsuitable for young people who would normally have a more expansive social life, privacy and autonomy. Some residents’ behaviors were considered problematic for staff and older residents (Jervis, 2002). A qualitative study of young residents in two Canadian NHs – defined as ages 40–70 – also found that many of them had psychiatric or substance use disorders, and that the NH environment appeared unsuitable for them (Hay & Chaudhury, 2015). The situation in the U.S. may be similar.

To further explore how NH populations are currently changing and to delve into the issues that changing NH populations present in more depth, we conducted semi-structured interviews with Directors of Nursing (DONs). We listened to what they perceive to be the changes they observed in their NH population, the resulting challenges, and the approaches they used to address these challenges.

Methods

This research was approved by the Institutional Review Board of Brown University.

To achieve rapport and limit social desirability response bias, we used a modified funnel approach to the order of questions, first asking what we considered the least sensitive questions before addressing more potentially stigmatized populations that we understood to reside in NHs today (Harrell & Bradley, 2009) (See appendix for the interview guide.). We asked first about residents who are younger than the typical NH population, then those with mental illness, then with SUDs, sexual and gender minorities, and finally people living with HIV. We piloted the draft interview guide with two local DONs. Their feedback was incorporated to enhance the clarity and scope of the questions.

Interviews

A research assistant drew a sample of NH facilities from across the United States from a quantitative study of care quality for people with HIV. Interviewers were blinded to the stratification criteria. DONs who could not be reached after repeated attempts, or who refused to be interviewed, were replaced with successive waves of samples. Telephone interviews, lasting 25 to 35 min, were conducted by two members of the team, audio-recorded, transcribed by an outside service, and the transcripts corrected by the interviewers.

Data Analysis

The interdisciplinary study team consisted of a sociologist (MBL), an anthropologist (RS) and two masters-trained public health researchers (AB and SH). Our modified grounded theory approach included a phenomenological analysis. We read four of the transcripts and agreed on an initial set of broad codes derived from the interview domains (Curry et al., 2006; Miles & Huberman, 1994; Ritchie & Lewis, 2012). The sociologist team member (MBL) coded the transcripts using Atlas.ti (Scientific Software Development GmbH); the coding was discussed in team meetings until consensus was achieved and no new codes emerged. Coding labels included a priori categories and domains derived from the interview guide questions, plus new codes from the elicited data (Crabtree & Miller, 1999; Flyvbjerg, 2006; Glaser & Strauss, 1967; Gubrium & Sankar, 1994; Miles & Huberman, 1994). Both unexpected and anticipated findings resulted in patterns within and across interviews that were interpreted as themes (Curry et al., 2006).

The team then specified the codes relevant to the broad themes and reviewed the quotations within the groups. Our audit trail recorded the decisions in our analytic process, and listed emerging and final themes across interviews (Holloway & Wheeler, 1996; Ritchie & Lewis, 2012). To optimize validity and trustworthiness, we searched for competing interpretations iteratively and used constant comparison throughout (Inui & Frankel, 1991; Ritchie & Lewis, 2012).

Human Subjects Protection

We read participants an informed consent script over the telephone and received verbal consent. We documented consent by asking participants to affirm it once we began recording. Audio recordings were transcribed by a HIPAA-compliant service. Transcripts were stored on a secure server, and the interviewers removed any identifying information prior to analysis.

Results

Problems and challenges associated with individuals with behavioral health disorders were prominently voiced by our participants. Participants said that people with behavioral health disorders tended to be younger than the typical NH population, and that this age difference presented specific problems, which we report on below.

