Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program

Abstract

The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

Introduction

Nursing homes (NHs) in the United States care for a growing number of adults with mental health conditions, with the prevalence of bipolar disorder and schizophrenia in NHs increasing from 10.5% in 2007 to 18.6% in 2017 (Hua et al., 2020). Compared to adults admitted without mental illness, adults admitted to NHs with mental illness tend to be younger and have a higher likelihood of transitioning to long-stay status (Grabowski et al., 2009). Despite these trends, evidence has shown that many NH residents would be able to live successfully in the community if appropriate community services and supports were available (Grabowski et al., 2009), raising questions over the appropriateness of NHs in meeting the needs of this growing population (Grabowski et al., 2010; Rahman et al., 2013).

Concern over the number of adults with serious mental illness (SMI) living in NHs prompted action within the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87), which included the creation of a federal screening program for all NH admissions. The federal Preadmission Screening and Resident Review (PASRR) program requires all NH admissions to be screened for SMI in order to avoid inappropriate NH placement and unnecessary institutional care without appropriate supports (O’Connor et al., 2011; “Preadmission Screening and Resident Review | Medicaid,” 2020). The PASRR program (formerly PASARR) functions as a level of care determination and aligns with decades of social and health policy favoring community-based care. PASRR screening is performed in two steps. The Level I assessment is completed for all applicants to Medicaid-certified NHs. If the Level I assessment is ‘positive’ for a primary diagnosis of SMI (excluding a primary diagnosis of Alzheimer’s disease and related dementias (ADRD) or a condition secondary to ADRD), the designated state mental health authority (SMHA) will perform a Level II assessment.

As per the proposed revision to the federal rule (85 FR 9990), an individual is considered to have a serious mental illness if within the past year, they have had a serious and persistent mental health condition meeting Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5) criteria (with the exception of substance use disorder or substance/medication-induced disorders, neurodevelopmental disorders, neurocognitive disorders, i.e., DSM-5 V codes), with moderate or severe level of severity (DSM-5), and be acute, in “partial remission,” or recurrent/persistent as per clinician determination (“Preadmission Screening and Resident Review | Medicaid,” 2020). Additionally, the mental health disorder must have led to functional impairment interfering with or limiting a ‘major life activity’ (ADLs; IADLs; social, family, academic, or vocational participation) or have the potential to do so without service intervention (“Preadmission Screening and Resident Review | Medicaid,” 2020). The Level II assessment is intended to discern whether applicants with SMI do require NH care, and if so, whether they also require ‘specialized services beyond the services typically provided in a nursing facility’ (Levinson, 2007; “Preadmission Screening and Resident Review | Medicaid,” 2020).

Despite the PASRR program’s three decade existence, little is known about how this policy works in practice. O’Connor et al. (2011) noted that “many states implemented PASRR with a focus on minimum compliance rather than with intent to maximize its reach or potential.” The administration of the PASRR program might also have important implications for quality of care in NHs. McGarry et al. (2019) and Jester et al. (2020) found that higher concentrations of individuals with SMI in NHs was associated with worse quality of care for residents both with and without SMI (quality as assessed via the use of physical restraints, acute inpatient hospitalization in the previous 90-days, use of indwelling catheter or feeding tube, presence/absence of pressure ulcers, and deficiencies). Individuals with SMI also have a higher likelihood of being admitted to lower quality NHs (Li et al., 2011).

The purpose of this exploratory study was to examine the administration of the PASRR program, a federal policy initiative. We aimed to examine the mechanisms of policy administration and reasons for program heterogeneity, which have been previously documented in quantitative and descriptive studies. To explore this topic, we conducted qualitative interviews with state and national stakeholders to answer the following primary and secondary questions: (1) How is the PASRR program administered and used in practice and (2) What is the PASRR program’s role in NH admissions and quality within the context of social determinants of health (e.g., structural racism)? We define social determinants of health (SDOH) as the context and environment where people live, work, and age, grouped into the following domains: economic stability, education access and quality, health-care access and quality, neighborhood and built environment, and social and community context (“Hua et al., 2020,”).

