Long-term care alternatives for the mentally ill elderly.
Deinstitutionalization of psychiatric hospitals has had a significant impact on nursing homes over the past 15 to 20 years, as they have been asked to extend residential care to elderly, chronically mentally ill persons in areas where alternative community-based residential services have been inadequate or missing. National Institute of Mental Health (NIMH) data show a decrease of 76% for chronically mentally ill persons age 65 and older in state hospital populations between 1964 and 1981, the period when deinstitutionalization had its greatest impact.|1~ A significant percentage of these persons were transferred to nursing homes. According to a 1971 NIMH study, 40% of the patients aged 65 and over discharged from state and county mental hospitals in 1969 were transferred to nursing homes.|2~ By 1977 this percentage had increased to 54%.|1~
Deinstitutionalization, as a policy, has also increased the number of elderly persons with serious mental illness who need long-term care but are no longer eligible for admission into public psychiatric hospitals, and now have no place to turn other than nursing home care.|1~ Aside from public psychiatric facilities, general hospital psychiatric units and private psychiatric hospitals also generally lack adequate accommodations for elderly mentally ill persons and, as a result, often discharge such persons to long-term care in nursing homes.|3~
Problems Posed for Nursing Homes
The wisdom of using nursing homes to provide long-term care for the elderly with serious mental illness has been questioned.|4-6~ Few of these facilities have been designed to provide the rehabilitative, psychotherapeutic programs these mentally ill persons need. These facilities' lack of specialized staff trained in working with the mentally ill may have resulted in the excessive use of medication to control psychiatric symptoms and a decreased focus on developing independent skills.|5,6~ Consequently, nursing homes in some cases have inadvertently perpetuated another form of "institutionalization," with many of the same problems inherent in the structure that existed in state mental hospitals.|4~
Regrettably, nursing homes themselves have been faced with the same problems chronic mentally ill persons in the community have experienced -- namely, inadequate community programs and services. This situation is due, to some extent, to nursing homes having inadequate ties to the community mental health system. Many nursing homes have not had access to crisis intervention and respite services from their area Department of Mental Health programs.|5~ Also, until the recent advent of the PASARR regulations it was very difficult for nursing homes to curtail services to mentally ill residents who were no longer suitable for the facility.
This was evidenced by a 1989 survey, by one of the authors, of level III and IV nursing homes in Western Massachusetts which had had substantial experience in caring for elders with a history of psychiatric hospitalization. The study found that 75% of the administrators (level III = 78.8%; level IV = 65.5%) reported that their facility did not have the support services that the deinstitutionalized, psychiatric elders in their facilities needed.|5~ Almost all of the administrators ranked crisis intervention as the most important of the mental health services needed in providing care to psychiatric-impaired elders. However, only 36.8% of the level III and 61.1% of the level IV administrators reported that crisis intervention was available from the Massachusetts Department of Mental Health. Case consultation and inservice training, which also ranked as very important services, were reported not to be available by many administrators as well.
This lack of mental health services has been problematic for the nursing homes. A majority of the level III (79.4%) and level IV (89.5%) administrators who had admitted deinstitutionalized elders reported having experienced severe problems with them. Most of the problems involved the resident going into an acute phase of his/her psychiatric condition or producing some highly disruptive behavior. As a result, about half the nursing homes had curtailed residential services to elders with a history of psychiatric illness. Meanwhile, administrators of the remaining facilities reported being more cautious in their assessment procedures.
To some extent, the use of nursing homes as a residential alternative has been severely modified by OBRA '87, which stipulates that all nursing home applicants who have a primary or secondary diagnosis of a major psychiatric disorder must undergo a pre-admission screening to determine whether they are appropriate for nursing home care and if they need active treatment for mental illness. The psychiatric disorders specifically targeted by the PASARR regulations include schizophrenia, paranoia, major affective and schizoaffective disorders, and atypical psychosis as defined in the DSM-III R. Individuals with dementia as a primary diagnosis who are admitted to a nursing home without the pre-admission screening are denied Medicaid coverage.
In addition to screening new admissions, OBRA requires that annual reviews be conducted of residents with the designated psychiatric conditions, who were admitted prior to the implementation of OBRA, to determine if they are in need of active treatment for mental illness and therefore no longer qualify for nursing home level care. Additional stipulations have been mandated by OBRA for psychiatric-impaired residents in need of active treatment and for those on psychotropic medications.|5~ In fact, the more recent requirement that these residents have their psychotropic medication reduced to the point where they display behavioral indication of their need for the medication is likely to further dissuade nursing homes from admitting elders with serious mental illness in need of "active treatment."