We succeeded in interviewing 32 DONs throughout the country, out of 129 who were selected. There were no statistically significant differences between participants and nonparticipants on the variables used to draw the original sample. These were quality rating, operationalized as low (1–2 stars) vs. high (3–5 stars); HIV prevalence, operationalized as 1–2 patients per year, 3–5 patients per year, 6+ patients per year, or 75% HIV+ or greater. On average, DONs had 18.6 years of experience in long term care and 4.8 years of experience as DON in their current facility. Facilities reported an average of 133.6 beds; most were located in urban settings. At least 11 (34.4%) DONs identified their facility as situated in an economically disadvantaged community. DON and NH characteristics are shown in Table 1. NHs in this study housed both long-and short-stay residents.

Table 1.

Characteristics of Participants and Facilities.

Respondent Years of Experience In Nursing Years as DON Highest Degree Number of Beds Location Median Income Socio-economic status For profit
2 50 30 Associate’s b Rural $43,341 Middle No
3 12 5 Associate’s 120 Urban $49,300 Middle No
12 14 5 Bachelor’s 20 Urban $19,236 Low No
13 >1 >1 Bachelor’s 83 Urban $48,207 Middle/Low (per DON) Yes
20 10 10 Associate’s b Urban 83,373 High Yes
le 10 >1 Bachelor’s 62 Urban $53,247 Low (per DON) Yes
42 35 35 Associate’s 109 Urban $58,970 Middle Yes
59 10 5 Bachelor’s 85 $40,702 Low Yes
61 25 25 (1@ current) Bachelor’s 118 Rural $36,030 Low Yes
63 25 18 (1@ current) Bachelor’s 120 Urban $64,680 High Yes
67 22 2 Bachelor’s 90 Urban $37,296 Low Yes
82 18 15 Bachelor’s 100 Urban $54,090 High Yes
90 5 3 Associate’s 159 Rural $48,561 Middle Yes
91 30 1 Master’s 104 Urban $39,313 Low (mention homeless) Yes
92 4 1 Master’s 132 b $41,618 Low (mention homeless) Yes
94 5 1 Bachelor’s 60 Rural $49,588 Low (mention homeless) No
96 12 >1 Associate’s 225 Urban 60,000 High Yes
100 17 3 Master’s 100 Urban $50,880 Middle Yes
101 25 2 Bachelor’s 90 Urban $25,979 Low Yes
103 37 1 Bachelor’s 126 Urban $53,369 Middle No
109 7 3.5 Master’s 112 Urban $25,416 Low Yes
112 30 4 Master’s 240 Urban $53,617 Middle Yes
115 15 1 Bachelor’s 200 Urban $57,776 High Yes
117 12 4(1@ Current) Bachelor’s 180 Urban $39,413 Low Yes
118 17 2.5 Associate’s 120 Urban $32,319 Low Yes
121 18 <1 Bachelor’s 320 Urban $48,400 Middle No
123 a a a a Urban $44,967 Middle Yes
136 30 29(>1 @Current) Associate’s 117 b $41,939 Low Yes
140 19 >1 Associate’s 68 b $46,381 Middle Yes
146 24 3 Bachelor’s 120 Urban $49,202 Middle Yes
154 25 4.5 Master’s 405 Urban $20,754 Low Yes
166 13 1 Bachelor’s 88 Urban $42,270 Low (mention homeless) Yes
a

Beginning of tape missing.

b

Could not be ascertained.

Note. SES of facility location is based on census data for zip code, unless DONs specifically indicated serving a low income or disadvantaged population. Zip code boundaries are large enough to includes areas of varying SES.

Below we briefly describe the younger population in NHs, and people with SUD and SMI. We then describe how DONs report challenges in caring for them, and the solutions they have introduced. As is standard practice in reporting qualitative results, we report what participants voiced without altering their language; this language reflects biases toward the NH residents that can be considered troubling.

Broad theme 1: The growing population of younger people poses specific challenges:

DONs noted an increasing number of younger residents in their NHs, in part due to SMI and SUD, and a lack of appropriate alternative care facilities. Health conditions such as diabetes, heart disease, stroke and trauma, sometimes precipitated by SUD or nonadherence to medications were some common reasons for their NH admissions.

