Care of Older Adults with Mental Illness in Long-Term Care Residential Facility: A Scoping Review

OBJECTIVES

Mental illness affects approximately 1 in 8 people globally, with approximately 15% of adults aged 60 years and older experiencing a mental disorder. With the aging population, there is a growing demand for long-term care. This scoping review focuses on older adults with non-neurocognitive and non-neurodevelopmental mental illnesses (NNNDMIs) in nursing homes, exploring how the care is provided.

DESIGN

A scoping review.

SETTING AND PARTICIPANTS

The review includes studies addressing care for older adults with NNNDMI in nursing homes.

METHOD

The PRISMA-ScR protocol was followed. Four research databases (EBSCO, PubMed, Web of Science, and Scopus) and article bibliographies were used for the literature search. Thematic analysis identified the main themes.

RESULTS

From a total of 1948 search results, 13 articles were analyzed to reveal 5 themes: (1) challenges and recommendations in nursing home admission for older adults with mental illness; (2) impact on the quality of the care; (3) need for specialized staff training and competency; (4) contributions to psychiatric and behavioral symptoms; and (5) need for a range of interventions.

CONCLUSION AND IMPLICATIONS

Older adults with NNNDMI face barriers during admission to long-term care facilities that highlight concerns about care quality and systemic issues. Behavioral symptoms require specialized mental health support, but access to such services is lacking. Deficiencies in staff education and burnout prevention initiatives further underscore the need for comprehensive reforms to address the unique needs of this overlooked population in long-term care settings.

Disparities in Access to Highly Rated Skilled Nursing Facilities among Medicare Beneficiaries with Opioid Use Disorder

OBJECTIVES

To investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD).

DESIGN

Nationwide, retrospective observational cohort.

SETTING AND PARTICIPANTS

Medicare Fee-for-Service beneficiaries aged ≥18 years admitted to SNFs following hospitalization during 2016-2020 (n = 30,922 with OUD and n = 137,454 without OUD).

METHODS

Data used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay, and state and year fixed effects.

RESULTS

The overall study sample had a mean (SD) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were as follows: 63.9% vs 62.2% for quality, 32.8% vs 34.9% for health inspections, and 46.2% vs 45.0% for staffing, respectively. Adjusted regression models indicated that beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR 0.90, 95% CI 0.87-0.92), health inspection (OR 0.90, 95% CI 0.88-0.93), and staffing (OR 0.91, 95% CI 0.89-0.94) ratings compared with beneficiaries without OUD, whereas quality (OR 0.98, 95% CI 0.95-1.01) ratings did not differ.

CONCLUSIONS AND IMPLICATIONS

Despite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.

Barriers and facilitators to caring for individuals with serious persistent mental illness in long-term care

OBJECTIVE

Many older adults in the United States with serious persistent mental illness reside in long-term facilities, and evidence suggests increasing numbers of long-term care residents with serious persistent mental illness. Healthcare professionals in these settings may face challenges in providing care to these residents. The purpose of this study was to describe health care professionals' perceptions of the barriers and facilitators to caring for long-term care residents with serious persistent mental illness.

METHODS

A qualitative descriptive design was employed.

RESULTS

Ten healthcare professionals working in long-term care were interviewed. Themes that emerged from the interviews were: coming to know the individual and their unique needs takes time; offering choices and being flexible facilitates trust; respecting the inherent worth of each individual promotes caring.

CONCLUSIONS

Caring for individuals with serious persistent mental illness in long-term care requires an individualized, person-centered approach.

Perspectives on Admissions and Care for Residents With Opioid Use Disorder in Skilled Nursing Facilities

Importance

Skilled nursing facilities (SNFs) are being referred more individuals with opioid use disorder (OUD), even when their medical needs are not directly associated with OUD.

Objective

To characterize factors that influence SNF admission for individuals with OUD and identify strategies for providing medications for OUD (MOUD) in SNFs.

Design, Setting, and Participants

In this semistructured qualitative study, interviews were conducted with SNF administrators from 27 SNFs in Rhode Island from November 5, 2021, to April 27, 2022. Data analysis occurred from August 22, 2022, to May 31, 2023.

