The state and government movement known as “deinstitutionalization” in the 1970s and 1980s was responsible for closing psychiatric hospitals and residences across the United States. The idea was to have these patients receive community-based services at a lower cost and hopefully improve their lives. Whether it did or not is debatable, but one major outcome of this movement is a dramatic increase in the number of nursing home residents with severe mental illness, which most facilities are poorly equipped to handle.
What is Severe Mental Illness?
Many patients residing in huge psychiatric hospitals or asylums as they were once called, suffered from many forms of severe mental illnesses including schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, bipolar disorder, psychotic mood disorder and history of suicide. They may have been prescribed heavy antipsychotic medications and had undergone electroshock therapy or ECT, lobotomy, and other extreme treatments for their illnesses.
Prevalence
Studies show that over 40% of long-stay nursing home residents on Medicaid and under age 65, are diagnosed with severe mental illnesses and another 20% aged 65 and older are as well. There are also roughly 3 million adults over age 50 living with a severe mental illness and many will be admitted to a nursing home at some point in their life. Nursing homes today are serving these residents more than ever before and it seems like they are from distinct geographic areas in the United States including southeastern states, Tennessee, Ohio, and West Virginia.
Snapshot of Residents with Severe Mental Illness
Today’s nursing home resident diagnosed with severe mental illness is almost always on some type of psychotropic medication including antipsychotics, antidepressants, hypnotics, and anxiolytics or anti-anxiety medications. Many have difficult to manage behaviors including combativeness and aggressiveness, hallucinations and delusions, paranoia, confusion, depression and anxiety. Some have suicidal tendencies. These individuals are usually younger than the average nursing home resident, have a history of tobacco, alcohol and illegal drug use and have illnesses related to these behaviors.
Challenges Faced by Care Staff
To begin with, nursing homes are not the most ideal setting for individuals with severe mental illness, but in many cases, there are no better options. Still, residents must be screened using the Pre-Admission Screening and Resident Review (PASRR) which identifies people with mental illness, developmental and intellectual disabilities and related conditions which helps in finding alternate placement when possible.
Lack of Specialized Training
Many care providers in skilled nursing home settings have not received proper training in managing behaviors associated with severe mental illnesses. As a result, behaviors become difficult to manage in an environment not appropriate for this type of care. Nursing staff may be unfamiliar with psychotropic medications and their side effects. These residents can consume vast amounts of staff time, taking them away from their daily routines. Although most staff will do their very best to provide care, most operate outside of their area of expertise which is fertile ground for ethical and legal risks.
Characteristics of Nursing Homes Serving Residents with Severe Mental Illness
Overwhelmingly, nursing homes caring for residents with severe mental illness share similar characteristics including:
- Lower direct-care staffing hours
- Greater Medicaid-paying resident census
- Score lower on all Nursing Home Compare star ratings
- Higher employee turnover
- Threats to quality of care
- Are part of a larger chain of for-profit homes
- Higher utilization of physical and chemical restraints
Improving Quality
With all of this being said, how can nursing homes with increasing numbers of residents with severe mental illness provide high quality care? Fortunately, there are a number of ways to provide good clinical care and enhance quality of living.
The Role of Leadership
Improving care and services must begin with strong, knowledgeable leaders who are skilled in communication, collaboration and planning. Leaders must also act as appropriate role models for their staff. Leaders can include:
- Administrators
- Directors of Nursing
- Social Workers
- Activity Professionals
- Therapists (PT, OT and Speech)
- Medical Directors
- Nursing Supervisors
- Lead STNAs
Nonpharmacological Interventions
Before medications are prescribed for severe mental illnesses, best practices encourage the use of as many psychosocial interventions as possible before relying on psychotropic medications. It’s important to include counseling, case management and psychotherapy to the care plan. Helping the individual deal with stress and coping can be effective in self-management.
Judicial Use of Psychotropic Medications
While the use of psychotropics is highly controversial and a strike against quality metrics in nursing homes, the truth of the matter is that they are necessary for various forms of severe mental illness. In some cases, the individual would suffer far greater without them. Therefore, under the close scrutiny of the prescribing physician and the close observation of direct care staff, these medications can be used to better manage negative symptoms and improve quality of life.
The Role of Staff
A best practice in providing care to residents with severe mental illness is to have a team of qualified, experienced and well-trained healthcare professionals working together as a team. Nurses who have experience in behavior management with residents diagnosed with dementia can apply that knowledge to those with mental illnesses. Direct care staff can apply person-centered methods including getting to know the person, understanding triggers for behaviors, applying psychosocial interventions and spending quality time with their residents.
Education and Training
Perhaps one of the most important elements to providing care to residents with severe mental illness is to learn about such disorders, medications used to treat them, behavior management, and creating a therapeutic environment. Because nursing home staff aren’t especially prepared to work with these residents, they should take every opportunity to learn in person or online.
Final Thoughts on Challenges Providing Care to Residents with Severe Mental Illness
Over the past few decades, people with specific types of severe mental illness like schizophrenia and bipolar disorder, have moved from hospital settings to the community. Many have been admitted to skilled nursing homes which aren’t entirely appropriate for their care, but have been their only option. Despite how they got there, these people require a special level of care that can only be provided by the best, most caring, well-educated and trained care staff.