Policy Changes to Promote Better Quality of Life for People with Serious Mental Illness Living in U.S. Nursing Homes

As the Baby Boomers age, long-term care systems, including nursing homes (NHs), are accommodating an increasing number of middle-aged and older adults with serious mental illness (SMI). serious mental illness encompasses a range of mental, behavioral, and emotional disorders that result in functional impairments significantly interfering with or limiting life activities (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). For this article, we classify SMI as encompassing psychotic, bipolar, and treatment-refractory personality, depressive, and anxiety disorders. Many NH residents have co-occurring SMI and dementia (49%; Hua et al., 2021), but NH trainings, practices, and policies primarily focus on dementia care. Clinical management of dementia and SMI require different approaches (e.g., flexibility for dementia, boundaries for SMI; Muralidharan et al., 2019) and NH staff report low confidence for care planning with residents with SMI (Gammonley et al., 2021). For these reasons, more attention to policy, training, and practices for SMI in NHs is needed. Thus, this article focuses solely on SMI.

Currently, access to and funding for community-based supports for aging adults with SMI are insufficient to meet the needs of this growing population, especially in historically and systematically underresourced communities (Bucy et al., 2022b). Without community safety nets in place, NHs are serving as the “landing place of least resistance” and accommodating higher rates of SMI (Jester et al., 2020). The prevalence of NH residents with SMI has increased by nearly 80% in the past 15 years and, as of 2017, almost one in five residents has a diagnosed SMI (Hua et al., 2021; Laws et al., 2022). Few NHs specialize in psychiatric care, and most facilities report 20%–40% of residents with SMI, suggesting the increase in SMI is widespread throughout the NH sector (Jester et al., 2020). In general, NHs have not yet succeeded in accommodating this influx of residents with SMI. Insufficient staff knowledge, training, and access to appropriate mental health services raise quality-of-care concerns for the rising number of NH residents with SMI (Bucy et al., 2022a). Indeed, a growing body of research underscores the need to improve NH practices and policy to enhance quality of care for residents with SMI (Hugunin et al., 2022; Jester et al., 2020; Molinari et al., 2011). For this relatively recent spike in SMI admissions within the past 15 years (Hua et al., 2021), policy has not yet responded with regulatory reform (e.g., Pre-Admission Screening and Resident Review [PASRR] changes; Ne’eman, 2023).

The rising rate of residents with SMI and subsequent quality concerns are disruptive to the already struggling NH sector. Nursing homes with greater proportions of residents with SMI evidence poorer quality indicators (e.g., hospitalization rates) among residents both with and without SMI, which may be partly explained by lower direct care hours per resident per day (Rahman et al., 2013). Nursing homes with higher rates of SMI are also more likely to be cited for resident abuse and neglect and have lower quality ratings and staffing levels, including social services and activities staff who often take on elevated roles for residents with SMI (Jester et al., 2022; Rahman et al., 2013). Together, these factors make NHs hesitant to admit residents with SMI and, in doing so, exacerbate existing disparities in NH care.

Mental health care is notoriously challenging in NHs. In fact, about 20% of all NHs have received deficiency citations related to mental health care (Grabowski et al., 2010). Most NHs contract with external psychiatric or behavioral health care organizations to deliver mental health services, which commonly include medication monitoring, behavioral management, case consultation, and treatment planning. However, intensive nonpharmacological services (e.g., counseling) are less often available and vary by market (Grabowski et al., 2010; Orth et al., 2019).

In aging adults, SMI is best managed with a collaborative care model, consisting of medication, psychosocial skills training, and caregiver training (Bartels et al., 2018; SAMHSA, 2021). The current model of mental health care in NHs is not well suited to meet the needs of residents with SMI, especially regarding nonpharmacological approaches to care, which would require behavioral health specialists and increased direct care hours (Isaksson et al. 2009; Molinari et al., 2011). Further, despite differences in care approaches (Muralidharan et al., 2019), many nonpharmacological interventions tested and implemented in NHs are tailored to residents with dementia or mood disorders, not those with SMI (Kua et al., 2019; Simning and Simons, 2017). Therefore, the field of clinical research for nonpharmacological interventions for NH residents with SMI is still in its nascent stage.

The field of clinical research for nonpharmacological interventions for nursing home residents with SMI is still in its nascent stage.

