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Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.
A high proportion of nursing home residents have a significant mental disorder, with estimates ranging from 65% to 91% (B. J. Burns, Taube, Fogel, Furino, & Gottlieb, 1990; Smyer, Shea, & Streit, 1994; Tariot, Podgorski, Blazin, & Leibovici, 1993). Dementia, as well as its behavioral and psychiatric symptoms, has long been the most prevalent mental disorder in nursing homes (Beck et al., 1998; Kamble, Chen, Sherer, & Aparasu, 2008; Krauss & Altman, 1998; Magaziner et al., 2000; Magaziner, Zimmerman, Fox, & Burns, 1998). However, over the past decade, the mix of residents with mental illness and dementia in nursing homes has changed. Recent data indicate that the proportion of new nursing home admissions with mental illness other than dementia, including major depression and serious mental illness, such as schizophrenia and other psychotic disorders, has overtaken the proportion with dementia only. Of the 996,311 persons newly admitted to U.S. nursing homes in 2005, 19% (N = 187,478) were admitted with mental illnesses other than dementia, whereas 12% (N = 118,290) had dementia only (Fullerton, McGuire, Feng, Mor, & Grabowski, 2009).
Despite the high prevalence of mental illness other than dementia in nursing homes, nursing home staff are often ill equipped to serve residents with mental illness. An early study suggested half of nursing homes did not have access to adequate psychiatric consultation, and three quarters were unable to obtain consultation and educational services for behavioral problems (Reichman et al., 1998), and the need for improved access to and quality of mental health services within nursing homes remains a prominent concern today not only among administrators, clinicians, and advocates but also for policy makers, payers, and survey and enforcement systems (Streim et al., 2002).
The aim of this review is to provide a summary of the research literature on the quality of mental health care for nursing home residents with common mental illnesses other than dementia-related psychiatric disorders. For the purpose of this review, we define “mental illness” as mood disorders (e.g., depression, bipolar disorder), psychotic disorders (e.g., schizophrenia, schizoaffective disorders, delusional disorders), anxiety disorders (e.g., generalized anxiety disorders, posttraumatic stress disorder), and other mental illnesses described in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994), excluding dementia, psychiatric and behavioral symptoms of dementia, delirium, and other psychiatric conditions secondary to a medical disorder.
The treatment of individuals with mental illness has been a large part of nursing home care since the early days of the deinstitutionalization movement (Sherwood & Mor, 1980). With the accelerated downsizing and closure of state psychiatric hospitals during the 1960s and 1970s spurred on by deinstitutionalization policies, many persons with mental illness were transferred to nursing homes and other residential settings (Carling, 1981; Kruzich, 1986; Schmidt, Reinhardt, Kane, & Olsen, 1977). It is estimated that the number of elderly persons in psychiatric hospitals decreased by about 40% during that period, while the mentally ill in nursing homes increased by more than 100% (Institute of Medicine, 1986). Even states that developed comprehensive community mental health services were often ill equipped to provide community-based alternative placements for persons who had lived for many years in state-run psychiatric facilities (Bartels & Drake, 2005). Thus, nursing homes became the de facto destination for individuals with mental illness. Although many of these individuals with mental illness who are admitted to nursing homes have been elderly, this phenomenon has also occurred among middle-aged individuals (Fullerton et al., 2009). Medicaid beneficiaries with schizophrenia aged between 40 and 64 years are four times more likely to be admitted to a nursing home compared with Medicaid beneficiaries in the same age group without a mental illness (Andrews, Bartels, Xie, & Peacock, 2009).
The growing number of persons with mental illness entering nursing homes greatly strained the existing systems of care. Increasing reports of grossly inadequate nursing home care and resident abuse surfaced in the years following deinstitutionalization (Accordino, Porter, & Morse, 2001; Shadish & Bootzin, 1984). In a 1986 report, the Institute of Medicine cited both the inappropriate use of antipsychotic drugs and physical restraints, as well as inadequate treatment of depression in nursing homes. In response, when Congress enacted the Nursing Home Reform Act as part of the Omnibus Budget Reconciliation Act (OBRA) of 1987, it included regulations designed to address the unmet mental health needs of nursing home residents.
With the passage of this landmark legislation, criteria were established for Medicare- or Medicaid-certified nursing homes to use in admitting and retaining persons with mental illness. The legislation requires that nursing homes must “ensure that a resident who displays mental or psychosocial adjustment difficulties receives appropriate services to correct the assessed problem” (Health Care Financing Administration, 1991), including treatment not otherwise provided by the state (Administration on Aging, 2001). In addition, the law prohibits the use of unnecessary physical restraints and provides guidelines for the use of antipsychotic medications. The regulations require that periodic evaluations of nursing home residents be conducted with a standardized resident assessment instrument designed to enhance the recognition of mental and behavioral symptoms that should be addressed in the treatment plan (Health Care Financing Administration, 1992). All together, this federal mandate aims to improve the detection and treatment of mental illness in nursing homes.
Despite more than 20 years of nursing home reforms and federal legislation intended to address the needs of residents with psychiatric disorders, significant problems in the quality of mental health care in nursing homes persist. Advocates and providers have been outspoken about the critical need for policies that support quality mental health care in nursing homes (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003a), and research agendas appear increasingly focused on examining mental health service use and unmet need in the nursing home (Bartels, Mueser, & Miles, 1997; B. J. Burns, Scott, Burke, & Kessler, 1983; Levin et al., 2007; Sakauye & Camp, 1992). In a 2003 consensus statement, the American Geriatrics Society and the American Association for Geriatric Psychiatry offer recommendations for policies in support of quality mental health care in U.S. nursing homes, especially in rural and publicly financed nursing homes. Bartels, Horn, et al. (2003) concluded from a review of the literature on models of mental health services in nursing homes that more well-designed intervention and services research studies are needed to form the basis of changes in nursing home regulations and reimbursement policies.