Broad theme 2: Mental Illness and SUD are prevalent in some NHs, which has major implications for the environment and care practices:

Some DONs reported small numbers of residents with SMI, such as a few long-term residents or people admitted for post-acute care with psychiatric comorbidities, whose management was straightforward with medication, while others reported high prevalence of both SMI and SUD. Some said they try to avoid admitting those with behavioral health disorders.

Subthemes that follow provide information and interpretation offered by participants.

Challenges and Strategies for New Populations

Younger Residents.

Younger residents were characterized as residing in the NHs due to a variety of factors. These precipitating causes of institutionalization are seen to contribute to challenges in caring for them. In describing how “atypical” these individuals are, R59 provided this description of the new population:

Some are alienated, some just have families who are ill prepared to provide care at home. Even for those who could be potentially be cared at home, they don’t have the resources. They don’t have the support systems… They themselves are challenged… some are a breath away from homelessness themselves, so they’re not able to provide care. So, we have a lot of people who are under 50, who are here with TBI’s, status post-strokes, status post-gunshot wounds, brain injuries from overdosing, and so forth.

In addition, younger populations are considered to have distinctive preferences and may defy traditional ways of caring for them, as seen in the following subthemes.

Subtheme 1: Younger people have different preferences and needs from the traditional older NH population:

DONs said that traditional NH activity programs are ill-suited to younger people. As R112 said:

… you have to have … all the gadgets nowadays. They need the phone … they need their choices of channels on the TVs all the time…they want access to all the media…. They want to do privacy in their own room…. You have to have enough staff in recreation, maybe two people or three people were enough, now you need at least 10 to 15 in the building. R101 noted:

Well, … their interest is different…. You’re not going to engage them in bingo, … or, you know, stuff like that, because they want to be outside, they want to hang out.

Young people tend to like different, sometimes less healthy, meals than older adults, according to our participants. As R154 noted:

Even though we try to maintain them on a diet here, they send out for food… and it’s a resident’s right…. We are caught in the middle.

According to R154, families can bring unhealthy foods to the residents. R118 says some young people defy the facility’s smoke free policy. DONs try ethnically themed parties and favorite foods of diverse communities as well as outside excursions. To accommodate these individuals, R146 offered, “We do way more outings…trips to the movies, more trips to WalMart.” R166 noted, “We have different groups coming in, like from colleges … [and] more movie nights.” And R96 described activities such as card games and wine and cheese parties.

In these ways, the DONs try to serve the younger residents while they constitute a fundamental mismatch with the older population more commonly served in NHs.

Subtheme 2: Younger people can also pose daunting challenges for staff:

Younger people were also described as more demanding than the traditional elderly NH population. As mentioned by R118:

They are like… impatient of waiting…. They cannot wait five minutes. They just want it right there and now.

R121 said young people also have difficulty adapting to dependency:

… the younger clientele … you’ll have more … fall incidents. Because these are… less inclined to ask for help, because of course they feel that they should be so independent.

As elaborated further below (subtheme 1), the special challenges of drug abuse and alcoholism require unique solutions. R94 provided examples:

We soon had to learn how to take care of younger residents for multiple reasons, from drug overdose, alcoholism…

Then added,

… That required a lot of education to all of the staff members on how to deal with it, emergency preparedness, and such.

Extra time, education and strategies to address these issues can be formidable, we were told.

DONs also expressed empathy for the loneliness they ascribed to being younger in a NH setting, as seen next.

Subtheme 3: The NH environment is considered isolating and deprives younger people of a satisfying life:

As R59 noted, young people can feel lonely and sexually unsatisfied:

… they have the urges … of young people. So, we have to find ways to allow them to express themselves…. A lot of them are very frustrated and they vent, because I’m 23 years old sitting in a wheelchair and I have no girlfriend I have no boyfriend. I have nothing that would, you know, be a part of my life here.