Background and context

The deinstitutionalization movement and related sociopolitical environment

To fully contextualize the proportion of adults with SMI in NHs, it is important to consider the history and continued influence of the deinstitutionalization movement on U.S. mental health policy. Following World War II, poor living conditions within underfunded state hospitals, the rising number of mental-health related deaths, and the possibility of outpatient management for schizophrenia after the approval of chlorpromazine in U.S. markets prompted people to advocate for community mental health treatment (Davis et al., 2012). The growing perception of mental health care as a social problem ultimately prompted federal policy action in the 1960s and 1970s (Koyanagi, 2007). President John F. Kennedy called for community programs to replace institutions in 1963, including resources for mental health education, outpatient treatment, and dedicated funding for the creation of community mental health centers (CMHCs; Koyanagi, 2007). However, these reform efforts were hampered by the difficult reality of providing community-based services, limited funding, and poor coordination of the funding that was available – effectively blocking a transition from institutions to community care (Koyanagi, 2007). These changes occurred in parallel to the advent of Medicaid in 1965, which included federal funding for long-term care costs for eligible beneficiaries (O’Connor et al., 2011). This action ultimately incentivized states to care for people with mental illness in NHs, funded through federally matched Medicaid dollars, as opposed to psychiatric facilities, which were supported primarily through state funding (O’Connor et al., 2011).

Disparities in the prevalence of mental illness in U.S. nursing homes

Serious mental illness is broadly defined by the National Institute of Mental Health (NIMH) as, “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities” (NIMH » Mental Illness,” 2021). This broad definition allows for variability in how SMI is classified, as evidenced by the PASRR federal rules’ definition for SMI. A common group of diagnoses classified as SMI includes severe major depression, bipolar disorder, and schizophrenia/schizoaffective disorders (Bartels, 2004; Substance & Mental Health Services, 2017).

The prevalence of SMI varies by race and ethnicity. According to data from the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2016, among U.S. adults, those who reported two or more races had the highest prevalence of SMI (7.5%), with American Indian/Alaskan Natives reporting the next highest prevalence (4.9%), followed by those identifying as White (4.8%), Hispanic (3.6%), Black (3.1%), Native Hawaiian and Other Pacific Islander (1.9%), and Asian (1.6%; American Psychological, 2018). As the American Psychological Association (APA) (2018) stated, “within SMI populations, racial and ethnic minorities experience mental health disparities related to access and utilization of services, diagnosis and outcomes.” While the rate of mental health diagnoses is similar between Black and White adults in the U.S., mental disorders are “more severe, persistent, and disabling” among Black and Hispanics (Alang, 2019; Breslau et al., 2005; Williams et al., 2007). Previous research has noted that although less likely to receive mental health services generally, when care is provided, it tends to be of lower quality for Black persons as compared to White (Alang, 2019; Alegría et al., 2008; Cook et al., 2014; Jimenez et al., 2013).

There also exists a relationship between structural racism and mental health outcomes, including how discriminatory practices and stereotypes can hinder access to services, cause chronic stress, and promote emotional and physiological responses (Alang, 2019; Jackson et al., 2010). A series of focus groups conducted by Alang (2019) described how a lifetime of discrimination and racial oppression influences expectations toward mental health services and heightens institutional mistrust; the “fear of double discrimination – from mental illness and from being Black” is an additional barrier. Thus, PASRR assessment, and the settings in which screenings are likely to be initiated, may be another place where we can expect structural racism to impact people’s experiences and access to services.

