Caring for the Chronically Mentally Ill in Nursing Homes

The chronically mentally ill represent one of the most socially disadvantaged segments of our population, which has been subject to the unwelcome consequences of the shifting healthcare policies. The deinstitutionalization program, which started in the late 1950s, has resulted in the closing of many state hospitals or in a drastic reduction in the number of beds in state hospitals, where these persistently mentally ill patients had been cared for. The census of the nation’s state hospitals reached its peak of 560,000 in 1955 and declined dramatically to under 170,000—a decrease of more than 60% in the late 1970s and to about 100,000 in the mid1990s.^1-3 The most important factor that led to this decline was the shift in funding opportunities under Medicaid, Medicare, and Supplemental Security Income that allowed states to shift the fiscal burden of the mentally ill to federal auspices if they moved patients out of state facilities. The other factors included the impact of community mental health philosophy, effectiveness of newer psychotropic agents, and the increasing importance of legal, judicial, and legislative actions defining the circumstances for mental health treatment.^3,4

The chronically mentally ill patients who were essentially unable or unprepared to handle the outside world were released into adult homes, group homes, foster homes, supervised residences, “hotels,” and nursing homes. As patients aged, many of them have been transferred to nursing homes from lesser care settings. A number of patients have become homeless as a result,^5,6 and the number of mentally ill persons in the prison population also increased significantly. Approximately 750,000 patients with chronic mental illness have been placed in nursing homes by the late 1980s.⁷ Eighty-nine percent of the older people with serious mental illness who are institutionalized reside in nursing homes.⁸ Pilgrim State Hospital in New York, which was considered to be the largest mental hospital in the world, once cared for about 10,000 patients. The bed capacity has now shrunk to about 650. States have saved a significant amount of money by these maneuvers, but is this a real saving in terms of true costs, or is it just a shift of fiscal burden from the state to the federal government? What about the consequences—the human suffering and quality-of-life issues—for this underrepresented segment of our population? The taxpayer is still responsible for the monetary burden as a result of the revolving-door situation of these patients.

The Pulitzer Prize–winning series of articles published in The New York Times in 2002 eloquently brought to light part of these problems.⁹ We as psychiatrists and as part of a civilized society need to address these issues in a political forum, to bring forth the necessary changes needed to improve the quality of life for these unfortunate patients.

Long-term care facilities are vastly underserved, resulting from an inadequate number of psychiatrists, psychologists, and social workers treating these patients and a lack of staff awareness and training in these facilities.⁸ In New York State, the problem has been compounded by other developments in the discharge planning of the chronically mentally ill patients in state hospitals and other psychiatric units, and the changes in the reimbursement policies. Around the year 2000, there was a sudden trend of opening “secure units” in nursing homes to care for the “difficult-to-place” patients from state hospitals, particularly in New York State. In late 2002 after The New York Times publication,⁹ the Office of Mental Health fiercely contested the legal representation of these patients in the courts. This, coupled with other reimbursement issues for the nursing homes, resulted in closure of most of these units in New York State. However, many of the patients in these units have been moved to regular nursing homes. Many patients who were discharged to lesser care settings, like adult homes and group homes, have eventually found their way into nursing homes after further hospitalizations in community hospital psychiatric units.

Attempts to rehospitalize these patients in state hospitals generally are futile because of the frequent rejections by the state hospitals or the unusually long waiting periods of several months to a year for a bed. Thus, the saga of the “revolving door” continues. Have we really saved any money? A 2001 report of the Office of Inspector General of the U.S. Department of Health and Human Services found only 42% compliance for a Level II Preadmission Screening and Resident Review (PASRR), which screens for serious mental illnesses. Many times, hospitals use a dementia diagnosis to bypass the Level II. Not infrequently, the cognitive deficit syndrome of schizophrenic patients are erroneously labeled as dementia. Only 29% of patients who had an initial Level II PASRR screening had a review with significant change in residents’ mental health condition, as required.⁸

Bartels et al¹⁰ have attempted to address one part of this equation. As they have concluded, “schizophrenia is one of the most expensive disorders across the adult lifespan,” and interventions to improve independent functioning irrespective of age and in conjunction with community services would decrease expenditure of institutionalization. By the same token, there are a significant number of patients who still need to be cared for in state hospital settings and nursing home settings for long-term care. Mental health services in nursing homes need to improve, particularly in light of the ever increasing number of mentally ill patients filling the vacant beds in nursing homes. All nursing homes should have adequate numbers of consultant psychiatrists, psychologists, and social workers on staff to care for mentally ill individuals. Behavior management programs should be instituted to assist in the training of staff to effectively deal with the mental health problems.

Medicare has a discriminatory restriction on providing services to nursing home patients with mental illnesses. The program reimburses psychotherapy and other mental healthcare services at 50% of the allowed amount as compared with 80% of the allowed amount for physical illnesses. Until recently, the difference was covered by Medicaid for dual-eligible patients in New York State. The recent drastic reduction of Medicaid crossover payments to 4% for psychiatrists in New York State, caring for this very same segment of this disenfranchised population, is going to significantly affect the mental health delivery system for these patients. The long-term care and office-based psychiatrists caring for these patients may soon be forced to look for other areas of practice unless some immediate policy changes are made to improve the situation. Healthcare policymakers need to effectively and urgently address these issues.

Conclusion

The care of chronically mentally ill persons in the nursing homes has not been adequately addressed by the healthcare policymakers. Adequate services of psychiatrists, psychologists, and social workers should be available in nursing homes caring for these patients. Behavior management programs may be established in nursing homes to improve staff awareness and training. Reimbursement for psychiatrists and other qualified mental health providers needs to improve to attract and retain these professionals in nursing home practice. Healthcare policymakers must make it a priority to improve the funding for these needs and to resolve the issues regarding parity for mental health.

The authors report no relevant financial relationships.