Policy and regulatory factors have shaped the increasing prevalence of aging adults with SMI in NHs, dating back to the deinstitutionalization movement in the 1950s (Bucy et al., 2022b). The Omnibus Budget and Reconciliation Act of 1987 introduced the federal and state-mandated PASRR process, which was designed to evaluate facilities and prospective residents to determine whether an NH was the appropriate place of care. However, PASRR assessments often leave NHs as the only option for residents with SMI. Further, PASRR has been critiqued for poor standardization and effectiveness as well as having limited relevance to practice and care planning; rather, serving as a “regulatory checkbox” (Bucy et al., 2022b; Ne’eman, 2023). More broadly, many NH regulations were conceived prior to the influx of residents with SMI and the COVID-19 pandemic, decreasing their relevance to the current state of the NH sector.

If NHs are going to continue to be a key provider of long-term care for aging adults with SMI, updates or amendments to the current Code of Federal Regulations for NHs are needed. Although CMS does provide regulatory guidance on SMI in the State Operations Manual (SOM; Centers for Medicare & Medicaid Services [CMS], 2023a), the Behavioral Health Services sections (F740–F745) and F-tags applicable to SMI lack specificity and often combine SMI with neurocognitive disorders and substance use. Additionally, regulatory guidance on SMI is spread among multiple sections of the SOM, such as resident rights, quality of care, pharmacy services, and training requirements. Collectively, these factors make interpretation and, ultimately, implementation of best practices difficult. Below, we highlight prominent policy issues related to residents with SMI that may help improve quality of care for all residents and quality of work life for staff; see Table 1. Importantly, our goal is to first clarify policy and enhance infrastructure to avoid the need for additional regulatory requirements.

Table 1.

Policy Issues and Recommendations

Policy issue	Recommendations
Defining, assessing, and reporting SMI	Convene a CMS TEP to: (1) define and classify SMI in the context of NH; (2) assess the current regulatory guidance applicable to care of NH residents with SMI; (3) provide recommendations for improved organization and greater clarity of the regulations. (ST/LT) Decouple neurocognitive disorders and SMI regulatory guidance and consolidate SMI regulations into one section. (ST/LT) Increase funding for research to evaluate and optimize standardized resident assessment tools related to SMI in NHs. (LT) Provide clinical guidance documents for standardizing procedures to address specific mental health diagnoses with an emphasis on nonpharmacological approaches. (ST) Make aggregated SMI data publicly available. (LT) Include language on personality disorders in CMS regulatory guidance. (ST/LT) Assemble a task force (or TEP) to evaluate and recommend updates to increase the clinical relevance of MDS and PASRR for aging adults with SMI. (LT)
Best practices for SMI	Develop implementation guides for interprofessional team approaches to mental health care in NHs (e.g., psychiatrists, psychologists, social workers, and/or behavior analysts interacting with medical directors, nurses, and CNAs). (ST) Partner with community mental health programs and inpatient psychiatry settings to create a continuum of care and promote safer care transitions. (LT) Reduce obstacles to reimbursement for nonpharmacological mental health care to promote more clinicians being willing and able to practice in NHs. (LT) Invest in pragmatic trials focused on best practices for SMI in NHs. (LT)
Staffing, workforce, and program challenges	Encourage psychiatric and behavioral health specialists to complete skills training and/or earn additional credentials for working with NH residents with SMI. (LT) Build loan forgiveness programs for mental health clinicians working with aging adults with SMI in the community and NH setting. (LT) Focus GWEP funding on improving training programs for mental health care in NHs, with a focus on nonpharmacological services. (ST/LT) Invest in research focused on staffing levels and programming needs for NHs with high proportions of SMI residents. (LT)
Pharmacotherapy guidelines and education	Develop specific trainings for surveyors focused on effective use of psychopharmacotherapy in NHs. (ST) Streamline informed consent process for mental health treatments with resident representatives (e.g., health care agents, guardians, conservators). (ST) Have the TEP consider potential unintended consequences of any regulations focused on pharmacotherapy. (ST)
Access to educational opportunities for direct care staff	Incentivize NH staff member participation in existing education programs focused on mental health care, such as SAMHSA and Behavioral Health in Nursing Facilities Center of Excellence materials. (ST/LT) Target mental health stigma in NHs through nomenclature initiatives and education initiatives. (ST/LT) Develop a task force to guide recommendations for payment structures and workflows to allow for closer team-based consultation and training between behavioral health specialists and direct care staff. (LT)

Note: CMS = Centers for Medicare & Medicaid Services; CNA = certified nursing assistant; GWEP = Geriatric Workforce Enhancement Program; LT = recommendations that may require longer time frame to implement; MDS = Minimum data set; NH = nursing home; PASRR = Pre-Admission Screening and Resident Review; SAMHSA = Substance Abuse and Mental Health Services Administration; SMI = serious mental illness; ST = recommendations that may be started in the short-term; TEP =  technical expert panel.

If nursing homes are going to continue to be a key provider of long-term care for aging adults with SMI, updates or amendments to the current Code of Federal Regulations for NHs are needed.