To date, there have been no systematic and critical reviews of the current literature on quality of care measures and correlates of care for nursing home residents with mental illnesses other than dementia. However, the primary clinical symptoms, service needs, and course of dementia are different from other mental illnesses, and thus, the quality of care provided to residents with dementia cannot be generalized to those with other mental disorders. For example, dementia is primarily defined by a progressive cognitive impairment with associated medical and physical care needs. Behavioral symptoms are secondary, occurring in 30% to 40% of persons in the early and middle phase of the illness (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003b; Bartels & Colenda, 1998; Bartels, Miles, Dums, & Levine, 2003). In contrast, psychiatric symptoms are a primary and persistent need for persons with mental illness in nursing homes, with varying degrees of medical and cognitive impairment as a secondary or associated need. These needs may require specialty mental health services delivered through specific mental health service models that have been developed to provide care to this population (American Geriatrics Society & American Association for Geriatric Psychiatry, 2003a; Bartels, Moak, & Dums, 2002). Recent data on the large influx of nursing home admissions with mental illnesses other than dementia (see Fullerton et al., 2009) underscores the urgent need to address the specialized mental health care needs of this subgroup of nursing home residents. We offer a critical appraisal of the available research on quality of care for nursing home residents with mental illness other than dementia in an effort to help illuminate significant knowledge gaps, highlight progress to date, and ultimately provide direction for future research that will inform the development of clinical and policy interventions to improve care for this vulnerable population.
This literature review has two goals: first, to review the different nursing home mental health quality measures used in the literature, and second, to document the various resident- and facility-level factors related to these measures. Toward the first objective, perhaps the most widely accepted construct for assessing care quality was posited by Donabedian (1966). His framework has been applied extensively to both the domain of general medical quality and to more specific areas such as health maintenance organizations, mental health, and nursing homes (Davis, 1991). As a basic framework for guiding quality improvement efforts, Donabedian's (1966) conceptual framework has been used to study mental health care quality in a variety of service delivery settings and contexts (Brown, 2005; Ravelli et al., 2003; Yakimo et al., 2004). Donabedian (1966) formulated a definition of quality based on the triad of structural factors, process-of-care variables, and outcomes or end results of that care.
Toward our second objective, we assume a basic model of the nursing home's provision of quality care to residents with mental illness, which incorporates several factors including resident welfare, provider norms, and financial incentives. These factors encompass factors specific to residents with mental illness (e.g., presence of psychiatric services) and factors more general to the entire nursing home population (e.g., ownership of the facility). Specifically, resident welfare relates to sociodemographics and health characteristics. For example, certain mental health conditions will necessitate certain care practices. The resident's welfare will also be affected by the number of specialized nurse staff and the availability of mental health treatments. Provider norms are influenced by local practice patterns. For example, the norms of care may be very different in urban versus rural areas. Last, financial incentives relate to the generosity of nursing home payment and the mix of residents with different payment sources in the facility (Grabowski, 2001; Mor, Zinn, Angelelli, Teno, & Miller, 2004). Moreover, the ownership status of the facility (e.g., profit status, chain affiliation) will also affect how the facility balances objectives such as resident welfare and the cost of additional services (Hillmer, Wodchis, Gill, Anderson, & Rochon, 2005).
To highlight the scope of the population, we first provide a detailed review of past and current literature documenting the prevalence of mental illness in the nursing home. We then apply our conceptual framework in a review of the literature on nursing home mental health quality measures and the various resident- and facility-level factors related to these measures.
To ensure the review contained a comprehensive assessment of all aspects of quality of care in nursing homes for persons with major mental illness other than dementia, an electronic literature search of the PubMed database was conducted. The studies included in this review were restricted to only those written in English, conducted in the United States between 1980 and 2008, and that were focused on mental health quality measures for persons of all ages. All references associated with these studies were reviewed to identify additional relevant studies.
We conducted a search of the PubMed database using the search terms nursing homes and mental illness, linked with each of the following terms (the number of publications found is expressed in parentheses): quality of care (114), preadmission screening (5), antipsychotic medications (14), mental health deficiency citations (0), psychiatric hospitalizations (52), psychiatric consultations (13), facility characteristics (34), nursing staff ratio (19), locality (14), patient characteristics (95), service use (90), and ADL limitations (279), for a total of 729. An additional search was conducted through PubMed regarding the prevalence of the different types of mental illnesses found among nursing home residents. We also searched for relevant reports from the National Institute of Mental Health, Substance Abuse and Mental Health Services Administration, other government agencies, and research organizations.
A manual review was performed to eliminate publications without a clear research focus and those that involved dementia-related care. Studies pertaining to mental health quality of care for persons in other care settings outside the nursing home, such as home or community-based care, were excluded. Inclusion criteria for this review included (a) publication in a peer-reviewed journal and (b) a research study relating to variables linked to mental health quality of care for nursing home residents. Ultimately, we identified 35 publications examining quality of care for nursing home residents with a mental illness. We also identified five additional studies providing prevalence estimates of mental illness in nursing home residents.
Relatively few studies document the overall numbers of individuals with mental illness living in nursing homes (see Table 1). Key distinctions in the literature are whether the studies sample existing residents versus new admissions and whether the data identify primary versus secondary mental illness diagnoses. Given the high degree of physical disability and disease in the nursing home population, both primary and secondary diag-noses of mental illness are useful indicators of the prevalence of mental illness in this population. Early studies using the 1977, 1985, and 1999 waves of the National Nursing Home Survey (NNHS) estimated that the prevalence of nursing home residents with chronic mental illness or dementia was roughly 50% (Goldman, Feder, & Scanlon, 1986; Mechanic & McAlpine, 2000). The NNHS also indicated that the number of residents with a primary mental illness diagnosis—excluding residents with primary or secondary dementia-related condition or mental retardation—decreased from approximately 101,000 (6.8%) in 1985 to 70,000 (4.5%) in 1995 (Mechanic & McAlpine, 2000).