DONs noted that the NH setting may present an essential problem of their not “fitting” with the older residents. As R90 discussed,

I think they have complaints, you know. They don’t want to be with those type of people, we hear a lot. You know, they, “Well, I don’t want to go to the dining room and eat with those people.” We hear … that a lot.

People with Behavioral Health Disorders

Subtheme 1: People with behavioral health disorders pose specific challenges for care. They may stay longer than their acute needs would require, and some have no appropriate discharge destination:

R103’s facility mostly houses older adults in long term care, but contains a larger younger population with SMI than previously. The DON commented that with “the economic situation out in the community, it’s tough for them to survive.” R13 cited a contrast with the past: “…nursing homes are not 80-, and 90-year-old cute little mom and pops that are retired anymore. They’re … more psych people, more opiate users.” R35 similarly stated:

My nurses are telling me we never used to have people like this, … little, old, sweet ladies with broken hips (laughs) and, and now we have very young, high-maintenance residents who you have to really be careful with because they come in with [peripherally inserted central catheter] lines but they’re heroin addicts.

R26 also said physicians are reluctant to discharge people with SUD to the community while they have open IV access.

R136 also attributed a surge in young residents to SUD, and R35 saw a large influx of young people due to psychiatric illness and opioid use disorder (OUD) specifically:

Our population right now is pretty young…. The heroin epidemic is huge … and I get four to five referrals a day for overdoses…. And we’re also seeing a lot more of the, you know, more higher-acuity psychiatric patients.

R59 reported their facility houses people with brain injuries from violence or substance abuse, who lack family resources to care for them. R90 explained that while SUD per se doesn’t bring people into the facility, SUD comorbidity is common. R2 said:

We dry out people all the time…. If you break your leg in car accident, and you’re drunk… we’ll take care, or if you’re high, we’ll work on that also while you’re here, because those kind of rehab people typically stay three to six weeks until they’re healed. It isn’t going to do any good to send them out to do that again…. I see a lot of young people that have had strokes due to drug issues.

DONs reported that some people with SMI and SUD had no appropriate place to be discharged. R91 said, “… most of them have addiction problems and have nowhere to go. We can’t put them out so they’re stuck here.”

R42 expanded:

Most of them end up being here … because they don’t have any housing, they came from nowhere… on the streets …or they’ve come from the Salvation Army …. So it’s a lot of work with social services and trying to find placements for them after we get them better.

R13 similarly blamed inadequacies in the safety net, saying that while

… some of them have a lot of medical illnesses, … most people are psych patients that just have nowhere to go because of what we’ve done to psych. They’re not appropriately placed in this community…

R109 noted the increase in people who have become addicted to prescription drugs. R112 remarked: “Oh yeah. [SUD] is like 100% more than the past because pain management has gone up and everybody wants Percocet and codeine.” Others in our sample confirmed that residents were dependent on prescription drugs.

SUD is generally associated with young age, according to these DONs. R13 said that of their 20% of patients with SUD, three quarters were young. R136 noted 80% or more of young patients had SUD. R42 said that 60% of people with SUD were over age 70, but noted cases of alcohol-related dementia in younger people. R154 said their facility’s residents with SUD had sometimes needed naloxone to reverse overdoses. R35’s facility contained homeless residents admitted subsequent to overdose. R59 observed how SUD may be comorbid with HIV, strokes and traumatic brain injury. R20 also said that while residents are admitted due to physical trauma resulting from intoxication, SUD is not always discovered until after admission, whereupon they try to transfer them to other facilities. R13 reported a similar policy. Some DONS did not report having people who used illicit drugs, but noted patients dependent on prescription opioids. R92 described difficulties in tapering patients’ opioid dosages:

… we try to keep them medicated … to prevent withdrawals…. We do try to titrate, but we don’t have like Suboxone and methadone…. I mean, some of them get mad…. If we titrate or lower their doses of their pain medications, they may want to leave, and go home.

However, R20, R103 and R115 flatly stated their facilities do not admit people with SUD.