Serious mental illness, nursing home admission and quality of care

Since the PASRR program is used to determine a need for specialized mental health services in addition to appropriateness of NH placement (Levinson, 2007), it is important to evaluate whether these mental health services are provided, and whether or not they improve outcomes for residents with SMI. Residents experience an increased likelihood of adverse severe behavioral health events in NHs that do not provide adequate behavioral health services (Orth et al., 2020). A national survey by Linkins et al. (2006) evaluated access to mental health services in NHs among agencies responsible for PASRR implementation in all 50 states and the District of Columbia. This study found that roughly 30% of respondents indicated that NHs who provided mental health services varied in quality, and access to the NHs that provided such services was limited (Linkins et al., 2006). While all NHs evaluated provided psychiatric consultations, there was considerable variability in access to services such as counseling and psychosocial rehabilitation (Linkins et al., 2006). The combination of an increased prevalence of mental illness in NHs (Grabowski et al., 2009), uncertainty surrounding the effectiveness of the PASRR program (O’Connor et al., 2011), lower quality of care in high-proportion SMI NHs (Jester et al., 2020; Li et al., 2011; McGarry et al., 2019), and a lack of access to quality mental health services in NHs (Linkins et al., 2006) raises concerns about quality of life and care for NH residents with SMI.

Preadmission screening and resident review program

Research on PASRR to date has focused on different elements of the program. Findings have suggested process improvements meant to identify an expanded number of mental health conditions in order to facilitate recommendations for more comprehensive mental health services (Borson et al., 1997). Additionally, poor NH compliance with PASRR documentation and administration has been raised as a concern, alongside acknowledgment that PASRR screening and documentation do not guarantee increased access to mental health services (Linkins et al., 2006; Sherrell et al., 1998). Lastly, there are few to no monitoring or penalty processes in place to address noncompliance with the PASRR program (Snowden et al., 1998). Although literature detailing the examination of the PASRR program does exist (see, Linkins et al., 2006), there has been little subsequent research to investigate PASRR program administration – including processes of local assessments and subsequent institutional actions.

Given the dearth of existing research examining the PASRR program from the perspective of stakeholders tasked with program administration, this project aims to describe the mechanisms of program administration in order to support existing quantitative and descriptive research that acknowledges program variability, but does not elaborate on the drivers. We qualitatively examined how the PASRR program is administered, and acknowledge how SDOH, such as the long-standing absence of a strong community mental health infrastructure and structural racism, impact the ability of the PASRR program to meet its original goals.

Methods

Sample frame and interview design

This qualitative study was part of a broader mixed methods study examining system-level mechanisms for racial/ethnic disparities in quality of life for NH residents and the role of SMI. The sampling frame for this study included multiple state-level stakeholders involved in PASRR program administration and/or care for NH residents with SMI, as well as stakeholders in advocacy and policy research positions across the U.S. Since this was an exploratory study on an understudied topic, we used a two-stage, adaptive non-probability sampling design. Non-probability sampling is useful when the intent of the research is to understand a process, which requires connecting with individuals who are both familiar with the process and who can discuss variation in, and deviation from, intended implementation (Bernard et al., 2016). Typically, 20 to 60 knowledgeable individuals are enough to “uncover and understand” core themes (Bernard et al., 2016).

A two-staged approach to sample selection was complementary to our sampling design. The first stage consisted of purposive sampling to identify PASRR content experts with characteristics of interest (e.g., experience with PASRR referrals, completing assessments, and the collection, review, and storage of completed PASRR assessments) – this included some stakeholders and local experts in response to new knowledge generated in initial interview responses (Table 1). Purposive samples are a good approach for pilot or exploratory studies, and include participants that are generally alike in a predetermined way (Bernard et al., 2016). In the second stage of interviews, we used snowball sampling (chain referral methods). Participants included key stakeholders from three states (two Midwest, one West Coast) and national stakeholders from provider organizations and policy groups, with a total sample size N = 20 (Table 1). About half of our sample is from Minnesota due to state agency interest in this topic. We also supplemented the Minnesota sample via the chain referral method and by contacting national and state stakeholders and asking them to identify members of their networks who are invested in this space. Research staff contacted relevant stakeholders by e-mail and provided information about the study.