Two recent efforts have attempted to update these estimates. First, Bagchi, Verdier, and Simon (2009) used three different data sources from 1999 to estimate the number of nursing home residents with a mental illness diagnosis. The sample was restricted to those individuals with Medicaid as a primary or secondary payer. Mental illness diagnoses included schizophrenia, depression, anxiety disorder, or bipolar disorder (ICD-9 codes 295–302 and 306–314). Estimates of the percentage of nursing home residents with a primary diagnosis of mental illness varied from 4.4% in Medicaid claims to 7% in the NNHS. When individuals with a secondary mental illness diagnosis were also included, the estimates of mental illness were 7% in Medicaid claims, 33.1% in the NNHS, and 46% in the minimum data set (MDS). Using a sample of all “first-time” nursing home admissions from the MDS in 2005, Fullerton et al. (2009) found that 24% had a mental illness as defined by schizophrenia, bipolar disorder, depression and anxiety disorder. Using a similar definition of mental illness, Grabowski, Aschbrenner, Feng, and Mor (2009) found significant cross-state variation in the prevalence of mental illness among newly admitted nursing home residents.
Most prior research on specific mental illnesses other than dementia in the nursing home has focused on depression (both depressive symptoms and major depression) or serious mental illnesses such as schizophrenia and bipolar disorder. Depression is the most common mental illness among nursing home residents, with rates as high as three to five times that of older persons living in the community (Blazer, 2003). Estimates of the prevalence of depression in nursing homes range from 6% to 26% for major depression and from 11% to 50% for depressive symptoms (Jongenelis et al., 2003). In the Medical Expenditure Panel Survey–Nursing Home Component, chart diagnoses or MDS assessment records suggested the prevalence of depression was 20.3% among noncomatose nursing home residents (R. N. Jones, Marcantonio, & Rabinowitz, 2003). The results of a 4-year, multistate study showed that 10.9% of the 428,055 nursing home residents had depression documented in the MDS assessment form between 1992 and 1996 (Brown, Lapane, & Luisi, 2002). An analysis of the MDS also revealed that between 1999 and 2005 the prevalence of depression among newly admitted nursing home residents increased from 11.0% to 15.5% (Fullerton et al., 2009).
Among existing nursing home residents, the 1995 NNHS indicated that 7.1% had schizophrenia and related disorders, while the Medical Expenditure Survey for 1996 suggested 5.9% (Mechanic & McAlpine, 2000). Using nursing home MDS assessments from 2005, Grabowski et al. (2009) found that 2.7% of new admissions nationally indicated a schizophrenia or bipolar diagnosis. However, there was large cross-state variation with rates of schizophrenia or bipolar diagnosis among new nursing home admissions ranging from 1.2% (Wyoming) to 3.4% (Missouri).
Despite the high prevalence of mental illness in the nursing home, most nursing homes do not have access to mental health providers with training in psychiatry and mental health treatment. In a retrospective study of Medicare Part B claims for mental health care among nursing facility residents, Shea, Russo, and Smyer (2000) reported that 80% of nursing home residents with some form of mental illness did not receive mental health visits from a psychiatrist, clinical psychologist, or licensed clinical social worker. In contrast, a study of unmet need among elderly public housing residents found that 58% of those in need of mental health care had unmet needs (Black, Rabins, German, McGuire, & Roca, 1997), and a more recent study of homebound elderly found that two thirds with clinically significant depression had not received treatment (Sirey et al., 2008). A survey of practitioners suggests that psychiatric services in nursing homes, if they are available, are commonly provided by psychiatric consultants who are not full-time members of the nursing home staff (Moak, Borson, & Jackson, 2000). Similar to other medical specialists, they provide care as needed, coming to the nursing home only when needed by a specific resident. Both clinicians and administrators agree that the traditional “as-needed” consultation models are inadequate to address the many needs of nursing home residents and staff (Moak et al., 2000; Reichman et al., 1998).
A potentially important resource for the detection and treatment of mental illness in nursing home residents are frontline providers such as certified nursing assistants (CNAs; Glaister & Blair, 2008). However, nurse training focuses on medical care, with minimal attention to mental and behavioral health care (Beck, Doan, & Cody, 2002). Current federal regulations require just 75 hours of preemployment training and 12 hours of continuing education annually for CNAs working in facilities that participate in Medicare and Medicaid programs. Given the short period of time devoted to overall training and the complexity of mental illness, it is not surprising that CNAs often report a lack of training in the management of residents with mental illness and in effectively communicating about such residents (Mercer, Heacock, & Beck, 1993).
In a systematic review of the research literature on effective models of mental health services provided to nursing homes, Bartels, Miles, et al. (2003) identified three types of service models with outcome data: psychiatrist-centered, nurse-centered, and multidisciplinary team models. Based on a limited research literature, the authors concluded that the least effective model involved a traditional consultation–liaison service in which a lone clinician provided a one-time, written consultation on an as-needed basis. For example, a randomized British trial of psychogeriatric consultation model of care conducted by Ames (1990) found no difference between consultation services and usual care. Although this study is somewhat dated and based on a sample of nursing home residents from the United Kingdom, it underscores the inherent limitations of conventional models of consultation. Only one third of treatment recommendations were followed, most likely accounting for the lack of effectiveness of this model found in this study. Multidisciplinary team approaches were favored as preferred service models, in conjunction with a “train the trainer” nurse specialist model. Of note, effective models of nurse training that focused on identifying and addressing mental health needs of nursing home residents were associated with improved staff knowledge and performance, as well as decreased staff turnover (Bartels et al., 2002).