Policy Issue 1: Defining, Assessing, and Reporting SMI

There remains a lack of agreement regarding what diagnoses constitute SMI in NHs. In NH research, SMI regularly includes psychosis and bipolar disorders, but there is less agreement on other functionally limiting disorders (e.g., treatment-refractory depressive and anxiety disorders; Bucy et al., 2022a). Whereas depression, anxiety, schizophrenia, and bipolar disorders are discussed in the SOM, personality disorders are not (CMS, 2023a). In NHs, personality disorders disrupt person-centered care practices, staff wellness, other residents’ quality of life, and the milieu (Gibson and Ferini, 2012). Based on PASRR reports, personality disorders range from 0% to 3% (Linkins et al. 2006), but other studies using validated measures report up to 58% of residents (i.e., higher rates in NHs than the community; Penders et al., 2020). More attention is needed to the classification of SMI, which ideally would consider the impact of symptoms on staff, residents, and facility culture. For current residents with SMI, psychiatric assessments, including the PASRR and MDS 3.0, are limited in scope, and poor training for administration decreases validity of results (Simon et al., 2012). Psychiatric and psychosocial assessment tools and procedures should be revisited in NHs to ensure an accurate biopsychosocial profile of the resident population, particularly given the potential increased needs of NHs with higher proportions of residents with SMI (e.g., specialized staff training, more nursing or other direct care hours per resident day, behavioral specialists).

Policy Issue 2: Best Practices for SMI

Although CMS (2023a) requires NHs to provide nonpharmacological behavioral health care, benchmarks for appropriateness of these services are often too vague to guide practice. A collaborative interprofessional approach between trained psychiatric prescribers, behavioral health specialists, and medical providers is preferred to address SMI (Bartels et al., 2018). Best practices for mental health care for both short- and long-stay NH residents involves nonpharmacological treatments, prescribing medications when medically indicated and other approaches have not been successful, and consultation with staff (O’Shea Carney and Norris, 2017; Plys et al., 2022). However, in practice, consultation is notoriously difficult due to workflow challenges and staff turnover. Especially for nonpharmacological providers, reimbursement rates are unfavorable or not reimbursed at all (e.g., staff consultations, attending care plan meetings), which disincentivizes behavioral health specialists from contracting with NHs (Molinari, 2021; O’Shea Carney and Norris, 2017; Orth et al., 2019). Additionally, high numbers of residents not appropriate for psychotherapy services due to cognitive impairment coupled with higher likelihood of cancellation (i.e., due to acute medical concerns and competing appointments) may further disincentivize behavioral health specialists from contracting with NHs. Although telehealth may offer an option to better connect NH residents with these providers (Wilcock et al., 2023), it may also overburden NH staff. These barriers to implementing best practices for mental health care in NHs need to be addressed through strategies that incentivize better collaborative interprofessional mental health care in NHs.

Policy Issue 3: Staffing, Workforce, and Program Challenges

Nursing homes must provide sufficient staffing that considers “the number, acuity and diagnoses of the facility’s resident population” (CMS, 2023a, p. 471). However, staffing needs are not appropriately weighted to accommodate SMI, which typically requires increased direct care hours per resident day (Isaksson et al. 2009). The NH sector’s struggles with staff retention and post-COVID-19 workforce shortages are well documented. In response to these immediate issues, many NHs have increased their use of temporary or agency staff, which may affect person-centered and team-based care practices. These staffing issues most affect nonpharmacological services, which are the first line of defense for mental health care in NHs (CMS, 2023b; Kuo et al., 2019). For example, NHs typically manage suicidal ideation with “close observation” (e.g., 15-minute staff checks) or temporary psychiatric hospitalization (i.e., voluntary or involuntary “psychiatric hold”), which are ineffective long-term solutions and burden the workflow of already understaffed units (O’Riley et al., 2013). Relatedly, caring for residents with SMI may increase staff burnout and safety issues (Muralidharan et al., 2019) and NH staff are already 3.5 times more likely to be physically injured on the job than the average U.S. worker (i.e., not inclusive of emotional abuse or other psychological challenges, which may be exacerbated by insufficient resources to manage SMI; Paraprofessional Healthcare Institute [PHI], 2020). Therefore, issues related to staffing and SMI may also negatively affect NH staff wellness.

Of note, in addition to direct care staff, there are significant workforce shortages among behavioral health specialists trained to provide nonpharmacological services in NHs (Molinari, 2021). The absence of behavioral health specialists not only decreases nonpharmacological treatment options for residents but increases the need for formal staff training (i.e., fewer opportunities for consultation). Further, best practices for SMI include psychosocial skills training and self-management programs (Bartels et al., 2018; SAMHSA, 2021), which are rarely offered in NHs, and it is unclear whether NH staff (e.g., nursing, social services) or external behavioral health specialists are better equipped to provide these types of services.