Table 1.

Description of the professional roles held by our N = 20 interview participants.

Interview Participants’ Role	Description of Role
PASRR assessors	County staff responsible for completing PASRR Level II assessments for individuals with serious mental illness detected during PASRR Level I screening. These individuals might also be responsible for the supervision of county staff who complete Level II assessments.
Hospital discharge planners	Complete the PASRR Level I referral for inpatients with an approved hospital discharge and recommended post-acute nursing home placement.
Advocates	Hold positions in advocacy organizations (e.g., ombuds office, nonprofit organizations) for adults with mental illness and/or adults accessing long-term services and supports (i.e., nursing home care, assisted living).
Policy stakeholders	State employees involved in the implementation and coordination of the PASRR Level I and Level II programs. This group also includes employees of national organizations that are involved in (a) long-term care research, or (b) mental health and long-term care with a policy orientation.
Managed care organization (MCO)	MCOs in Minnesota are responsible for facilitating the PASRR screening process for dual eligible (Medicare/Medicaid) beneficiaries receiving services through a waiver program. Under these programs, beneficiaries have an MCO-contracted care coordinator who oversees care transitions. The MCO care coordinators receive the completed PASRR Level I screening, and then pass this to their county partners for Level II assessment if serious mental illness is detected by the care coordinator.
Care provider organizations	Professional role at membership associations that represent post-acute and long-term care providers.
Clinical service providers/Clinicians	Clinical professionals who provide direct care to nursing home residents (e.g., mental health services, routine clinical care).

Several key concepts of interest guided the development of our open-ended interview questions. These included details on the process and impact of the PASRR program and quality of care for Black, Indigenous, and Persons of Color (BIPOC) residents with SMI or SMI plus ADRD in NHs. Interviews were semi-structured, with a set of eight questions that were asked of all study participants. These questions primarily focused on their professional capacity, experience working with NH residents with mental illness, understanding of the PASRR program, policies or programs that might relate to BIPOC residents, key issues, and other topics they felt were relevant to our discussion (see Supplemental Online Appendix). We tailored additional questions to stakeholder role and content expertise. Interview questions were developed based on existing literature and were asked based on guidance for conducting semi-structured interviews (essential questions, probes as needed). All interviews were recorded and professionally transcribed. Interviews lasted an average of 32 minutes (range: 19–47 minutes), and we interviewed some participants more than once to clarify any issues identified on review to ensure valid representation. We obtained informed consent from all interview participants and the study was approved by the University of Minnesota Institutional Review Board.

Measures and coding

We used a partially deductive/partially inductive approach to coding interview transcripts. The initial coding framework and domains were based on interview questions related to the PASRR program, care for NH residents with SMI, and recommendations and key issues surrounding this topic. We also used an inductive approach to identify additional codes for findings or themes that arose through interviews but did not fit existing domains.

To establish the coding framework, one investigator first read all transcripts and developed an initial list of codes, organized by the predetermined domains (PASRR program, NH care for residents with SMI, key issues and recommendations). Two additional investigators then independently read and coded several transcripts using the initial framework, making notes about possible revisions. We developed the inductive codes through a team process of reflection, discussion, and coming to consensus on the meaning of the text. The team met frequently until the codebook was finalized–the final codebook was then used to re-code all transcripts. We first coded text to the relevant domain (e.g., PASRR program), then used “line by line” coding (Charmaz, 2014) to organize data into more specific categories (sub-codes; e.g., delayed hospital discharge).

When transcript coding was complete, we summarized findings for each stakeholder group (e.g., psychology/psychiatry, care provider organization). One member of the team took primary responsibility for creating the case summary for each stakeholder role. Two additional investigators who participated in data collection provided an “external check” of the coding process and findings (Creswell & Poth, 2018). NVivo qualitative software (QSR International) was used for data management.