Subtheme 2: NHs may be limited in meeting behavioral health needs; some NHs may benefit from outside resources and others have in-house capacity:

DONs reported variable access to psychiatric care. R101 noted that a psychiatric nurse practitioner provides psychotherapy for the 40% of the facility’s residents who have behavioral health disorders. R103 said she has a consulting psychiatrist to help the facility manage people with psychiatric medications.

Regulatory policies limiting use of psychotropic medications were cited as an obstacle to adequate care of residents with SMI, however. R103 said:

… federal guidelines have become so stringent… it makes it much more difficult with our new federal guidelines; you’ve got to have a whole lot of documentation and justification, why you’re using that particular medication.

R146 noted obstacles in using medication for people with dementia who may also have psychosis:

… they put such a regulation on what meds we can give them, because … the perception is … people are drugged up, chemically restrained and so the state’s very protective of … elderly people in the nursing home and they don’t feel like someone who has Alzheimer’s or dementia should have antipsychotic medicine. But a lot of the people had schizophrenia/bipolar … before they got dementia, but just ‘cause they get dementia doesn’t mean their bipolar went away.

Some DONs said they successfully reduced psychotropic medication by careful management and documentation. As R154 stated:

[the psychiatrist is] always trying to do … Gradual Dose Reduction. But … some of them outburst and they become violent, we have no other choice. We just have to make sure that we document accordingly as to the signs and symptoms that they’ve been displaying.

R2 reported temporarily transferring people to a psychiatric unit at a nearby hospital:

If they’re combative, we will send them there…. Nursing homes are regulated so tight that it’s very difficult to maintain medication on these long-term psychiatric patients, but … once they stabilize them, send them back to us.

Other DONs reported that hospitals bounce such patients back to the NH, after diagnosing them with a medical problem, without acknowledging the acute psychiatric exacerbation. As R154 stated:

We have a lot of patients that are bipolar, schizophrenia, … [hospitals] don’ t keep them … we have this revolving door where the hospitals … send them right back … and that becomes very challenging, mental illness is a big problem here.

R166 also said the hospitals do not diagnose patients correctly:

Psych care is a challenge. We send them out because they’re in a psychotic state. And the emergency room automatically diagnose[s] them with a [urinary tract infection] … or pneumonia … and send them back.

Some facilities have resources for substance abuse treatment. While R101 provides suboxone in-house, sends people for methadone maintenance, provides substance abuse counselors, and allows for psychoeducational groups and 12-step meetings, this DON reported that 50% of people with SUD are nevertheless readmitted due to relapse. R42 also offers Medication Assisted Treatment for OUD. Regarding alcoholism, this DON stated:

It’s very hard when you’ve been alcoholic over 30 years and then all the sudden somebody tells you, you can’t have alcohol and how do I deal with all these stresses in life? [Our strategies] include psychiatric, psychology, we gotta make sure they’re not in full bloom DTs, make sure we’ve got something for the anxiety, get them involved in programming and allowing them to go out to AA meetings….

R60 has a contract with the VA to provide substance abuse treatment:

I’ve been seeing a lot. Some are 55 and above from the VA… mostly the Vietnam War. So … it’s that clear from the VA, veterans to have this benefit. And VA’s a really good partner for us because they provide all necessary equipments and medications….

P59 was explicit that with CMS regulations,

… you pretty much can’t not take that patient. It doesn’t matter how the behaviors are unmanageable, and even to put someone on one-on-one indefinitely, it’s a cost to the facility, severely. … these patients would do better in the long-term psychiatric facility. But, there’s no such thing here in [state] and so nursing homes and the prisons are the only places that provide this care.

R109 noted additional challenges associated with appropriate post-discharge services:

The challenges would be to continue to work with them, to get them off of the opioids…. I mean it can be a long process. And then we [are] trying to either discharge them, or … get them set up with home health care, and provide them with the right services to help them continue in the community, without having to go back to using.

