Tara Cortes

Serious mental illness, substance use disorders, and anxiety and depressive disorders are at crisis level in older adults. These mental health issues are frequently experienced by older adults who are in long-term care settings. 

It has been found that among long-term care residents, approximately 75% of residents have one or more mental health diagnoses with dementia, depression, anxiety disorders and serious mental illness being the most prevalent. It is believed that this mental health crisis has been escalated by social isolation and loneliness experienced during COVID-19. The escalation of mental health disorders among older adults has created an urgent need to better equip long-term care settings, whether residential or community-based. 

This is supported by the Biden-Harris administration’s plan for long-term care reform, which calls for the transformation of our mental health and crisis care systems to provide holistic and equitable care to people across the long-term care continuum. 

One of the biggest issues in offering this type of care is that the long-term care workforce does not currently have the capacity to recognize, assess or treat mental health disorders. Behavioral health specialists are rarely found among staff in long-term care facilities. Registered nurses, licensed practical nurses and direct care givers are managing the care of individuals with multiple medical co-morbidities, but often do not receive specialized training in behavioral health. 

To provide high-quality person-centered care, staff must be able to address all aspects of a person’s health, including chronic diseases, a spectrum of mental illness, and substance use disorders. This requires strategically planned education that is role appropriate. Education of the licensed staff is important for the assessment and treatment of mental health issues. 

But education cannot be exclusive to only licensed staff. Direct care givers are the staff who spend the most time with residents, and they must have the tools to recognize and manage behaviors that characterize mental health disorders. 

Another factor is that the long-term care industry typically does not employ mental health specialists and often operates in a silo without affiliation to other organizations, such as large healthcare systems which may have access to mental health providers. Long-term care organizations must partner with community organizations that offer behavioral health services and have processes in place for referral and follow-up. Mental health specialists offering group or individual therapy are available through these services to see residents in nursing homes, assisted living or private homes. Older adults may also avail these services in the community. However, the staff in long-term care must be educated to know what services are available and how to help people access them.

Finally, reimbursement for mental health services must be aligned with medical care. Many insurance companies, including Medicare, do not pay the total cost of these services, leaving the burden to the individual or, in the case of nursing homes, to the facility. This disincentivizes the engagement of a mental health specialist. Mental health care can be built into a value-based payment system as research has shown untreated mental health issues lead to more hospitalizations and exacerbate chronic disease. 

As the population ages, the nation needs a trained workforce that can meet older adults’ mental and physical health needs in addition to mental health specialty care networks that partner with long-term care organizations and federal investment into long-term care to support the provision of value-based mental healthcare. Without these elements, holistic, equitable and person-centered care will remain out of reach. 

Tara A. Cortes, PhD, RN, FAAN, is the Executive Director of the Hartford Institute for Geriatric Nursing and a professor of geriatric nursing at NYU Rory Meyers College of Nursing.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.