Results

Participants described the complex processes involved in PASRR program administration, including the mechanisms of reporting and feedback that occur between assessment and dissemination of findings. We describe the general process in Figure 1, using Minnesota for reference, to illustrate the PASRR program from referral to NH-level of care determination. Screening is performed by the State Mental Health Authority, and the Level II assessment is completed by the county or tribal area where the applicant is located at the time of referral. Figure 1 outlines possible trajectories for those with a negative versus positive PASRR Level I result and provides the relevant screening questions.

Figure 1.

Diagram of the federal PASRR screening process for non-waiver beneficiaries in Minnesota. Non-Waiver beneficiaries are those who are not currently covered under a home and community-based waiver or managed care plan. ^PASRR Level I: Completed by nursing staff, discharge planners, or social workers. Form is competed for all persons who wish to enter a Medicated-certified NH in Minnesota.PASRR Level I screening questions: (1) Does the person have a DSM diagnoses of a major mental disorder? (2) Did this significantly impair psychosocial function in the last 3–6 months? (3) Does the person’s treatment history within the last 2-years indicate a psychiatric treatment more intensive than outpatient therapy or “an episode of significant disruption to the normal living situation” which required supportive services or involvement by law enforcement or housingPositive identification of suicidal ideation during the Level I assessment automatically triggers a Level II assessment.

Four key themes arose across all stakeholder roles: (1) lack of communication between stakeholders, (2) lack of standardized training on use of PASRR among assessors and NH staff, (3) limitation of PASRR assessments to meet mental health needs, and (4) stigma and structural racism create barriers to PASRR effectiveness.

Theme one: lack of communication between PASRR stakeholders

Most participants agreed that there is a lack of consistent communication between key stakeholders involved in the PASRR process, which creates variability at the state and county level. To varying degrees, administration of the PASRR program requires the involvement of many of our interview participants. These participants described how the absence of a standardized reporting and feedback process contributes to a lack of closed-loop communication. An employee from a managed care organization stated,

It’s not real streamlined and because every county just has their own processes, it’s done a little bit differently. The counties have a responsibility then to follow back up with the health plan who sent in the information for the Level II, just to kind of close the circle sort of, but we don’t ever hear back from the counties.

Acknowledging the uniformity of the PASRR screening form, a policymaker described the disconnect between the intention of the policy and the administration of the process in practice,

Although it’s a uniform assessment, it [PASRR] wasn’t being applied uniformly. And there were a lot of other factors at play here.

The PASRR final rule requires that Level I and Level II screening be completed before NH admission. Stakeholders varied in their opinions of how the PASRR program impacts hospital discharge processes. For example, one policymaker stated,

If you are stuck in a hospital, the discharge planners are just eager to get you out. And so [they] don’t take the time or the effort to get information so that the [PASRR] form is accurately completed.

In contrast, a discharge planner had an opposing view, stating,

Someone could be medically ready to leave the hospital, but they’re going to be in the hospital for several days waiting for an accepting facility, and then several more days waiting for their Level II.

This disconnect between stakeholders’ perspectives alludes to a lack of consistent communication between roles, as well as challenges related to the coordination of PASRR screening not only with the person who is to be screened but across multiple individuals at different locations. Actualizing the PASRR program requires manpower, and as outlined by our participants, is a secondary or tertiary component of their job role. A more streamlined or standardized PASRR process across coordinating entities could be beneficial in reducing duplicative work and reduce the use of unnecessary acute care services consumed from the time between discharge referral, PASRR screening request, and the final level of care determination.