Need for Residential Alternatives
Residential care of the elderly with serious mental illness remains a need, and should consist of a variety of alternatives geared to the specific needs of the individuals. These alternatives exist in Western Massachusetts, which since 1979 has undergone a court ordered deinstitutionalization of its state psychiatric hospital. The continuum of residential care for the elderly with serious mental illness generally includes Department of Mental Health-contracted community programs, nursing homes (Level III), rest homes (a cross between a nursing home and board and care home), foster care, and independent living arrangements.
Criteria for placement in these alternatives is based upon availability and client characteristics such as cognitive functioning, physical abilities, social skills and behavior problems.|7~ As a rule, those with physical disabilities and medical problems go to Level III nursing homes, provided that their psychiatric conditions have stabilized or are in remission. Individuals with fewer deficits in activities of daily living (ADL) but who need supervision over diet and/or medication usually go to rest homes. The mentally ill elders who are placed in adult foster care show many of the same characteristics as those placed in rest homes -- they can independently perform ADL tasks and need some supervision -- but frequently have better social skills and fewer psychiatric symptoms. Elders who exhibit more active psychiatric conditions and/or exhibit behavioral problems tend to be placed in specialized community programs.
Of these, two basic types exist. One type consists primarily of shared apartments in which three residents are supervised around the clock by a trained staff person. Recreational, medical and clinical services are provided by supplementary staff and consultants.|8~ As compared with nursing homes, the community residential programs tend to accept the most difficult clients, i.e., those with low self-care skills and/or severe behavior problems. Staff are specifically trained to deal with aggression, polydipsia, self-mutilation and responses to hallucinations and delusional belief systems.
The second type of community program specializes in providing care to the severely mentally ill and medically ill elderly. These programs tend to house small groups of residents, between four and eight, in suites with more intense staffing. These Department of Mental Health-contracted programs were developed as Northampton State Hospital emptied its geriatric ward.
These programs, since they were designed to care for elders with more active cases of mental illness or behavior problems, are more costly than nursing homes. However, these programs are considerably less expensive than residential care in a psychiatric hospital.|8~
Other residential options exist. These options tend to be designed for mentally ill elders who can function independently and need minimal supervision.
For the most part, this continuum of residential alternatives evolved in an ad hoc manner as needs arose over ten years of deinstitutionalization. When the court-ordered deinstitutionalization of the remaining residents in Northampton State Hospital began in 1979, many of the elderly patients were transferred to area nursing homes and rest homes. Community programs were established for those deinstitutionalized elders who were not considered to be suitable for nursing home placement. Meanwhile, some elders were discharged to independent living arrangements. In short, over time, mentally ill elders who under other circumstances would have been admitted to the state psychiatric hospital were diverted to nursing homes, community programs, or foster care.
During the ten years of deinstitutionalization, however, some problems arose. This was discussed by Peter Gordon, the then vice-president of the Massachusetts Federation of Nursing Homes, who at a Massachusetts Department of Mental Health conference in 1986 described the growing problem of using nursing homes as a primary source of residential care for the elderly with a history of psychiatric illness. Not only were nursing homes not designed to meet the specialized needs of the seriously mentally ill, he noted, but the ever-increasing demand for level III beds by the general elderly population, nursing homes' negative experiences when some of the mentally ill residents experienced a psychotic episode or exhibited behavior problems, and lack of assistance from the Department of Mental Health taken altogether made directors of these facilities more cautious in accepting psychiatrically-impaired elders.|5~
Rest homes, however, with more readily available beds and somewhat less negative experiences with the mentally ill, have been more willing to continue admitting the psychiatrically-impaired. The increasing number of elders with serious mental illness being admitted to the rest homes led the Massachusetts Department of Public Health (DPH) to mandate changes in the regulations established for these facilities. Implemented in 1988, these required that the facilities classify themselves into one of three categories: 1) Conventional (no psychiatric elders); 2) Conventional with Community Support Residents (less than 50% psychiatric residents); or 3) Community Support Facility (50% or more psychiatric residents). At present, only rest homes which are formally classified as a Community Support Facility are permitted to freely admit psychiatric-impaired residents. Conventional facilities are not permitted to admit mentally ill elders, and the Conventional with Community Support residents must receive a waiver from DPH for each mentally ill resident admitted. Facilities which designated themselves as one of the two types of Community Support programs require an increase in staffing and services.
