Dr. Robert Figlerski, Team Health


As part of my early clinical training, I spent some time treating patients at a large psychiatric hospital that has long since closed. While it is common for young mental health professionals in training to spend time working with a chronic psychiatric population, I never anticipated that my experience would become so relevant to my current work in skilled nursing facilities.

Over the last few decades, the nationwide closing of psychiatric hospitals has created a situation in which nursing facilities now play a major role in providing care to individuals with serious and persistent mental illness. This has changed the whole landscape of post-acute care, in some cases inundating facilities with patients that staff is not trained to care for.

Once admitted, many of these residents will remain at the facility for an extended period of time due to sparse discharge resources for this population. Over time, a facility’s census may come to be heavily weighted toward a psychiatric population. This shift in the facility’s diagnostic demographics puts staff members at risk of becoming overwhelmed, as they are continually confronted by emotional and behavioral issues of a population they are not prepared to treat.

Nursing homes face a number of challenges when dealing with individuals with chronic mental illness. To maintain quality care, facilities must directly confront these issues – which include, but are not limited to:

  • Demographic shifts. If the demographics of the facility get ahead of staff training, staff may burn out and feel frustrated about responding to residents with SPMI.
  • Confusion and anxiety about how and when to utilize psychotropic medications. Increased scrutiny around psychotropic medication use in nursing homes has led to uncertainty about how to best utilize these drugs with patients who have historically benefited from them.
  • Inadequate understanding of how to develop and use nonpharmacological interventions to manage behavioral challenges. These nonpharmacological interventions should be clearly stated in a resident’s care plan and certainly be part of any care plan for a resident taking a psychotropic medication.
  • A lack of or poorly integrated behavioral health services (psychiatry and psychology). Having psychiatry and psychology round in your facility is essential, but these specialties must also be integrated into your interdisciplinary structure, reviewing cases and creating realistic treatment plans. One helpful approach is to establish regularly scheduled behavioral rounds for the mental health providers, social work and nursing staff. Integrated care is essential to optimal care, and it all starts with good communication among disciplines.
  • “Creeping institutionalization.” Over time, these residents may experience a degraded ability to function in the community. Establishing programs to maintain community living skills and promoting independence is necessary if the resident is going to be discharged back into the community.
  • Frequent psychiatric hospitalizations. If SPMI residents don’t receive optimal treatment, they may require re-hospitalization. This is obviously of great concern clinically, since psychiatric issues are always best treated in-house, as well as financially, as re-hospitalization rates are an important part of a facility’s performance metrics.

While one could argue that nursing homes are a reasonable alternative to psychiatric hospitals, current regulations, funding issues and poor staff training set up nursing homes for failure unless they fully embrace the need to reinvent certain aspects of their care strategies for the SPMI population.

So what can be done to improve the care of the chronically mentally ill in the skilled nursing setting? There are seven strategies that can help.

  • Don’t allow the number of psychiatric patients admitted to overwhelm your facility’s capability to appropriately address their needs. If the percentage of SPMI residents gets ahead of your ability to provide them with good treatment, it will have a significantly deleterious impact on all of your residents, as well as their families and your facility’s reputation in the community.

One good indicator of readiness is the amount of training that your staff has received related to providing care to these patients. Another is your relationship with the behavioral health professionals — psychiatrists, psychiatric nurse practitioners and clinical psychologists — who deliver direct care and also consult with your primary care providers and the entire staff.

  • Establish training programs for staff to upgrade their skills to better understand and manage the emotional and behavioral issues related to individuals with SPMI. Adding mental health topics to  annual mandatory training would be a good start.

Nursing facilities need to establish a strong mental health team if they are going to successfully manage behavioral health issues. The most important training needs to be dedicated to the CNA staff since they have the most interactions with residents and therefore the most opportunities for positive contacts. A large percentage of behavioral issues can be avoided by creating a CNA staff that becomes adept at managing this population.

  • Understand the CMS guidelines regarding psychotropic medications and gradual dose reductions as they apply to residents with chronic mental illness. The primary treatment for individuals with SPMI is receiving the correct medication on a consistent basis.

    In the current regulatory climate, the threshold for the use of psychotropic medication has been raised, but with good documentation of diagnosis, clinical rational, and the use of nonpharmacological interventions, the facility should be able to confidently provide the necessary pharmacological treatments.

  • Charge the Therapeutic Recreation Department with the responsibility of developing more unique and focused therapeutic activities for a population with chronic mental illness. This population is often younger, with different interests than an elderly population. A proactive approach by therapeutic recreation can be one of the most important nonpharmacological interventions to reduce behavioral issues.
  • If and when psychiatric hospitalization is indicated for a SPMI resident, it pays to have established strong relationships with local hospitals, emergency rooms, and private psychiatric hospitals. Although I believe that most psychiatric hospitalizations from SNFs can and should be avoided with proactive behavioral healthcare, at times the only option is hospitalization.
    Unfortunately, hospitalization often results in a revolving door of care as the emergency room sends the person right back to the facility. Building relationships with the hospital can help make those admissions stick when they understand that you’ve done everything possible to treat in-house and are clear on the reasons why you believe inpatient care is needed.
  • Make sure that you are capturing depression through the PHQ-9 on the MDS 3.0. The identification, treatment, and additional compensation for the treatment of depression will help all involved —residents, primary care and the facility itself.
  • Continue to expand and integrate telemedicine into the nursing home setting. There is a national shortage of psychiatry providers, but CMS will pay for telepsychiatry and telepsychology for facilities in a Provider Shortage Region.

Finally, recognize that almost all nursing home residents struggle with psychiatric, psychological and adjustment issues and that long-term care should be as much about the psychological well-being of its residents as it is about their medical condition. All nursing homes need to become proficient in caring for the SPMI population, as well as the more traditional depression and anxiety that our residents have always evidenced.

Robert Figlerski, Ph.D., is the director of behavioral health, New York region, for TeamHealth.