Beyond mental health care, residents with SMI present with unique care needs compared with other NH residents. Generally, residents with SMI are younger and more medically complex (Laws et al., 2022), increasing demands on clinical (e.g., managing comorbidities) and recreational therapy staff (i.e., activities to meet multigenerational preferences). In addition, residents with SMI often present with higher case management needs, increasing the role of social services staff, especially among short-stay residents (e.g., addressing housing needs; Hua et al., 2021; Laws et al., 2022). Although the burden is on NHs to meet the needs of residents with SMI, there is little information to guide staffing and programming to accommodate varying proportions of residents with SMI.

Policy Issue 4: Pharmacotherapy Guidelines and Education

Psychopharmacology is an important component of best practices for SMI. A clinician familiar with use of antidepressant, anxiolytic, and antipsychotic medications is necessary for successful treatment. Other medications, such as antipsychotics and mood stabilizing agents, require additional monitoring and can be safely and effectively used in NHs. Specifically, the CMS National Partnership to Improve Dementia Care in Nursing Homes began in 2012 to address the appropriate use of antipsychotics (CMS, 2023c). This program provides quarterly reports on antipsychotic use for each U.S. NH and trends over time for each CMS region. As part of that effort, regulations were updated to hold NHs accountable and use enforcement if antipsychotic use is high without appropriate clinical indication(s). Although some progress in deprescribing was made over the last decade, there has been an uptick in antipsychotic use again during and after the COVID-19 pandemic (Brandt et al., 2023). There has also been an increase in the use of other psychoactive medications such as anxiolytics, antidepressants, and antiseizure medications as alternatives to antipsychotic use (Brandt et al., 2023). Further, unintended consequences of deprescribing efforts have been noted, such as inappropriate reduction of antipsychotics among NH residents with SMI (Wastila et al., 2023), increased prescribing of alternative psychotropic medications (Candon et al., 2023), and evidence of misdiagnosis of schizophrenia among NH residents (Winter et al., 2019).

Policy Issue 5: Access to Educational Opportunities for Direct Care Staff

Across multiple research studies, NH staff and leadership report the need for more specialized staff training for SMI (Molinari et al., 2008; Muralidharan et al., 2019; Orth et al., 2019). Insufficient training also increases the risk of stigma, which is linked with social isolation and negative mental health outcomes among residents with SMI (Tzouvara et al., 2018). Currently, there are various opportunities for staff training available through Quality Innovation Networks–Quality Improvement Organizations (CMS, 2023b), the Center of Excellence for Behavioral Health in Nursing Facilities (Center of Excellence for Behavioral Health in Nursing Facilities [COE-NF], 2023), and independent organizations or investigators (Molinari et al., 2017). These existing training programs often focus on education and skills for clinical staff; future directions may also consider incorporating multilevel approaches that provide resources for organizations and physical design features to meet the needs of residents with SMI. In addition, there may need to be focused modules on specific presentations, such as personality disorders and hoarding. Further, implementation and dissemination of trainings continues to be a challenge, especially when factoring the high burden of postlicensure training requirements for NH staff (Trinkoff et al., 2017).

Conclusion

Nursing homes are home to an increasing number of aging adults with SMI, raising concerns for this sector’s preparedness to provide a high quality of care for this resident population. In this article, we highlight various policy issues to be addressed in regulatory updates to accommodate the needs of NH residents with SMI. These strategies offer hope for more inclusive NHs that can support quality of life for residents with a variety of needs as well as improve working conditions for staff. Although many of these improvements can be started now, substantive widespread systematic change in NH capacity to adequately care for people living with SMI will require longer-term policy and regulatory support to ensure best practices can be implemented, disseminated, and sustained. Policy and practice changes are also needed beyond the NH to support aging adults with SMI and improve care transitions. For example, funding is needed to increase community-based services for aging adults with SMI to increase options for discharge location (i.e., from hospitals and NHs) and ensure that care is delivered in the least restrictive environment (e.g., assisted living, group home, day programs). In addition, there has been little focus on behavioral health specialist clinicians and agencies that contract with NHs. These clinicians and organizations may benefit from additional training, guidelines, and incentives to ensure NH residents receive access to the highest-quality mental health care. These are just some of the many opportunities for policy-makers, NHs, clinicians, and researchers to collaborate and advance care for NH residents with SMI.

Funding

Evan Plys is supported by the National Institute on Aging under grant #K23AG078410.

Conflict of Interest

None.