Sub-theme 3: People with behavioral health disorders often present problematic behaviors:

Combative behaviors by people with SMI was often reported as a major problem by these DONs. Some reported that their facilities house people with cognitive damage from sustained drug use or alcohol misuse. R2 said, “Sometimes we can’t handle them. They’re combative, and difficult, and we have to do them one-on-one until we can find them someplace else to go,” adding, they can be readmitted numerous times.

R121 said some residents are aggressive and “try to beat people too. Beat up my staff.” Staff were not sufficiently trained, this DON stated:

[T]he residents who have mental challenges or psychiatric issues, and the behaviors and the outbursts, that sometimes presents a big problem for the staff. … More teaching [is needed] on how to deescalate certain situations.

R118 explained that patients with drinking problems may leave against medical advice and R91 noted:

… [Sometimes] they sign out, then we see them three months later … because they’re found in an alley drunk, and they haven’t taken their meds, one guy’s been here four times. … And he gets very demanding and very abusive.

Managing withdrawal, and drug-seeking and other behaviors is challenging. R136 said:

These younger folks …may have … some type of substance abuse…. Those folks are very difficult to take care of, even in the elderly population but more so in the younger population…. I want to make absolutely certain that they have been thoroughly detoxed. … they can become drug seeking, manipulative. … They don’t want to be here and of course my nurses, and my nurse aides, they’re front line, they take the brunt.

Individuals may also bring drugs into the facility or continue to drink, as R154 noted. R35 said,

When family members or visitors bring things in for those residents, we have to be really careful to make sure that there’s no needles, there’s no drugs, there’s nothing that’s going to harm. You know fentanyl is really big in our area as well, and if you touch a bag that the fentanyl was in, you can get it into your skin, and it can cause a nurse to be sick.

R59 said they call the police when somebody brings drugs into the facility. R20 said some residents leave for their fix,

… come back and … you can tell that they’re … intoxicated. … then they become disruptive, not just to themselves, but to the other patients. Sometimes … we’ll tell them that we are giving them a 30-day notice… [but] we just can’t say, “You’ve got to go today.” … they don’t have anywhere to go.

However, R136 is a psych nurse experienced in substance abuse treatment, and her social worker is in recovery from SUD. She said:

… to have a social worker that can say, “Hey, I’ve been there, I’ve done that, you can’t say anything that I haven’t already done.”

R154 said the workers’ union helps:

The unions have come in and given the staff training on defusing situations … with the angry or the aggressive resident…. Despite whatever it is, they’re still our customer and they’re still our patient. So, we have to put our judgment aside and just deal with what is actually happening and not take it personal.

Discussion

This paper helps to update information as well as the literature about how NHs care for new populations in their facilities that do not adequately reflect the overall context of changing NH care. In our study, DONs frequently described their facilities as a last resort provider of housing and supportive care for people, such as those living with SUD and/or SMI who may be homeless, or who do not have other options. These groups also tend to be younger than the traditional NH populations. Some DONs in economically disadvantaged communities report a high prevalence of such residents.

DONs attribute the rising prevalence of residents with behavioral health needs to states’ failure to provide adequate community resources for people with SMI and SUD and note they have become de facto mental hospitals and SUD treatment facilities. Individuals may enter the NH because of medical problems associated with self-neglect or trauma, but end up as long-term residents lacking an appropriate discharge destination. Behaviors that are perceived as disturbing, harmful, or threatening to other residents or staff by those with SMI and SUD can present substantial problems. These populations pose greater demands on staff and limit their ability to create a suitable environment with appropriate activities, manage problem behaviors, and provide labor intensive services such as detoxification and counseling. The needs of these residents may consequently deplete resources for other residents (Table 2).

Table 2.

Summary of themes and sub-themes.