In response to documented problems in the appropriateness and quality of care for individuals with mental illness in nursing homes, regulatory reforms focusing on preadmission screening and evaluation of mental health care needs were introduced. Implemented in 1990, the OBRA 1987 regulations mandated a Pre-Admission Screening and Annual Resident Review (PASRR) to identify nursing home applicants and residents with mental illness. Under the PASRR program, nursing facilities are prohibited from admitting any individual with a serious mental illness unless the State Mental Health Authority determines that nursing home level care is appropriate for that individual (Linkins, Lucca, Housman, & Smith, 2006).
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 serious mental illness, applicants then undergo a Level II evaluation of their physical and mental health status to verify whether they have serious mental illness. For applicants diagnosed with 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 (Linkins et al., 2006).
Research has generally suggested that PASRR has not been effective at ensuring the appropriate placement and treatment of persons with mental illness. For example, according to a report by the Office of Inspector General (2001), fewer than half of nursing home residents with a serious mental illness receive appropriate preadmission screening. Linkins et al. (2006) found that the PASRR process does not ensure that nursing facility residents receive proper mental health services. Although these authors agree that the PASRR legislation does help to identify mental illness, they doubt its ability to ensure the delivery of mental health services beyond standard case consultation and medication therapy. As further evidence of PASRR's inefficacy, a study by Snowden and Roy-Byrne (1998) found compliance with only 35% of written treatment recommendations for mental health services in Level I screens and only 29% compliance with recommendations for alternative placements.
Using a sample of facilities from four unidentified states, Linkins et al. (2006) observed significant cross-state variation in the administration of Level II screens for individuals with disabling mental illness. The administration of required Level II screens for persons identified to have a mental illness ranged from 0% to 60% of residents (Linkins et al., 2006). PASRR has also been criticized because it does not take “comorbidity” into account, and it does not assure that active treatment alternatives are available elsewhere (Smyer, 1989).
A potential unintended consequence of the PASRR and other assessments includes use by nursing homes to identify and deny admission to those with the most serious mental illnesses. These individuals have much higher costs relative to other nursing home residents, yet corresponding higher Medicaid payment rates typically are not provided for residents with mental illness. Mechanic and McAlpine (2000) observed significant changes in admission patterns in the periods before and after the introduction of the PASRR requirements. In 1985, close to 67,000 residents were admitted to nursing homes from mental health facilities; and in 1995, that number fell to less than 27,000. In 1995, fewer than 8,000 severely mentally ill residents with no physical comorbidity were in nursing homes, an approximate 80% reduction from 1985. The increase in dementia and depressive diagnoses between 1985 and 1995 and the decline of schizophrenia-related diagnoses show that the screening process may have enabled nursing homes to identify better which individuals with serious mental illness are most in need of nursing home care. However, it is also important to acknowledge that there were other trends over this same period that may have influenced admissions (e.g., alternative settings such as assisted living), and the most recent data suggest an increase in nursing home admissions for persons with mental illness (Fullerton et al., 2009).
In addition to federal legislation under PASSR, consumer-based initiatives subsequently stimulated reforms aimed at reducing the use of nursing homes as the primary setting of long-term mental health care for persons with serious mental illness. In June 1999, the U.S. Supreme Court ruled that it is a form of discrimination under the Americans with Disabilities Act to institutionalize a disabled person who wishes to live in the community when the individual is capable of benefiting from living in a community-based setting. Known as the Olmstead decision (Williams, 2000), this case established that unnecessary and undesired institutionalization constitutes discrimination for persons with mental disabilities because it severely diminishes the individual's ability to interact with family and friends, work, and make a life for himself or herself.
Despite PASRR and the Olmstead ruling, controversy persists with respect to the appropriate setting of care for middle-aged and older adults with serious mental illness (Bartels, Brewer, Mays, & Rawlings, 2005; Bartels & Van Citters, 2005). The placement of individuals with serious mental illness is dependent on the existence of physical comorbidities, in which case the nursing home setting may be more appropriate. Adults suffering only from serious mental illness may find alternative care settings more beneficial and therapeutic for their recovery and be better suited for home- and community-based care. For example, one study found that two fifths of nursing home residents with serious mental illness preferred community-based settings. Similarly, clinicians judged the community to be most appropriate for half of older adult nursing home residents with serious mental illness. Interestingly, clinicians strongly favored group homes as the best option for community living, whereas persons with serious mental illnesses identified independent living as best, indicating some discord in consumer and provider preferences (Bartels, Miles, et al., 2003).
The MDS is a federally mandated assessment tool for clinical evaluation of all residents in Medicare- or Medicaid-certified nursing facilities. The MDS is incorporated into the Resident Assessment Instrument, providing a comprehensive assessment resident functioning and directs nursing facility staff to identify and address physical and mental health problems. Despite the comprehensive nature of this tool, the embedded mental health evaluation measures have been criticized as lacking adequate reliability and validity to accurately inform and evaluate treatment. Wagenaar et al. (2003) conducted a study on the assessment tools that nursing homes use to measure depression comparing the mandated MDS with validated clinical depression screening instruments including the Geriatric Depression Scale (GDS), the Center for Epidemiologic Studies Depression Scale, and the Cornell Scale for Depression and Dementia. They found that the GDS was the only assessment tool that the panel of psychiatrists and counselors overwhelmingly (~90%) endorsed as practical and preferred in the identification of clinically significant depression. In addition to limited utility of the MDS for depression, significant limitations have been identified in the value of this mandated instrument in evaluation of symptoms and functional characteristics of older residents with schizophrenia (Bowie, Fallon, & Harvey, 2006).
