There is significant variation across states in the nursing home admission of persons with mental illness. Moreover, persons with mental illness are significantly younger than other nursing home residents and more likely to transition to long-stay status. These results highlight a need for further research to better understand the cross-state variation in nursing home admissions for persons with mental illness. This variation may relate to different nursing home and mental health factors across states.
Medicaid is the dominant payer of nursing home services, and there is considerable discretion across states in the method and generosity of payment.11
In theory, Medicaid payment policies may relate to the varying nursing home admission of persons with mental illness across states. The most common system used to case-mix adjust Medicaid payments to nursing homes is the Resource Utilization Groups (RUGs) system.12
Based on clinical characteristics, RUGs divides individuals into 44 (or 34, depending on Versions used) Medicaid payment groups. Mental illness is incorporated in two ways. First, for individuals with “clinically complex” conditions (e.g., pneumonia, dehydration, chemotherapy), a higher rate is paid in the presence of depression. Second, individuals with behavioral problems such as wandering, hallucinations and delusions can qualify for a higher rate, but only if their physical problems are minimal. In other words, for individuals with more extensive physical problems requiring assistance with multiple deficits in activities of daily living, there is no additional payment for the presence of behavioral problems. All else equal, these payment rules may incentivize the admission of less physically disabled persons with mental illness, particularly if treatments are not expensive.
The cross-state variation in nursing home admissions for persons with mental illness may also relate to state efforts to “rebalance” their long-term care systems away from nursing homes and towards home- and community-based services (HCBS). As part of the Deficit Reduction Act (DRA) of 2005, the DHHS initiated a program under which CMS has awarded grants to states totaling $1.4 billion over the five-year period 2007–2011 to provide alternatives to nursing home care. Of interest to mental health advocates is that states may not restrict access to HCBS on the basis of disability or diagnosis under the DRA. This had been a longstanding dilemma in Medicaid mental health policy.13
In efforts to rebalance long-term care, certain states have invested more heavily than others in Medicaid HCBS waiver programs.14
Clearly, some of the state investment in HCBS alternatives may create additional community-living opportunities for persons with mental illness.
As an important point, this is not to suggest that all persons with mental illness are candidates for transfer out of the nursing home. Individuals in nursing homes with chronic psychiatric conditions have greater cognitive and functional deficits, as well as more behavioral problems, when compared with community-dwelling persons with the same psychiatric condition.15
Although it is debatable as to whether nursing homes are the best institutional model to deliver services for these individuals, there are likely a small minority of patients who cannot survive outside a full-care psychiatric institution.16
However, similar to elderly nursing home residents and the recent rebalancing effort, there may be potential candidates for nursing home discharge if community mental health services were expanded.
A third potential explanation for the large cross-state variation in the admission of nursing home residents with mental illness is the state’s adherence to the PASRR requirements. PASRR involves two parts: preadmission level I and level II screens. Level I screens are used to identify Medicaid recipients applying for new nursing home admission who may have a serious mental illness (e.g., schizophrenia, bipolar disorder, or major depression). If suspected of having a serious mental illness, applicants then undergo a Level II evaluation of their physical and mental health status to verify whether they have a serious mental illness. For applicants diagnosed with a serious mental illness, an independent evaluator, with no ties to the nursing facility or State Mental Health Authority, is used to determine whether the applicant requires nursing home level care and/or whether specialized mental health services are needed.17
Although these guidelines are national, there is considerable room for discretion and interpretation in the implementation of the rules at the state level. For example, Ohio, one of the states we documented with a high rate of nursing home admissions indicating a mental illness, uses the hospital (convalescent) exemption that allows a bypass of the PASRR requirements. Individuals discharged following an acute hospital stay are able to gain admission to nursing homes for the treatment of the same condition for which they were treated in the hospital for up to 30 days, through the certification of an attending physician. In both Ohio and other states, we found a large proportion of nursing home admissions with mental illness ultimately become long-stay residents. Thus, in spite of the best intentions of the PASRR rules, a number of persons with mental illness are gaining admission to nursing homes in Ohio, and other states that use this exemption, without being screened for mental illness.
Finally, the cross-state variation in nursing home admissions indicating a mental illness may also be related to the mental health infrastructure. Although specialized state psychiatric hospitals have closed in many states, these hospitals continue to care for tens of thousands persons with major mental illnesses. Clearly, the differential presence of these hospitals across states will influence whether individuals with mental illness ultimately are admitted to nursing homes. A 1999 Supreme Court ruling on the Olmstead
case found that states have an obligation under the Americans with Disabilities Act to administer services, programs, and activities in the most integrated setting appropriate to individuals’ needs. Currently, several states have Olmstead
cases pending against them for the inappropriate admission of persons with mental illness into nursing homes. Interestingly, Connecticut, the state we estimated to have the highest rate (0.54%) of persons with mental illness (narrowly defined) in nursing homes, and Illinois, the state we estimated to have the highest rate (3.7%) of nursing home admissions with mental illness (narrowly defined), both have cases pending.18
The lawsuit against the state of Connecticut alleges that more than 200 people with mental illnesses were “needlessly segregated and inappropriately warehoused” in three Connecticut nursing homes.19
The Illinois lawsuit is a class action suit on behalf of the 5,000 state-funded individuals housed in 27 private for-profit nursing homes within the state.
We found that a high percentage (54%) of persons entering nursing homes with mental illness (narrowly defined) were between the ages of 18–64. Both mental health advocates and researchers have long pointed to an inadequate system of care and a lack of appropriate community-based residential services as major obstacles to helping adults with mental illnesses leave institutional settings and succeed in the community, and in preventing inappropriate institutionalization.20
Persons with serious mental illness face a fragmented and underfunded system of care that does not sufficiently provide the safety net needed for vulnerable individuals trying to live in less restrictive and more independent environments.21
They must negotiate multiple and distinct systems of care, including medical care, mental health care, and aging services, each with its own operating principles.22
Perhaps this is why those with persistent serious mental illness newly admitted to the nursing home were much more likely to become long-stay residents relative to other newly admitted residents. Without a critical safety net of community supports in place, persons with serious mental illness may face a substantial risk of nursing home placement at any age. There is clearly an urgent need for future research on mental health policies that facilitate community-based supports for persons with serious mental illness across the lifespan.
This analysis is limited in several ways. First, the MDS depends on assessment nurses accurately recording the information. Studies have generally confirmed the reliability and validity of these data, with some variability across nursing homes.23
If anything, one would generally expect there to be an underreporting of mental health diagnoses rather than an over-reporting. The potential under-diagnosis of mental illnesses such as schizophrenia may be related to the onset of dementia among these individuals in later life, which may mask the underlying schizophrenia.24
We do not, however, have a reason to suspect that there is any systematic variation across states in the recording of mental illness diagnoses. Second, we constructed our sample based on first-time nursing home admissions rather than a single cross-section of residents at a given point in time. As such, our data examine the flow of residents into nursing homes rather than the cumulative number of persons with mental illness receiving services. Finally, it is important to acknowledge, once again, that mental illness among nursing home admissions is defined differently relative to mental illness among the general population. In spite of these differences, we do not expect there to be systematic biases across states in calculating the proportion of persons with mental illness admitted to nursing homes.
In sum, persons with mental illness in nursing homes are a large, vulnerable and under-studied population. This paper has provided data suggesting large cross-state variation in the admission of individuals with a mental illness in the nursing home setting. Future research will need to consider the underlying reasons for this variation and the appropriateness of nursing home admission for individuals with mental illnesses.