Compliance with PASARR recommendations for Medicaid recipients in nursing homes. Preadmission Screening and Annual Resident Review

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.

BE-ACTIV for depression in nursing homes: primary outcomes of a randomized clinical trial

OBJECTIVES

To report the primary outcomes of a cluster randomized clinical trial of Behavioral Activities Intervention (BE-ACTIV), a behavioral intervention for depression in nursing homes.

METHOD

Twenty-three nursing homes randomized to BE-ACTIV or treatment as usual (TAU); 82 depressed long-term care residents recruited from these nursing homes. BE-ACTIV participants received 10 weeks of individual therapy after a 2-week baseline. TAU participants received weekly research visits. Follow-up assessments occurred at 3- and 6-month posttreatment.

RESULTS

BE-ACTIV group participants showed better diagnostic recovery at posttreatment in intent-to-treat analyses adjusted for clustering. They were more likely to be remitted than TAU participants at posttreatment and at 3-month posttreatment but not at 6 months. Self-reported depressive symptoms and functioning improved in both groups, but there were no significant treatment by time interactions in these variables.

DISCUSSION

BE-ACTIV was superior to TAU in moving residents to full remission from depression. The treatment was well received by nursing home staff and accepted by residents. A large proportion of participants remained symptomatic at posttreatment, despite taking one or more antidepressants. The results illustrate the potential power of an attentional intervention to improve self-reported mood and functioning, but also the difficulties related to both studying and implementing effective treatments in nursing homes.

Assessment and treatment of behavior problems in dementia in nursing home residents: a comparison of the approaches of physicians, psychologists, and nurse practitioners

OBJECTIVE

To compare physicians (MDs), psychologists (PhDs), and nurse practitioners (NPs) regarding their approach to dementia-associated behavior problems in nursing home residents.

METHODS

A web-based questionnaire solicited information about symptoms, assessment methods, suspected etiologies, and interventions with respect to the last resident treated for dementia-associated behavior problems.

RESULTS

Responses were obtained from 108 MDs, 38 PhDs, and 100 NPs. All groups relied similarly on information from the nursing staff, speaking with nursing assistants, and care team meetings in assessment; NPs were more likely to consult with family members. A standard assessment instrument was used most frequently by PhDs (50%), but this generally assessed cognitive status rather than problem behaviors. PhDs most frequently noted depression in residents. Groups were similar in attributing the behavioral symptoms to dementia and to underlying medical conditions, but PhDs were more likely to indicate depression, loneliness/boredom, staff-resident communication, and insufficient activities as etiologies. Use of pharmacological and nonpharmacological interventions of MDs and NPs were similar. PhDs reported least satisfaction with treatment.

CONCLUSION

Awareness of similarities and differences in the approaches of different health professionals can facilitate interdisciplinary interaction in providing care for dementia-associated behavior problems in nursing home residents.

Mental health service delivery in long-term care homes

BACKGROUND

The prevalence of mental disorders in long-term care (LTC) homes is high, but quality and availability of mental health services to assess and help in management of cases have been criticized.

METHOD

Literature concerning mental health problems in LTC homes was reviewed, especially regarding models of mental health service delivery and factors that affect development, persistence and reduction of symptoms and distress.

RESULTS

The advantages of consultation-liaison arrangements and of telepsychiatry were noted. Discussions led to development of recommendations aimed at improving mental health expertise and provision of assessment and intervention services in LTC homes in diverse countries. Prompt recognition of mental health problems among residents is required, with availability of a team working within the facility to deal with these problems. Commonly such multidisciplinary teams are formed by facility staff linking with visiting mental health professionals or services. Quality of care is also affected by the organization, attitudes and education within LTC facilities.

CONCLUSION

Provision of optimal mental health care in LTC settings is dependent on adequate funding, availability of expertise and education, positive and caring attitudes, recognition of needs, and supportive teamwork. The latter should include cooperative links between well-resourced and under-resourced regions.