Unfortunately, the use of the MDS to quantify prevalence and incidence rates of mental illness in nursing homes may be limited because of unintended incentives for providers to both under- or overreport the presence of mental illness in administrative data such as the MDS used in many states to determine case mix–adjusted Medicaid payments. In addition, the MDS is also a part of the federal effort to monitor quality and provide Web-based profiles to the public to inform choice in nursing homes (e.g., the Nursing Home Compare Web site). Ideally, these two forces balance one another out in that facilities that overreport case mix will be identified as outliers on certain quality indicators, and facilities that underreport quality problems will reduce their case mix–adjusted payment (Zimmerman et al., 1995). However, a recent study found poorer quality based on four mental health quality indicators (prevalence of behavioral symptoms, prevalence of symptoms of depression, prevalence of symptoms of depression with no antidepressant therapy, incidence of cognitive impairments) within states that used the MDS for determining Medicaid reimbursement (Bellows & Halpin, 2008).
The appropriate use of psychiatric medications in nursing homes has been a long-standing quality of care issue. Of note, the majority of studies and regulatory efforts have focused on the use of sedating medications (i.e., antipsychotic and sedative-hypnotic agents) used to address challenging behaviors associated with Alzheimer's disease and related cognitive impairment disorders. Inappropriate prescribing has been identified as that aimed at addressing behavioral symptoms by using sedating medications, partly to compensate for poor staffing levels (Hughes & Lapane, 2005). Concerns about the possible misuse of antipsychotic medications in nursing homes led to the development of a special section of the OBRA regulations in order to restrict their use (Llorente et al., 1998). A regulation specific to psychiatric medication states that “the resident has the right to be free from any psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident's symptoms” (Health Care Financing Administration, 1995). Early reports following the implementation of OBRA suggested that this regulatory mandate has resulted in an overall reduction in the use of psychoactive agents in nursing homes (Lantz, Giambanco, & Buchalter, 1996). Today, as part of the Medicare and Medicaid certification process, government surveyors assign deficiency citations to facilities who fail to use more appropriate measures of treatment outside that of antipsychotics, such as psychosocial interventions.
Using data from the Medicare Current Beneficiary Survey and other sources, a recent study suggests that antipsychotic drug prescriptions in nursing homes are increasing, and approximately 27.6% of Medicare beneficiaries in nursing homes received an antipsychotic prescription during the study period (Briesacher et al., 2005). Only 41.8% of these residents received antipsychotic therapy in accordance with nursing home prescribing guidelines; 23.4% of residents had no appropriate indication, 17.2% had daily doses exceeding recommended levels, and 17.6% had both inappropriate indications and high dosing (Briesacher et al., 2005). In a related study using the 2004 NNHS, Stevenson et al. (in press) found that 40% of nursing home residents using an antipsychotic medication had no appropriate indication for such use, while 42% of residents who took benzodiazepines had no appropriate indication.
Of importance, despite the widespread use of antipsychotic medication in nursing homes, clinical trials research studies show modest effectiveness at best and underscore significant potential side effects. For example, the NIMH Clinical Antipsychotic Trials in Intervention Effectiveness Alzheimer's Disease Study evaluated the outcomes for 421 individuals with Alzheimer's dementia who were prescribed antipsychotic medications or placebo for delusions, agitation, or aggression. Although antipsychotics were somewhat effective, their overall effectiveness was offset by adverse events resulting in physicians discontinuing the medication (Karlawish, 2006; Schneider, Dagerman, & Insel, 2005). These findings have raised important questions on the appropriate use, comparative efficacy, and relative safety of second-generation antipsychotic agents in the treatment of older adults with Alzheimer's disease. Finally, increased rates of adverse cerebrovascular events and mortality in older adults with Alzheimer's (Schneider et al., 2005) as well as increased incidence of cardiometabolic risk factors and sudden death especially associated with second-generation antipsychotics are challenging clinical providers in nursing homes to consider the use of behavioral and environmental interventions.
Of particular relevance for this review, the primary goal of research and regulatory measures has been to address the overuse of antipsychotic medications and sedative hypnotic medications for challenging behavioral symptoms occurring in dementia and for other individuals without a primary psychiatric diagnosis. However, many reports on prescribing trends have failed to differentiate prescribing for mental health disorders other than dementia. The use of antidepressant medications for a diagnosis of depression is an evidence-based practice and quality indicator for appropriate treatment of a serious mental illness. Recent studies on the detection and treatment of depression in nursing home residents suggest substantial rates of antidepressant prescribing over the past decade (Nishtala, McLachlan, Bell, & Chen, 2009; Rigler et al., 2003). Although antipsychotic medications are an evidence-based treatment for serious mental illnesses such as schizophrenia and schizoaffective disorder, reports have commonly characterized the use of these agents as “tranquilizers” and “sedatives.” Overall, research and policy have failed to differentiate inappropriate from therapeutically indicated use of antipsychotics for the increasing number of residents in nursing homes with serious mental illness.
Nonpharmacological therapeutic approaches, such as “talk therapies,” on individual residents who suffer from mental illness are understudied, underutilized, and generally associated with fewer side effects compared with psychiatric drug regimens (Bharucha, Dew, Miller, Borson, & Reynolds, 2006). Reminiscence group therapies, the most commonly investigated psychotherapeutic modality in long-term care settings (Goldwasser, Auerbach, & Harkins, 1987), have been shown to significantly decrease depression scores, as measured by the GDS and the Beck Depression Inventory (Cook, 1991; Haight, Michel, & Hendrix, 1998; E. D. Jones, 2003). There were also documented improvements in psychological well-being, self-esteem, and life satisfaction (Frey, Kelbley, Durham, & James, 1992).
Other nonpharmacological therapeutic modalities such as control-relevant interventions, problem solving, and cognitive behavioral therapies have also been shown to decrease depression symptoms and improve the quality of life for residents in the nursing home (Zerhusen, Boyle, & Wilson, 1991). Potential serious complications of pharmacological therapy for frail elders with multiple comorbidities and polypharmacy suggest a strong need for methodologically rigorous trials of psychotherapy in the long-term care setting, especially in combination with pharmacotherapy (Bharucha et al., 2006).