Main Outcomes and Measures

Themes and subthemes on administrator perspectives on admissions and care for people with OUD in SNFs. Audio interviews were transcribed, coded, and analyzed using codebook thematic analysis and guided by community-engaged and participatory research principles.

Results

The study included 29 participants representing 27 SNFs in Rhode Island. Participant roles were administrators (17 participants [59%]), directors of nursing (6 participants [21%]), directors of admissions (5 participants [17%]), and unit managers (1 participant [3%]). Participants described active substance use, Medicaid insurance, housing instability, and younger age as potential barriers to SNF admission for individuals with OUD. The lack of formal guidelines for OUD management, staff shortages, facility liability, state regulations, and skills and training deficits among staff were cited among challenges of effectively meeting the needs of residents with OUD. Many participants reported inadequate institutional capacity as a source of negative outcomes for people with OUD yet expressed their concerns by characterizing individuals with OUD as potentially violent, nonadherent, or likely to bring undesirable elements into facilities. Participants also shared strategies they used to better serve residents with OUD, including providing transportation to support group meetings in the community, delivery in advance of resident arrival of predosed methadone, and telemedicine through the state's hotline to prescribe buprenorphine.

Conclusions and Relevance

In this qualitative study of administrator perspectives about admissions and care for individuals with OUD in SNFs, gaps in institutional capacity overlapped with stigmatizing beliefs about OUD; such beliefs perpetuate discrimination of individuals with OUD. Adequate SNF funding and staffing combined with OUD-specific interventions (eg, antistigma training, community partnerships for MOUD and recovery support) could incentivize SNFs to serve individuals with OUD and facilitate OUD care consistent with practice guidelines.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Changes in Nursing Home Populations Challenge Practice and Policy

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.

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

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.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness

OBJECTIVE

This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness.

METHODS

The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates.

RESULTS

Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11.

CONCLUSIONS

These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Abuse and Neglect in Nursing Homes: The Role of Serious Mental Illness

BACKGROUND AND OBJECTIVES

Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest ("High-SMI") quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusion.

RESEARCH DESIGN AND METHODS

We used national Certification and Survey Provider Enhanced Reports (CASPER) data for all freestanding certified NHs in the continental United States from 2014 to 2017 (14,698 NHs; 41,717 recertification inspections; 246,528 deficiencies). Differences in the number of deficiencies, a weighted deficiency score, the deficiency grade, and the facility characteristics associated with deficiencies for abuse, neglect, and involuntary seclusion were examined in High-SMI. Incidence rate ratios (IRR) and odds ratios (OR) were reported with 95% confidence intervals.

RESULTS

High-SMI NHs did not receive more deficiencies or a greater weighted deficiency score per recertification inspection. Deficiencies given to High-SMI NHs were associated with a wider scope, especially Pattern (IRR:1.03;[1.00, 1.07]) and Widespread (IRR:1.07;[1.02, 1.11]). High-SMI NHs were more likely to be cited for resident abuse and neglect (OR:1.49;[1.23, 1.81]) and the policies to prohibit and monitor for abuse and neglect (OR:1.18;[1.08, 1.30]) in comparison to all other NHs.

DISCUSSION AND IMPLICATIONS

Although resident abuse, neglect, and involuntary seclusion are rarely cited, these deficiencies are disproportionately found in High-SMI NHs. Further work is needed to disentangle the antecedents to potential resident abuse and neglect in those with mental healthcare needs.

Serious Mental Illness in the Nursing Home Literature: A Scoping Review

Nursing homes (NH) and other institutional-based long-term care settings are not considered an appropriate place for the care of those with serious mental illness, absent other medical conditions or functional impairment that warrants skilled care. Despite policy and regulatory efforts intended to curb the unnecessary placement of people with serious mental illness (SMI) in these settings, the number of adults with SMI who receive care in NHs has continued to rise. Through a scoping review, we sought to summarize the available literature describing NH care for adults with SMI from 2000 to 2020. We found that SMI was operationalized and measured using a variety of methods and diagnoses. Most articles focused on a national sample, with the main unit of analysis being at the NH resident-level and based on analysis of secondary data sets. Understanding current evidence about the use of NHs by older adults with SMI is important to policy and practice, especially as we continue to grapple as a nation with how to provide quality care for older adults with SMI.