To insure that the mentally ill resident receives appropriate services, a Licensed Social Worker, at the ratio of one hour per client per month, is required to prepare and oversee a Mental Health Treatment Plan. In addition, a full-time equivalent Support Services Coordinator, with a minimum of a Bachelor Degree in a Human Services-related field, at the ratio of one coordinator per 20 clients, is utilized. The Support Services Coordinator, who functions as a case manager and treatment coordinator, prepares and oversees the Individual Service Plan, which outlines rehabilitative goals and how these goals are to be met.
Increased education, training, and experience is required of these facilities' activity and direct care staff, as is increased supervision at night, i.e., at least one awake staff who is 21 years old or more and has documented training must be on duty. Ongoing service training is required for all direct care staff. Topics which must be covered include aspects of mental illness in the elderly, crisis intervention, psychotropic medication and the client's right to refuse medication. To insure staff learn about the medication being dispensed, they are evaluated following training.
For complying with these requirements, the two types of Community Support facilities receive a higher adjusted per capita reimbursement rate. This increase applies to all residents regardless of their diagnosis, since they all benefit from the increased services provided under the new regulations.|5~ On the negative side, the mandated DPH changes have severely affected some rest homes. The increases in staffing required under the new regulations have forced a number of small (fewer than 20 beds), homelike rest homes, which specialized in providing residential services to the mentally ill elderly, to close.
Today, the rest homes (Community Support programs) in Massachusetts continue to play an active role in providing residential care to the elderly with serious mental illness. Nursing homes tend to accept fewer mentally ill elders. Those who are admitted to nursing homes are usually physically disabled and have relatively few psychiatric symptoms. Also, the nursing homes have emerged as an important residential option for elders with a history of mental illness who develop a dementing illness.
The experiences with deinstitutionalization in Western Massachusetts have demonstrated that it is possible to provide community-based, residential care to the elderly with a history of mental illness, even those who have spent much of their lives in a psychiatric hospital. Today there are very few elders residing in Northampton State Hospital, which in fact is scheduled to close in the near future.
Although each geographic area must develop a system based upon the resources available, much can be learned from the Western Massachusetts experience. It shows that a particularly effective approach in meeting the residential needs of the elderly mentally ill is the provision of a continuum of care, in which these elders are placed in specialized long-term care settings depending upon their specific psychiatric and medical needs.
1. Kiesler C, Sibulkin A. Mental Hospitalization Myths and Facts About a National Crisis. Newbury Park, Beverly Hills, London, New Delhi: Sage Publications. 1987.
2. Toff G, Scallet, LJ. The Mentally Ill in Nursing Homes. Washington, DC: National Institute of Mental Health. 1986.
3. Gaitz C, Varner R. Principles of mental health care for elderly inpatients. Hospital and Community Psychiatry 1982;33:127-133.
4. Carling P. Nursing homes and chronic mental patients: A second opinion. Schizophrenia Bulletin 1981;7:574-579.
5. Mosher-Ashley P, Turner B, O'Neill D. Attitudes of nursing and rest home administrators toward deinstitutionalized psychiatric elderly. Community Mental Health Journal 1991;27:241-253.
6. Goldman H, Feder J, Scanlon W. Chronic mental patients in nursing homes: Reexamining data from the National Nursing Home Survey. Hospital and Community Psychiatric 1986;37:269-272.
7. Sommers I, Baskin D, Specht D, Shively M. Deinstitutionalization of the elderly mentally ill: Factors affecting discharge to alternative living arrangements. The Gerontologist 1988;28:653-658.
8. Mosher-Ashley P. A community-based residential care program for elderly people with chronic mental illness. Adult Residential Care Journal 1989;3:267-278.
Pearl Mosher-Ashley, EdD, and Nancy M. Henrikson, BA, are in the Department of Social and Behavioral Sciences, Worcester State College, Worcester, MA.
The authors wish to thank Marge Tuperkeizsis, Director, Florence Rest Home of Northampton, MA, for her invaluable contributions to this article.
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|Author:||Henrikson, Nancy M.|
|Date:||Jul 1, 1993|
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