Theme two: lack of standardized training on use of PASRR among assessors and NH staff

Through our interviews, we learned that PASRR assessors across organizations (e.g., hospitals, health systems) and jurisdictions (e.g., counties) do not receive standardized training. Training on PASRR administration and assessment was also inconsistent or absent at the NH level. Inconsistencies in training may create variability in the quality (and thus, usefulness) of the information that is collected. As one policymaker described,

So there’s a long history of just really bad PASRR and I think it is a lack of training because anybody who works in a health facility can just do a PASRR.

Our participants described barriers presented by high rates of NH staff turnover, specifically as it relates to realizing the full potential for high-quality mental health training, including meaningful use of information provided via the PASRR assessment. According to one participant,

It’s hard to train staff and have staff get really good at taking care of mental illness, when they don’t stay long enough to really build up an expertise or build up that training.

One policymaker related mental health training and the prioritization of mental health to NH culture change reform aimed at person- or resident-centered care, and NHs as “home-like” environments (Grabowski et al., 2014; Zimmerman et al., 2014):

It’s the idea to put the home back into nursing home and to deliver care that’s tailored to the emotional and mental health needs of the residents.

Theme three: limitations of PASRR assessments to meet mental health needs

While participants did agree that PASRR assessment results are used to some extent in NHs, none of them were able to describe how it is used in practice, specifically as it relates to creating the resident care plan. More than one stakeholder described the PASRR screening program as a “regulatory checkbox” rather than a meaningful tool in the care planning process.

I’ve always been concerned that I don’t know that it is always anything more than just checking a box that something has been evaluated.

It definitely feels more like a checkbox. There’s nothing in it, no information in it that the nursing home isn’t getting from either the referral, or the discharge orders, or from the nurse report that they’re getting when the patient discharges.

Stakeholders described organizational characteristics of NHs that can impact resident mental health irrespective of existing mental health diagnoses, such as loneliness, boredom, and learned helplessness. NHs were not created to explicitly treat or manage mental illness, which is reflected in the precedent set by the creation of the PASRR program. This makes it difficult to meet the needs of residents with SMI, even if PASRR screening determines the NH to be the most appropriate setting. As one geriatrician described,

From an administrative perspective, I think we feel sometimes that this [nursing homes] is just the landing place of least resistance.

While the PASRR program is well intentioned, as agreed upon by our participants, administration of the program is variable in practice. Few alternative options exist for people with SMI to access necessary services in the community, a barrier that has existed for decades. Similarly, ancillary mental health providers who are contracted to provide services within NHs are often stretched across multiple facilities, and this practice is not uniformly adopted by NHs. One advocate demonstrated this by stating,

There [are] just not great services out there for people with mental health needs in the nursing home setting. There’s a few providers that come in, but they’re overwhelmed. They don’t have the time that people might need to see them.

Theme four: stigma and structural racism create barriers to PASRR effectiveness

In addition to the deficiencies in the existing community mental health structure nationally, participants described social factors, such as structural racism and stigma around mental health, that doubly impact the effectiveness of PASRR and quality of care for NH residents with SMI. No stakeholder that we interviewed was aware of policies or initiatives that were specific toward BIPOC residents, although advocates had the most to say on the topic of race and ethnicity. They brought up issues around a lack of resources that cultivate cultural humility, as well as the ongoing issue of stigma surrounding mental health diagnoses and treatment, which may be especially prevalent in certain racial or ethnic groups and could prevent people from seeking mental health care altogether. As one advocate stated,

We find that in communities of color, and especially from a cultural standpoint, mental illness is looked at differently and there isn’t much written about it in the research. So I do tell people where they can go to [get] culturally competent resources … and there aren’t enough.

While not much was shared regarding policies or programs for BIPOC residents, several policymakers brought up the issue of the inequitable placement of BIPOC residents in NHs that score lower on quality measures.

My hypothesis would be, all of the inequities we see there, only more so because you have inequities in mental health. So I have no doubt you would see similar results here.

Stigma was cited as a much larger societal issue that permeates into organizational, group, and interpersonal dynamics. This was noted in the context of health-care providers who provide mental health services in the NH. One advocate stated,

One of the things we see on a very regular basis, even from providers who are providing the service is stigma. And the discounting of clients who are experiencing mental illness.