Changing landscape of nursing homes serving residents with dementia and mental illnesses

OBJECTIVE

Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster.

DATA SOURCES

2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States.

STUDY DESIGN

Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster.

DATA EXTRACTION METHODS

We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data.

PRINCIPAL FINDINGS

Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively.

CONCLUSIONS

Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.

Social Service Directors' Roles and Self-Efficacy in Suicide Risk Management in US Nursing Homes

Nursing home (NH) residents have many risk factors for suicide in later life and transitions into and out of NHs are periods of increased suicide risk. The purpose of this study was to describe NH social service directors (SSDs) roles in managing suicide risk and to identify factors that influence self-efficacy in this area. This study used data from the 2019 National Nursing Home Social Services Directors survey (n = 924). One-fifth (19.7%) of SSDs reported a lack of self-efficacy in suicide risk management, as indicated by either needing significant preparation time or being unable to train others on intervening with residents at risk for suicide. Ordinal logistic regression identified SSDs who were master's prepared, reported insufficient social service staffing as a minor barrier (versus a major barrier) to psychosocial care, and those most involved in safety planning for suicide risk were more likely to report self-efficacy for training others. Implications include the need for targeted training of NH social service staff on suicide prevention, such as safety planning as an evidence-based practice. Likewise, sufficient staffing of qualified NH social service providers is critically important given the acute and chronic mental health needs of NH residents.

Serious Mental Illness in Nursing Homes: Roles and Perceived Competence of Social Services Directors

Providing nursing home psychosocial care to persons with serious mental illnesses (SMI) requires understanding of comorbidities and attention to resident rights, needs and preferences. This quantitative study reports how 924 social service directors (SSDs) taking part in the National Nursing Home Social Service Director survey identified their roles and competence, stratified by the percentage of residents with SMI. More than 70% of SSDs, across all categories of homes, reported the social services department was "always" involved in conducting depression screening, biopsychosocial assessments and PASRR planning. SSDs in homes with lower concentrations of residents with SMI reported less involvement in anxiety screening. Those employed in homes with higher concentrations of residents with SMI reported lower involvement conducting staff interventions for resident aggression or making referrals. More than one-fifth of SSDs lacked confidence in their ability to compare/contrast dementia, depression, and delirium or to develop care plans for residents with SMI. SSDs' perceived competence in developing care plans for residents with SMI was associated with education and involvement in care planning. About one-quarter of social services directors reported not being prepared to train a colleague on how to develop care plans for residents with SMI. Training in SMI could enhance psychosocial care.

Trends in Serious Mental Illness in US Assisted Living Compared to Nursing Homes and the Community: 2007-2017

OBJECTIVE

Little is known about the prevalence of serious mental illness (SMI) in assisted living (AL) communities in the United States. Trends in the prevalence of SMI in AL communities were examined over time and in relationship to characteristics such as dual eligibility and health conditions. Within- and between-state variability of SMI in AL was also examined.

DESIGN

Samples of Medicare beneficiaries who lived in the 48 contiguous states were created: individuals who resided in the community, in a nursing home (NH), and in an AL community on December 31st of each year (2007-2017). We conducted univariate analysis to display the trends in SMI over time in AL compared with NHs and the community. To demonstrate intrastate variability, we examined the prevalence of SMI for each state. We described within-nation and within-state variability using a Lorenz curve and GINI coefficients, respectively.

RESULTS

The prevalence of SMI in AL increased by 54%, rising from 7.4% in 2007 to 11.4% in 2017. Residents with SMI were more likely to be dually eligible for Medicare and Medicaid than residents without SMI. The prevalence of SMI in AL ranged from to 3.2% in Wyoming to 33.1% in New York. Approximately 10% of AL communities had over half of the sample's AL residents with SMI.

CONCLUSION

Given the increased proportion of residents with SMI in AL, research is needed into the mental health and social care needs of this population. Analysis is needed to uncover reasons for variations among states.