Improving the treatment of mental health issues in nursing homes

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Eleanor Feldman Barbera
Eleanor Feldman Barbera

The recent Illinois legal decision to move mentally ill nursing home residents into smaller mental health settings is likely to prompt an industry-wide examination of the practice of accepting mentally ill residents into long-term care. If nursing home residents are lucky, it will also trigger an evaluation of how we treat mental health issues in nursing homes in general.

While those with a chronic mental illness require special programming, some of which I've outlined in my blog post, “Helping Mentally Ill Nursing Home Residents,” many residents would benefit from increased consideration of their mental health condition.  It's not uncommon for mentally healthy adults to become depressed and require psychological treatment or medication (or both) following medical conditions that take them away from their homes and create dependence after enjoying independent lives.  There is also a growing recognition of the problem of alcohol addiction in the elderly, with many of these individuals being admitted into our facilities.

Underutilization of psychological services

Residents are required to be assessed by many nursing home departments following admission, but, oddly enough, there's no requirement for a psychological assessment.  Psychological referrals are therefore haphazard, dependent upon the psychological-mindedness of individual staff members rather than upon any standard criteria.

Services tend to be underutilized, often because staff members are focused on medical issues, and also because of a lack of understanding about what psychologists do and how we can make your jobs easier.

Why psychology?

While medical problems are, of course, primary in a nursing home, when I read the medical diagnoses, this tells me nothing about what the person with the diagnosis has encountered. Residents are often traumatized by their medical experiences, which continue during their nursing home stay.

This can result in depression, anxiety, and noncompliance with treatment, in addition to using enormous amounts of valuable staff time.

The role of psychologists

As a psychologist working in individual therapy with residents, I become a resident ally, someone with whom they can share their experiences, and get information and support so they can work with the team to get the proper care. I help the treatment team find the best way to approach residents, often training the staff on behavioral techniques.

In the whirlwind of long-term care, I'm usually the only staff member who has the time to sit and listen to the resident, uninterrupted, on a regular basis.

How residents benefit from services

Using psychological services (which are funded through Medicare, Medicaid, private insurance or by the resident themselves, and not part of the nursing home budget), staff might expect to see:

* Decreased depression and anxiety

* Increased compliance with care

* Increased attendance at activities and interactions with peers

* Reduced irritability and argumentativeness

* Decreased neediness and use of staff time

* Increased involvement in the life of the facility

* Better understanding of treatment, the need for it or their reasons for declining

* Increased satisfaction of residents, staff and family members

When to consider a referral

Cognitively intact residents might benefit from referral for psychological services following:

* Admission to the facility, before problems have become entrenched

* A change in physical health, such as a stroke or amputation

* A decrease in mobility or decline in independence

* The loss of a roommate

* The loss of a relative or close friend

* Decreased visits from family or friends

* Transfer to a new unit

* Arguments with staff or peers

* Social withdrawal

If I could do things my way ...

I'd like to see further integration of mental and physical health services in nursing homes.  A part-time psychologist, funded through the nursing home, could provide more staff training, be available to consult with staff members about problems with particular residents or units, foster team-building, increase nursing home efficiency utilizing industrial-organization techniques, and work with family groups. 

Providing appropriate treatment for our residents means addressing mental health and substance abuse needs, as well as physical problems, whether or not they have a previously recognized mental health diagnosis.

With the passage of mental health parity and increased attention to our mentally ill residents, perhaps the time has come for a re-evaluation of how we address the mental health needs of all those under our care.

The author is a psychologist and founder of the blog entitled My Better Nursing Home.

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