Discussion

This exploratory study attempts to contribute to existing knowledge in two ways. First, to expand on PASRR program administration, the usefulness of the program in practice, and to describe drivers of heterogeneity. Second, we sought to provide insight into how the PASRR program fits into practices surrounding NH admission and quality of care within the context of SDOH. We conducted in-depth qualitative interviews with 20 stakeholders with relationships to PASRR program administration at both the state and national level and sought to better understand how the federally mandated PASRR program is administered, how stakeholders perceive the quality of care for NH residents with SMI, and what organizational or structural changes are necessary to improve care. Our findings show that, in general, participants agree that the PASRR process requires a more streamlined, standardized, and intentional approach, and that efforts are needed to create culturally sensitive mental health services to address stigma more broadly. There were some conflicting opinions regarding how PASRR requirements impact the hospital discharge process, which further alludes to a disconnect between the various stakeholders involved in PASRR administration. Lastly, we found that PASRR is equated to a regulatory checkbox; an assessment which provides information that is not used to tailor NH care and generally does not differ from hospital discharge records.

Our research findings reveal a need for further emphasis on determining the most appropriate care environment for aging and older adults with SMI. These findings, namely organizational barriers in PASRR program administration that limit its intended impact, align with previous research describing the state-based implementation of this federal requirement as focusing more on “minimum compliance” versus “with intent to maximize its reach or potential” (O’Connor et al., 2011). Further supported by the review of PASRR screening outcomes and NH residents with SMI conducted by Linkins et al. (2006), our participants spoke to the variation in mental health services facilitated by and provided within the NH. The PASRR assessment process must compete with organizational pressure and resource constraints related to care transitions and turnover. For example, when hospital bed capacity necessitates a quick discharge to a NH, but discharge is ultimately determined by an assessment or level of care determination dictated by an external entity. The multifaceted nature of the program and agencies charged with its administration speaks to the complexity of organizations at large, and an enhanced need for coordination and role definition.

Despite deep-seated sociopolitical efforts that have historically favored deinstitutionalization, the prevalence of SMI in NHs has increased by approximately 80% in the last 10-years (Hua et al., 2020). This phenomena might be attributed to NHs as the “landing place of least resistance,” as it was described by our stakeholders, and likened to the “lender of last resort” analogy in economics, used to describe the Federal Reserve as default (Bordo & Wheelock, 2011). The “landing place of least resistance” is akin to the “provider of last resort,” where NHs step in as the source of care in the absence of viable alternative options. Persons with SMI often experience “complex care needs” at the intersection of medical, mental, and long-term supported care (Muralidharan et al., 2019; Seitz et al., 2010). Additionally, previous research has cited the population of adults and older adults with SMI as experiencing cumulative inequality, manifested via excess morbidity and mortality, primarily due to medical or physical illness, and earlier onset of biological and physical patterns of aging than their non-SMI counterparts (Druss & Bornemann, 2010; Wolkowitz, 2018). If the PASRR program is to continue to be the method by which care determinations are made for NH applicants with SMI, revisions to PASRR administration and design might consider a holistic assessment of the individual applicant, including SDOH that might impact their long-term care trajectory.

If NHs are, in fact, the “provider of last resort,” then the ability to supply mental health services through capable staff becomes doubly important. Previous research has noted that NHs with a high proportion of SMI residents provide lower quality of care and have lower staffing levels (Jester et al., 2020), can result in worse quality of care for residents with and without SMI (McGarry et al., 2019), and that NH applicants with SMI are more likely to be admitted to lower quality NHs (Li et al., 2011). Our stakeholders described informal relationships between hospitals and NHs regarding ease of placement for applicants with SMI, based on the capacity and familiarity of the NH is caring for a similar resident population. This finding is supported by existing research describing selective admission processes based on social or clinical complexity, or staffing resources and organizational factors that might influence disparities in NH placement (Grabowski et al., 2009; Jester et al., 2020).