Theme Younger Residents Illustrative quotes
Subtheme 1: Younger people have different preferences and needs from the traditional older NH population … you have to have … all the gadgets nowadays. They need the phone … they need their choices of channels on the TVs all the time…they want access to all the media…. They want to do privacy in their own room…. You have to have enough staff in recreation, maybe two people or three people were enough, now you need at least 10 to 15 in the building.
Subtheme 2: Younger people can pose particular challenges for staff They are like … impatient of waiting…. They cannot wait five minutes.
They just want it right there and now. the younger clientele … you’ll have more … fall incidents. Because these are … less inclined to ask for help, because of course they feel that they should be so independent.
Subtheme 3: The NH environment is isolating and deprives younger people of a satisfying life … they have the urges … of young people. So, we have to find ways to allow them to express themselves…. A lot of them are very frustrated and they vent, because I’m 23 years old sitting in a wheelchair and I have no girlfriend I have no boyfriend. I have nothing that would, you know, be a part of my life here.
People with behavioral health disorders
Subtheme 1: Increasing prevalence of people with behavioral health disorders requires adaptation; many end up staying longer than their acute needs would require, and some have no appropriate discharge destination My nurses are telling me we never used to have people like this, … little, old, sweet ladies with broken hips (laughs) and, and now we have very young, high-maintenance residents who you have to really be careful with because they come in with [peripherally inserted central catheter] lines but they’re heroin addicts.
Most of them end up being here … because they don’t have any housing, [and] they came from nowhere … on the streets or they’ve lost their housing … or they’ve come from the Salvation Army … So it’s a lot of work with social services and trying to find placements for them after we get them better.
Subtheme 2: NHs may not be not well-suited to meet behavioral health needs, but they may benefit from outside resources and some do have more capacity … federal guidelines [about pschotropic medications] have become so stringent … it makes it much more difficult with our new federal guidelines; you’ve got to have a whole lot of documentation and justification, why you’re using that particular medication.
We have a lot of patients that are bipolar, schizophrenia, that’s very challenging. …[hospitals] don’t keep them…we have this revolving door where the hospitals … send them right back … and that becomes very challenging, mental illness is a big problem here. … they don’t keep them
I’ve been seeing a lot [of SUD]. Some are 55 and above from the VA … mostly the Vietnam War. So … it’s that clear from the VA, veterans to have this benefit. And VA’s a really good partner for us because they provide all necessary equipments and medications as they could.
Subtheme 3: People with behavioral health disorders often present problematic behavior: When you put the residents who have mental challenges or psychiatric issues, and the behaviors and the outbursts, that sometimes presents a big problem for the staff. We want to make sure that the staff has the special training to deal with these kind of residents. More teaching [is needed] on how to deescalate certain situations.
These younger folks … may have … some type of substance abuse…. Those folks are very difficult to take care of, even in the elderly population but more so in the younger population…. I want to make absolutely certain that they have been thoroughly detoxed. … they can become drug seeking, manipulative. … They don’t want to be here and of course my nurses, and my nurse aides, they’re front line, they take the brunt.

As a result, NHs appear to increasingly represent a residence of last resort, producing a back-door kind of re-institutionalization. While they make do as best they can, these facilities are fundamentally ill-equipped to take care of homeless people, younger individuals, as well as those with severe SMI and SUD.

These problems seem to particularly affect facilities in communities of low socio-economic status, with disproportionately minority populations, where there is high unmet need for behavioral health services (McAlpine & Mechanic, 2000). In contrast, facilities in relatively advantaged communities may outright decline to accept people with behavioral health problems, and are better able to care for the small numbers they do admit. Refusal to accept people with SUD or other behavioral health disorders may constitute illegal discrimination, but it continues (Kimmel et al., 2021; Wakeman & Rich, 2017).