Mental health consultations in nursing homes differ greatly from those conducted in the community because nursing home residents are often both physically and cognitively impaired, have impaired judgment and communication skills, receive infrequent visits from their practitioner, and have experienced relocation from their personal residence (Gupta & Goldstein, 1999). Prior to the implementation of OBRA 87, only 5% of nursing home residents received mental health treatment within a 1-month period (W. J. Burns, 1998; Smyer et al., 1994), and only 10% of residents with a known diagnosis of depression received treatment (Heston et al., 1992). A subsequent study conducted after the implementation of OBRA 87 found that the proportion of nursing home residents receiving mental health treatment within a 1-month time frame rose to 20%, perhaps reflecting a greater awareness of mental health needs (Fenton et al., 2004).
In any 6-month period, roughly 25% of nursing home residents are hospitalized for mental and/or physical health disorders, and 13% to 63% of nursing home residents are hospitalized per year (Becker, Andel, Boaz, & Howell, 2009; Castle & Mor, 1996; Grabowski, Stewart, Broderick, & Coots, 2008). Nursing home residents with dementia complicated by mixed agitation and depression have the highest rate of acute hospitalization compared with other groups (15.6% over 3 months), compared with only 9.4% for residents without a diagnosis of dementia (Bartels, Horn, et al., 2003). Although hospitalizations may have beneficial effects, they may also increase the health risks of an already vulnerable population. One study suggests that psychiatric hospitalization significantly benefits nursing home residents with and without dementia who are admitted with severe behavioral problems by decreasing general psychiatric symptoms, depression, violence, and agitation (Kunik et al., 1996). However, psychiatric problems that could be addressed or avoided with timely mental health services all too often worsen until hospitalization is required. Other studies suggest psychiatric hospitalizations expose residents to multiple health risks such as delirium, relocation stress syndrome, and increased mortality (Becker et al., 2009; Mallick & Whipple, 2000; Ouslander, Weinberg, & Phillips, 2000).
Deficiencies are evaluations of poor quality made by state surveyors under the federal nursing home certification regulations. Under the direction of the Centers for Medicare & Medicaid Services (CMS), state surveyors use 175 consolidated measures encompassing structural, procedural, and outcome measures of quality to assign deficiencies. When a facility fails to meet one of these standards, a deficiency is cited. In a study of mental health deficiency citations for nursing homes, Castle (2001) found that of 17,000 Medicaid-certified nursing home facilities, 1% (155 facilities) had at least one deficiency citation for assessment of mental status, 10% (1,349) had at least one deficiency citation for assessment of cognitive status, and 21% (2,851) had at least one deficiency for inappropriate treatment of mental conditions (Castle, 2001). From 1997 to 2003, 15.9% of facilities received deficiency citations for failing to include mental/psychosocial status in resident assessments, and 7.9% received deficiencies for inappropriate treatment of residents with mental/psychosocial difficulty, such as the inappropriate use of chemical or physical restraints (Castle & Myers, 2006).
As discussed in our conceptual framework section, factors related to a resident's welfare, provider norms, and financial incentives will all influence the quality of care provided to nursing home residents with mental illness. Table 2 summarizes the data and methods used in a subset of studies evaluating predictors of quality care for nursing home residents with mental illness. Only those studies that examine the association between factors related to the resident's welfare, provider norms, and financial incentives are included. Importantly, these studies range in the timeliness of the data, the generalizability of the study samples, and the quality of the methods.
Across numerous studies, resident characteristics have been found to predict the quality of care received in a nursing home environment. For example, residents younger than 65 years were more than three times more likely to undergo psychiatric hospitalizations (Becker et al., 2009). Resident age is also associated with mental health quality: A strong inverse association is present between age and treatment by a mental health specialist, with each year reducing the odds ratio for treatment by 6% (Shea et al., 2000). A nursing home resident with depression has less than a 10% probability of being seen by a mental health professional (Smyer et al., 1994).
The socioeconomic characteristics of nursing home residents also have significant implications for their mental health treatment. Greater educational achievement was associated with higher odds of receiving treatment for depression (Levin et al., 2007) but remained insignificant for other processes of care, such as the likelihood of psychiatric consultation (Fenton et al., 2004). Research has also indicated that Black nursing home residents were significantly less likely to receive depression treatment from a mental health professional (Levin et al., 2007).
The nursing staff is potentially an important predictor of quality mental health care because it determines how much time a resident with mental illness will receive appropriate counseling and care (Hughes, Lapane, & Mor, 2000). With regard to antipsychotic medications, increased nursing staff was found to decrease the use of psychiatric medications (Hughes et al., 2000; Svarstad, Mount, & Bigelow, 2001). Similarly, facilities were 6% less likely to receive a deficiency citation in the context of a 10% increase in registered nurse staffing levels (Castle & Myers, 2006), although higher levels of licensed practical nurses and nurse aides were significantly associated with a higher likelihood of receiving a deficiency citation. The use of mental health providers was not significantly related to the receipt of a deficiency (Castle & Myers, 2006).
Location within a metropolitan area increased the likelihood of receiving mental health treatment fivefold (Shea, Streit, & Smyer, 1994), while residents in rural areas were less likely to receive treatment and were less likely to receive a psychiatric consultation compared with urban residents (12% vs. 22%; Fenton et al., 2004). Reichman et al. (1998) found that the frequency of psychiatric consultations increased linearly from rural to suburban to urban facility locations and from small to medium to large facility sizes; smaller facilities and those in rural areas continue to be under-served by psychiatric consultants. In future research, it will be important to disentangle these cross-area differences from variation because of the supply of clinicians as opposed to variation in practice styles among clinicians.
