Dr. Richard Juman
Dr. Richard Juman

Consider the following scenario: A 78-year-old woman is admitted to a long-term care unit following a stroke, and after an unsuccessful 21 day stay on the facility’s subacute rehab unit. Confronted by the loss of her physical health, ambulation, home, church, dog, friends and hobbies in the community, she presents with anxiety, depression and insomnia. She also had an episode of delirium while in the hospital, for which she was prescribed the anti-psychotic medication Seroquel. Unfortunately, the Seroquel was not discontinued despite the fact that the condition that caused the delirium — dehydration — was quickly resolved.

Now, grappling with the loss of independence and control that are often part of a SNF admission, she is also prescribed Xanax, Zoloft and Ambien to combat the symptoms of anxiety, depression and insomnia. Tranquilized and sedated, she winds up on a total of 23 medications and quickly loses cognition and energy. She loses the resources she would have needed to confront the main challenge that she is facing — the task of creating a new life for herself in long-term care.

At continual risk for drug-induced cognitive impairment, deleterious drug interactions, confusion, hallucinations and delirium, she loses the opportunity for a successful adjustment to the SNF.

This scenario is unfortunately not unusual in the post-acute arena. The imperative to aggressively treat the symptoms of mental illness, typically with pills, often leaves the person underneath the symptoms essentially ignored.

In this and similar cases, SNF administrators must ask themselves, “Did we provide the kind of care the resident really needed to maximize her ‘whole emotional and mental well-being?’” That, in a nutshell, is the manifesto behind the revolution and the mandate from the Centers for Medicare & Medicaid Services, and we have a long way to go before it is realized. Right now the overwhelming majority of Medicare expenditures and provider attention in post-acute settings go toward medical, as opposed to mental health conditions, despite these facts:

  • Psychiatric illness in SNFs is the norm, rather than the exception.

  • Untreated mental health conditions, especially depression, lead to higher health care costs.

  • Many psychotropics, especially anti-psychotics, are extremely expensive — more expensive in the long run than the cost of providing evidence-based, non-pharmacologic care and staff training.

The role that skilled nursing facilities are currently being asked to play has changed drastically as sicker, more cognitively impaired and more psychiatricly-compromised residents are now the norm. With older people with moderate infirmities now much more likely to reside in assisted living facilities or at home than in a nursing home, SNFs are being asked to care for older residents with high levels of medical acuity as well as the significantly mentally ill and many younger residents with conditions such as ALS, multiple sclerosis, traumatic brain injury, post-traumatic stress disorder and addictions. According to a study published in the Journal of Aging & Social Policy in 2011, the percentage of new nursing home admissions with mental illness now exceeds the percentage presenting with dementia only.

These profound changes have occurred despite the fact that, in the vast majority of facilities, little has changed with respect to the physical characteristics, staffing patterns, staff training or professional staffing that facilities use to manage their populations. Although the quality of medical care provided to patients and residents has improved significantly, the imperative to meet the demands of the new populations found in SNFs has not been met with the sea change in attitude, competency and approach that is desperately needed.

Ironically, the improvements in medical care sometimes inadvertently work against the goal of treating the “whole person.” Staff members who have not received adequate training in mental health are frequently overwhelmed by the challenges that residents may present, particularly with respect to behavioral issues. And appropriately managing the behavioral symptoms of dementia and mental illness, even by well-trained staff, is more time-consuming than giving the resident a pill.

Many people who work in post-acute care actually have the misperception that anti-psychotics are the best approach to managing behaviors and that efforts to limit their use are well-meaning but misguided. That’s simply incorrect, but that mindset has led to the SNF cultural norm where an overreliance on psychotropics, particularly anti-psychotics, became the first-line treatment for behavioral disorders. In a paradigm that closely mirrors the rampant overprescribing of pain medications in the community that has caused our current national opioid epidemic, well-meaning providers created an epidemic of overprescribed anti-psychotics in the SNF population that facilities, at the insistence of CMS, are now scrambling to reverse.

It is the responsibility of all of us in post-acute care to rise to the challenge — first and foremost because the problem is staring us in the face every day, but also because CMS is demanding it. The “manifesto” is clear, and the mental health revolution looks like this:

  • Every SNF will have a comprehensive strategy for ensuring that each resident has the opportunity to achieve their highest level of mental health and personal integrity despite the losses they have shouldered and the challenges they face.

  • Staff will receive adequate training in helping residents cope with and overcome the most common manifestations of psychiatric illness and adjustment reactions in SNFs — depression and anxiety.

  • Caregivers will understand the basics of non-pharmacologic treatment of behavioral disturbances and will employ psychotropics, especially anti-psychotics and benzodiazapines, as a last resort and for the briefest possible duration.

  • SNFs will view behavioral health providers on a co-equal basis with medical professionals and will involve them in all episodes of care where a psychiatric diagnosis is present.

We need to go well beyond simply eliminating the knee-jerk reaction in which every symptom of psychiatric disorder receives a pill (although that will be a good start.) The “revolution” is simply this: We need to assess, understand and care for the unique individuals who are having psychiatric symptoms. We need to explore the meaning behind the symptoms, one resident at a time. We need to find global, person-centered solutions to fit each resident’s needs.

In this context, SNF administrators should now ask themselves: Would you like to bring your use of anti-psychotics and benzodiazapines to an all-time low, improve state survey results and family satisfaction scores, become a 5-Star facility and reward your staff by creating the kind of environment that’s a pleasure for them to come to work in every day? Let’s make it happen!

Richard Juman, Psy.D., is a psychologist and director of psychological services with TeamHealth.