Caring for the Chronically Mentally Ill in Nursing Homes-A Commentary

The authors have identified some of the issues and frustrations in providing psychiatric care in nursing homes. Providing care for the mentally ill and the chronically mentally ill requires planning, programming financing, and committed and trained healthcare providers. To provide adequate care now, and eventually, state-of-the-art care, many challenges need to be resolved.

These issues include:

1. Parity for mental health services.
Lack of parity has been an issue for years from the percent reimbursement to direct reimbursement to qualified mental health providers from nursing and social work.

Medicare compels a 20% co-insurance rate on most outpatient services, but mental health has a 50% co-insurance rate. This remains unfair and is a barrier to access to care. An American Association for Geriatric Psychiatry (AAGP) report states that these differences cause confusion among carriers who continue to reimburse only 50% for medication management services for Alzheimer's disease and other dementias, contrary to the directions identified by the Centers for Medicare & Medicaid Services (CMS).

Social workers and advanced practice nurses are also lobbying for parity in reimbursement for providing mental health services. Recently, Senator Barbara Mikulski (D-MD) introduced the Clinical Social Work Medicare Equity Act of 2007 (S1212). This bill would expand mental health services of nursing home residents, allowing clinical social workers to bill Medicare Part A directly for psychotherapy services in skilled nursing facilities. This bill is a beginning and opens the door for more expanded services and reimbursement in other supported living situations.

2. Access to mental health practitioners, including treatment and prescription drugs.
Reimbursement for psychotropics, an essential component for a number of mental illnesses, particularly for the chronically and persistently mentally ill, remains inadequate.

3. Nursing home reimbursement currently has disincentives built into policies and programs.
State and federal monies fund most mental health services in nursing homes. These programs are subject to ongoing policy changes and limitations.

4. Broader coverage of case management and care planning oversight to be offered in the continuum of supported living facilities.
These services are currently limited to home care and hospice care. Full coverage by Medicare/Medicaid for low-income patients is needed, and coverage should be expanded for services delivered in assisted living facilities. This broader care coverage would allow more able chronically mentally ill to live in a lesser-restricted living situation. Premature placement in nursing homes is countertherapeutic, restrictive, and costly.

5. Mental health training and education is lacking in most long-term care facilities.
The chronically mentally ill may require not only psychiatric treatment programs in place but are often not thoroughly evaluated and treated for medical conditions.

There are not enough trained geriatrics professionals to meet the needs and complexities of an aging society. The John A. Hartford Foundation has developed scholars programs for both nursing and social workers to meet the needs. To address this crisis, funding for the geriatric health professions program under Title VII of the Public Health Service Act should be restored to FY 2005 levels. Funding and demonstration projects of successful and innovative nursing homes with mental health programs needs be expanded.

6. Warehousing of the mentally ill as a result of deinstitutionalization has caused a crisis in nursing homes, conflict in those who provide care, and inadequate care for a too often forgotten and ignored venerable population.
This situation has become a crisis in four states: California, Connecticut, Illinois, and New York. These states have filed litigation seeking more appropriate placement for persons with mental illnesses than nursing homes. This litigation is a result of tragic abuses and deaths of ill-cared-for mentally ill individuals residing in nursing homes. Many professional aging organizations—The American Geriatrics Society, the American Association for Geriatric Psychiatry, and the National Association for Social Workers—have banded together to urge Congress to address this crisis in care.

Caring for chronically mentally ill persons in nursing homes demands access to appropriate mental health services. This access includes appropriate living facilities with trained staff, programs, and oversight. The barriers imposed by confusing reimbursement formulas and lack of qualified mental health providers is further complicated by a lack of understanding of mental illness and treatment.

Sources
American Association for Geriatric Psychiatry. www.aagponline.org/ advocacy

Mental Health Informational Center of the National Association of Social Workers. www.mentalhealth.samhsa.org

Mental Illness in Older Adults: Effective Treatment, National Institute of Mental Health. www.nimh.nih.gov

Nursing and Training, The John A. Hartford Foundation. www.jhartfound.org; www.gitt.org

The American Geriatrics Society & American Association for Geriatric Psychiatry Recommendations for Policies in Support of Quality Mental Health Care in U.S. Nursing Homes, 2003 Position Statement of American Geriatrics Society. www.americangeriatrics.org