Although the broader health services literature suggests poorer quality at for-profit nursing homes (Hillmer et al., 2005), studies of mental health quality have generally found few significant differences by ownership status. For example, in analyses of MDS assessments from a subset of states, two separate studies failed to obtain a statistically meaningful difference in the treatment of depression across ownership types (Lapane & Hughes, 2004; Levin et al., 2007). Similarly, a study of Florida nursing homes showed no significant difference in psychiatric hospitalizations by ownership (Becker et al., 2009), and analyses of the 1987 National Medical Expenditure Survey suggested no significant difference in specialist mental health services use across nonprofit and for-profit nursing homes. Using a range of structure, process and outcome measures of quality, Castle and Shea (1998) also found little consistent evidence that for-profit nursing homes provided poorer quality of care to residents with mental illness.
Although many nursing home residents are dually eligible for Medicare and Medicaid, the majority of short-stay rehabilitative residents are paid for by Medicare, while many long-stay chronically ill residents are covered by Medicaid. In addition, because Medicaid eligibility can include disability (including psychiatric disability), low-income status, or both disability and low-income status, a greater prevalence of mental illness is present in high-Medicaid facilities. These factors create the context for a high prevalence of psychiatric disorders and, in turn, a greater potential for mental health quality of care problems. For example, nursing homes with a majority of residents on Medicaid are associated with higher rates of psychiatric hospitalization (Becker et al., 2009). Similarly, facilities with a majority of Medicaid residents were more likely to demonstrate higher rates of antipsychotic medication prescription (Hughes et al., 2000).
The literature on the treatment of persons with mental illness in nursing homes provides several important takeaway points. First, a high prevalence of individuals with a mental illness other than dementia are present in nursing homes. Second, along a range of different measures of quality, the treatment of mental illness is often substandard. Finally, this poor quality of care is often associated with different factors related to the resident's welfare, provider norms, and financial considerations. In particular, these factors include the age, gender, education level, and race of the resident and the nursing staff ratio, locality, and payer mix of the facility.
Although the overall quality of nursing home care is often substandard and many of these same factors predict poor quality care more generally, the existing literature supports the idea that the production of mental health care in nursing homes is somewhat unique relative to other dimensions of care in these facilities. Specifically, nursing home residents with mental illnesses have unique care needs, unique indicators of quality, and unique predictors of this quality. A key question for policy makers is whether the needs of nursing home residents with mental illness are exceptional, and if so, should policymakers pursue policies that continue to integrate the care of these residents in mainstream nursing homes? Arguments for integration stress that mental illness and mental health care are like other medical conditions, and care should be organized and paid for in the same way. Furthermore, integration of psychiatric and other health care facilitates clinical coordination in the treatment of physical and mental illness. Arguments for exceptionalism are based on a distinction drawn between “mental” illnesses and their treatment and other types of “physical” conditions and care. For example, many mental health professionals and advocates have argued that psychiatric hospital care should be treated as an “exception” and not be paid via the diagnosis-related group system used by Medicare to reimburse hospitals, both because the measurement of mental disorders is less precise and because of the greater sensitivity of mental health care to financial incentives in prospective payment (Jencks, Goldman, & McGuire, 1985). Furthermore, specialization may be associated with expertise in management of a disease.
Although some nursing homes specialize in the treatment of major mental illness, the majority of persons with mental illness have been cared for alongside other chronically disabled nursing home residents largely consisting of individuals with cognitive impairment disorders. As a counterexample, it is quite common to have special care units in nursing homes devoted to the treatment of dementia. Published studies examining the implications of these dementia units on quality of care are numerous (Arling & Williams, 2003; Gruneir, Lapane, Miller, & Mor, 2008; Holmes, Teresi, & Kong, 2000). However, no corresponding literature considering the implications of specialization on the treatment of mental illness exists. Current federal policy discourages specialization through the Institutions for Mental Disease Exclusion, which restricts Medicaid beneficiaries aged 22 to 64 years from receiving Medicaid services of any kind in facilities that specialize in mental health care. The exclusion for older beneficiaries limits the practical impact of the Institutions for Mental Disease rule for the nursing home sector, but a byproduct of this rule is the incentive to integrate persons with mental illness into “mainstream” nursing home care. Nevertheless, some states do have qualified units of psychiatric hospitals as nursing home facilities.
Future research will need to directly test the potential benefits and harms, if any, of caring for residents with mental illness in a specialized environment. In addition, development of home- and community-based long-term care alternatives that specifically address the psychiatric and medical care needs of older adults with serious mental illness are needed. In the meantime, we can use the results of our review to consider several other areas in which policy makers encounter the tension between integration and exceptionalism in mental health policy for nursing home residents.
Most nursing home residents rely on Medicare to cover their health care services, regardless of the payer of their nursing home services. A recent set of policy recommendations by the American Geriatrics Society and the American Association for Geriatric Psychiatry (2003a) to support quality mental health care in U.S. nursing homes criticized Medicare for its lack of adequate coverage for Part B services by psychiatrists, nurse practitioners, physician assistants, psychologists, and social workers under psychiatric billing codes. As our review of the literature suggests, the increased presence of nurse staff and mental health professionals is associated with better quality among nursing home residents with mental illness. Congress recently passed the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, which provides parity in coverage across medical and mental health services. Prior to MIPPA, beneficiaries faced a 50% copayment rate for outpatient psychotherapy and services furnished by nonphysician mental health professionals, while other outpatient health services require only a 20% copayment. MIPPA will phase in a reduction of the higher copayment rate to 20% by 2014. In theory, this policy change should positively affect the mental health treatment of nursing home residents, but there has been no research to date evaluating this issue.