Risk of nursing home admission in association with mental illness nationally in the Department of Veterans Affairs

OBJECTIVE

We sought to determine whether patients with mental health diagnoses in the Department of Veterans Affairs (VA) are more likely to be admitted to nursing homes and to identify sociodemographic, utilization, and clinical characteristics, especially indicators of mental illness severity, associated with nursing home admission among mentally ill patients.

METHODS

Patients receiving treatment in the VA system nationally during FY 2000 and having no evidence of nursing home utilization during FY 1999 or FY 2000 were followed through FY 2003 using administrative claims data. Three-year incidence rates and unadjusted odds ratios were estimated for each diagnosis. Logistic regression was used to examine the correlates of admission among mentally patients, including analyses stratified by age.

RESULTS

Of 3,952,229 VA patients with no prior nursing home use, 15.2% received a mental health diagnosis, of which, 4.6% were eventually admitted to a nursing home. Among mentally ill patients, risk of admission was highest for those with any inpatient medical/surgical days (odds ratio [OR] = 2.28), followed by 3+ outpatient medical visits (OR = 1.48), inpatient mental health days (OR = 1.31), and outpatient mental health visits (OR = 1.09). Patients diagnosed with dementia were 58% more likely to be admitted. Patients diagnosed schizophrenia (OR = 1.26), other psychosis (OR = 1.15), and personality disorder (OR = 1.14) had the next highest probabilities. Elderly patients with bipolar disorder (OR = 1.28) were also more likely to enter.

CONCLUSION

Although factors leading to nursing home entry among the mentally ill are similar to those driving entry in the general population, those with more severe mental health problems are still more likely to be admitted.

The prevalence, diagnosis and treatment of depression in dementia patients in chronic care facilities in the last six months of life

OBJECTIVE

To assess the prevalence, diagnosis and treatment of depression among dementia patients and normal controls in chronic care facilities in the last six months of life.

METHOD

We reviewed perimortal data concerning dementia severity, depressive symptoms and diagnoses, and medication use for 279 dementia patients and 24 normal controls brought to autopsy through an Alzheimer's Disease Resource Center.

RESULTS

Major depression was highly prevalent among both dementia patients and normal controls in chronic care facilities in the last six months of life. This depression was under-diagnosed by physicians. Documentation of depressive symptoms by medical support staff has improved over time. However, physician diagnosis of depression has not improved. Recognition of depression was significantly lower for patients with severe dementia. Depression was under-treated in both dementia patients and normal controls, although treatment rates may be increasing. Anxiolytics and hypnotics were often used in lieu of, or in addition to, antidepressant therapy.

CONCLUSIONS

Major depression was highly prevalent in both dementia patients and normal controls, indicating that depression is an important issue for the elderly in the last six months of life irrespective of cognitive status. Under-diagnosis of depression may be an important clinical issue. As physician diagnosis of depression has not improved with time, further physician training and/or awareness initiatives may be warranted. Depression, a treatable cause of excess morbidity and mortality, was undertreated in all groups studied. However, treatment rates may be improving. The prevalent use of anxiolytics and hypnotics for depressed patients is problematic.

State long-term care screening and assessment programs

Long-term care screening and assessment programs were designed by states to control long-term care costs and to prevent unnecessary institutionalization of Medicaid participants. This study reports data collected by telephone survey of state officials in all 50 states and Washington, D.C. on state variation in LTC screening and assessment programs. The majority of the state screening and assessment programs cover an array of LTC services but this has resulted in multiple separate screening programs for different long-term care services and eligibility groups. Only three states coordinated screening and assessment across long-term care programs by operating a single state administrative agency, using uniform need criteria and standard tools, and having automated databases (Arizona, Colorado, and Maine). The design and implementation of multiple and separate screening and assessment programs in most states may create potential barriers to client access, information about services and choice of services.