Revisiting the motivations behind the dominant mental health and social policy actions of the 1960s, there is also the need to cultivate support for community-based mental health services (Koyanagi, 2007). Much like it did 60 years ago, this avenue requires financial investment and political support (Koyanagi, 2007). In the interim, emphasis on training and education based in the management of SMI in NHs and support for NH facilitated mental health services is important (“Long Term Care Providers Call for Workforce Support Amid Pandemic, 2021;” “Mental Health Care Health Professional Shortage Areas (HPSAs), 2020).” Training and education might also extend to those involved with the PASRR program at large, to ensure that those tasked with the responsibility are aware of its legislative purpose. Coordinated efforts to train PASRR assessors and NH staff is one way to address the issues of poor coordination and communication and takes a step toward standardizing state and county-based training, a suggestion highlighted by many of our stakeholders. While these suggestions fall within existing workforce strains, including high NH staff turnover rates and a shortage of mental health providers, they are relevant, nonetheless.

Lastly, there is a need to bring persons with SMI to the center of the process. This involves addressing stigma and using a lens of racial equity when doing so. Despite acknowledging cultural or community differences in perceptions of mental illness in NHs, our stakeholders could not identify programs that could better serve BIPOC residents. Additional research that targets the experience of older BIPOC adults with SMI needs to be prioritized, including access to quality mental health resources in NHs, and to resources, such as home- and community-based services and community-based mental health care, that support residence in a location that aligns with personal goals. This need will only continue to grow more urgent as the U.S. population continues to rapidly age (The US Population Is Aging | Urban Institute). Action should be taken to address the various inconsistencies and barriers that exist in the administration of the PASRR program, and the topic of SMI in NHs overall requires greater attention from policymakers and researchers alike.

Limitations

This was an exploratory project that attempted to better understand the administration of a federal policy intervention, which has existed for many years. We were able to interview a wide variety of stakeholders who provided a well-rounded array of perspectives on this topic. Due to the sample size (N = 20), we could not establish certain aspects of this topic, especially specific variation across the states or differences with others. Our analysis is not meant to be representative of PASRR programs nationally, but instead seeks to identify key challenges and issues, within the scope of our research questions, that may affect PASRR programs. More research is needed to fully understand the impact that PASRR has had at a federal level. In addition, more needs to be understood regarding quality of life and care for NH residents with SMI, and especially for BIPOC residents with SMI. We noted much uncertainty in stakeholder responses regarding how race and ethnicity impact care provided to persons with SMI, and a clear lack of adequate services to meet the needs of a diverse population. The issue of whether or not NHs are the best place for residents with SMI (depending on their full set of health or functional needs) requires further examination, as does how community-supported services can be bolstered to support people whose needs could be met outside of an institutional setting.

Conclusions

Although the PASRR program is a federal requirement, administration is entirely state and/or county-based, and stakeholders expressed concern regarding fragmentation and lack of uniform program application across jurisdictions. There is an ongoing need to understand mental health services as essential services and not merely an “add-on” benefit. This might manifest through reimbursement, expanded use of telehealth services, or state and federal initiatives for mental health training that mirror previous initiatives for dementia care. Given the number of individuals with SMI currently residing in NHs, policy and practice should take a person-centered approach and ensure the individual is informed and involved throughout the PASRR process. Future research should explore how to make PASRR reflect its intended value at both the state and NH level, as well as the impact this program has had on clinical and quality of life outcomes for NH residents.

Key points.

• Variability in PASRR program administration has contributed to fragmented patterns of communication and inconsistent training across entities.

• Stakeholders question the value of assessments beyond a regulatory requirement.

• Nursing homes are the “provider of last resort” for SMI and offer variable mental health support.