Medicaid covers chronically ill (long-stay) residents, accounting for roughly 50% of expenditures and 70% of bed days. Medicare covers short-stay, postacute nursing home services, accounting for 14% of total nursing home expenditures. In theory, Medicaid and Medicare payment policies could be used to reward nursing homes for admitting and caring for residents with mental illness. In practice, however, federal requirements mandating mental health services in nursing homes have generally not been successful in ensuring that those in need receive them (Colenda et al., 1999; Streim et al., 2002). The Medicare system and most state Medicaid programs case mix adjust payments using the Resource Utilization Groups system, which divides individuals into specific payment groups based on their clinical conditions. 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 quality 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 activities of daily living no additional payment is generated in the presence of behavioral health problems. In many cases, the Resource Utilization Group reimbursement system may provide a negative incentive for nursing homes to serve residents with mental illness, because it does not adequately value the added nursing home staff time and effort required to care for these residents' verbal or physically aggressive behavior. However, as Streim et al. (2002) note, previous research has not directly examined “the relationship between the method of payment … and access to psychiatric services or quality of mental health care” (p. 1417).
CMS is currently embarking on the three-state randomized nursing home value-based purchasing (NHVBP) demonstration. Nursing homes with better performance in terms of avoidable hospitalizations, staffing, survey deficiencies and various MDS-based quality indicators will be rewarded with higher incentive-based payments. Following an integration-based approach, the NHVBP demonstration will include all residents in the nursing homes, and there will not be any performance-based payment around specific mental health quality measures. It may be the case that performance-based payment improves quality across the board, regardless of diagnosis. On the other hand, the integrated nature of the NHVBP may lead to perverse incentives around the admission and treatment of persons with mental illness. Ultimately, the demonstration will serve as an important test of the ongoing tension between integration and exceptionalism in mental health policy.
Although frontline nursing home staff members are the gatekeepers and all too often the primary providers of mental health treatment for residents, they may know little about mental illness and its management. Our review of the literature suggested that facilities using greater numbers of nonprofessional staff provided poorer quality of care for residents with behavioral health needs. To address the inadequate preparation of frontline nursing home staff as caregivers for residents with mental illness, the American Geriatrics Society and the American Association for Geriatric Psychiatry report (2003a) recommended that CMS develop standards that promote and support the implementation of training models with demonstrated effectiveness. One successful model described in the literature is the “train the trainer” approach, in which an outside mental health nurse specialist provides ongoing training and consulting to a frontline nursing home staffer who becomes the internal expert responsible for training others within the facility (Lieff & Silver, 2001; Smith, Mitchell, Buckwalter, & Garand, 1994). Other promising models involve targeted educational interventions that emphasize the importance of focusing on training staff members who have the most direct contact with residents with mental illness, such as nursing assistants (Brannon, Smyer, & Cohn, 1992; Smith et al., 1994). Future research is needed to develop a more fundamental understanding of the competencies that are critical for nursing home staff who serve residents with mental illness and to determine the best approaches to teaching such core skills.
In 1998, CMS introduced a Web-based nursing home report card initiative known as Nursing Home Compare to improve consumer information. Nursing Home Compare reports data on three sets of quality measures: deficiencies (since 1998), facility staffing (since 2000), and MDS quality measures (since 2002). Starting in December 2008, the Web site also reports a composite five-star ranking of nursing homes based on the above factors. Importantly, the only quality measure on Nursing Home Compare specifically measuring mental health care is the proportion of long-stay residents who are more depressed or anxious (relative to the previous MDS assessment). Accordingly, an important need is the development and validation of mental health quality measures based on available data sets such as the MDS. For example, factor analyses to determine psychometric characteristics of MDS measures related to mental health quality measures found significant (though modest) validity coefficients for domains of cognition, activities of daily living, time use, depression, and problem behaviors (Lawton et al., 1998). Some have also argued for inclusion of additional measures of symptoms and functioning for persons with schizophrenia in nursing homes in the MDS (Bowie et al., 2006). As noted in our review, the literature has also employed a range of other measures that may be of use to policy makers, including psychiatric hospitalizations, treatment of depression, frequency of mental health deficiencies, and the presence of mental health professionals.
Nursing homes operate in a highly regulated environment. However, the enforcement of the PASRR regulations has been relatively ineffective, while CMS rules around antipsychotic use have not come close to eliminating inappropriate use. Based on these issues and others, CMS assigns a high number of mental health deficiencies each year as part of the federal survey process. This may suggest that CMS needs to monitor and enforce existing rules better, with appropriate penalties for deficient nursing homes. However, these results may also suggest that the current regulatory approach is not working for residents with mental illness and other more market-based approaches such as quality report cards and pay-for-performance might also be considered.
In summary, the existing literature suggests that persons with mental illness are frequently admitted to nursing homes, and their care is often of poor quality and related to a series of resident and facility factors. Building on the tension between integration and exceptionalism in mental health policy, we have identified some of the factors related to mental health quality measures in the existing literature. Yet, there remains much to be learned about the forces that affect mental health quality in the nursing home. Research has yet to examine the possible range of factors related to the resident's welfare, provider norms, and facility finances that affect the quality of care for nursing home residents with mental illness. For example, the potential racial and ethnic disparities in the quality of mental health care have not been examined in the published literature. In addition, the array of process, structural, and outcome variables that represent mental health quality measures is small compared with the wide range of quality of care measures studied in other chronic conditions (e.g., diabetes and heart failure). In particular, researchers should center future studies around outcome-based measures such as psychiatric symptoms, cognitive performance, and social functioning. Additionally, the extension of the this research to other long-term care settings such as assisted living and home- and community-based care is an important area for future inquiry. This review highlights the need for future research to develop further the knowledge base needed to improve the quality of care for nursing home residents with mental illness.
Funding The authors received the following financial support for the research and/or authorship of this article: David Grabowski was supported in part by a National Institute on Aging career development award (K01 AG024403), and Stephen Bartels was supported in part by a National Institute of Mental Health midcareer investigator award (K24 MH066282-07).
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.