Indeed, previous research finds that those NHs with advantageous relationships with hospitals and higher ratings may screen out people with behavioral health needs who may become long-term Medicaid residents, in preference for people likely to be short-term patients receiving more generous Medicare reimbursement. Hospitals may avoid sending people for post-acute care to facilities they perceive as having a higher risk of readmission, leaving those facilities that need to fill their beds with little option but to accept patients with complex needs who are at risk of long-term residency (2019), all of which adds to the disparities long known to accompany the “two tiers” of NH care (Mor et al., 2004). A recent study finds that facilities in the highest quartile of SMI prevalence reported lower direct care staffing hours and scored lower on all NH compare star ratings than other NHs (Jester et al., 2020).

These observations suggest some possible policy responses. The implication of much of what our participants told us is that more appropriate community-based resources are needed for younger people and those with behavioral health needs. Most basically, this means housing. For some people, that would also include supportive and treatment services. That the prevalence of SMI in assisted living has increased suggests that some people may be in NHs because they do not have access to assisted living, while others might also need more specialized psychiatric or substance use treatment services.

We note that DONs sometimes indicate judgmental attitudes and can lack training in behavioral health care. In some cases, they spoke about people with behavioral health needs and younger residents with discomfort. More training and education in behavioral health is needed for NH staff to adequately care for the new populations we have described here. Some DONs with whom we spoke conveyed troubling attitudes and may lack skills to manage problematic behaviors. Although some of them singled out people with behavioral health disorders as exhibiting aggressive behavior, one study finds that people with such disorders are actually less likely than people with dementia to do so (Cen et al., 2018). This may suggest that staff are more skilled at managing behaviors of people with dementia and so DONs view people with behavioral health disorders as more problematic. A survey of Social Service Directors in 994 NHs found that those in NHs with higher prevalence of SMI reported lower involvement conducting staff interventions for resident aggression. More than one fifth were not confident they could develop care plans for people with SMI (Gammonley et al., 2021). These findings underline the need for appropriate and more extensive training for NH staff, especially CNAs who perform most in-person care, as well as supervisors in behavioral health care.

DONs whose facilities had more access to psychiatric services, or had a relationship with the VA, told us they were able to transfer people to more appropriate settings, or bring in appropriate services. But NHs are not only ill-suited for these new populations, they are far more expensive than what might be better options (Latimer et al., 2019; Nelson & Bowblis, 2017). People who are in NHs because they do not have access to housing and the specific, but more limited supportive services they need are ill-served as a result, and further compromise the care of other residents, while society bears an unnecessary cost burden. Solutions to these problems could potentially shift some of the high and undue costs shouldered by NHs to create better care alternatives, including low-cost housing with properly targeted and appropriate services.

Limitations

This study has important limitations. Because the 32 participants who agreed to interviews were self-selected, we cannot know how widespread and shared their opinions are among DONs generally. Furthermore, though DONs appeared to express candid views, social desirability bias may have affected some of their responses. Exploratory qualitative research such as this describes meaningful phenomena through DONs’ own words; however limited, these data help enrich our insight into NH trends today. These qualitative observations are consistent with known trends in the composition of NH populations and identify significant problems. Furthermore, the large variation among facilities and the experiences of participants suggests that despite any selection bias, we have captured a substantial range of the population of NHs to reveal important trends.

Conclusions and Implications

These observations suggest a significant public policy challenge in the United States. The current system of supportive care for people with complex behavioral health needs and material deprivation is relegating them to unnecessarily restrictive settings not well-suited to their needs, while burdening society with extra costs and compromising care for people who are more appropriately placed in NHs. We can do better.

Acknowledgments

Thanks to Joanne Michaud and David Myers who assisted with sample selection. The sponsors had no role in the design, methods, subject recruitment, data collections, analysis and preparation of this paper.

Funding

This work is supported by National Institute of Mental Health: R01MH109394 and R01MH102202. I.B.W. is partially supported by the Providence/Boston Center for AIDS Research (P30AI042853) and by Institutional Development Award U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR) from the Rhode Island Institutional Development Award for Clinical and Translational Research (IDeA-CTR award) (U54GM115677).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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