Long-term care facilities are admitting more residents with longstanding psychiatric illnesses. Such individuals enter the nursing home for physical rehabilitation but are difficult to discharge back to the community due to their mental health needs, weak or nonexistent support networks and unstable prior housing situations.
This column focuses on why the severely mentally ill (SMI) population is increasing, and the impacts of this change and on strategies to manage care.
A mounting possibility
I predict we’ll be seeing greater numbers of SMI residents due to the combination of factors outlined below.
The movement toward deinstitutionalization in the 1970s and 1980s closed many psychiatric facilities without increasing community assistance. Because of the lack of community resources, parents of children with severe mental illness frequently became their lifelong supports.
Many SMI people are now over 50 years old; their caregiver parents are in their seventies and eighties. Older parents are less able to provide financial, practical and emotional aid for their adult children due to their own aging and health problems.
In addition, as adults with SMI get older themselves, they’re increasingly likely to experience medical problems requiring hospitalization and rehab, which brings them to our doors.
To estimate the numbers of older SMI individuals, I looked at statistics on mental illness and aging. According to the National Institute of Mental Health (NIMH), 2.7% of US adults aged 50 and older were diagnosed with SMI in 2016. In 2014, AARP notes that there were 108.7 million people aged 50 and over in the US. Combining these statistics gives us a rough estimate of almost 3 million SMI adults over age 50 in the US, with the number increasing as the baby boomers age.
I looked at the statistics on LTCfocus.org to ascertain whether this trend toward increasing numbers of people with SMI in LTC is beginning. The data show the numbers of residents diagnosed with schizophrenia and bipolar disorder between the years of 2000 and 2016. In my state, New York, 6.45% of residents had those diagnoses in 2000; in 2016 it was 11.8%. In Pennsylvania, the numbers increased during that time period from 4.45% to 9.3%. California: 8.87% to 15%. Texas: 4.91% to 13.4%.
The pattern is clear.
As a complicating factor, the US healthcare system has distinguished between treatment for physical health and mental health. There are very few institutional or community resources that are able to care for people with both physical and mental health impairments. There is virtually nowhere to discharge residents without family support who need assistance for comorbid medical disorders and severe mental illness.
Thus we have a perfect storm of treatment failures for our aging severely mental ill population and one that’s likely become more critical as the number of aging SMI individuals increases due to demographic shifts.
Why it’s a problem for facilities
There are a number reasons that nursing facilities are not suitable homes for people with severe mental illness, including:
- Behavior problems are difficult to control in an environment that isn’t staffed and trained to handle psychiatric illness.
- Pressure to reduce the dosage of psychiatric medications is inappropriate for these residents.
- They can consume vast amounts of staff time due to their interpersonal challenges.
- Facilities are operating out of their area of expertise, exposing themselves to legal risks.
- Younger, relatively physically healthy residents with or without behavior issues may be frightening to older residents and their families.
- Once the admitting diagnosis has been resolved, the reimbursement rate for these residents tends to be low.
Why it’s a problem for the SMI resident
People with severe mental illness may be getting the proverbial “three hots and a cot,” but long-term care facilities are inappropriate because:
- SMI residents may alienate staff and other residents with their behaviors, creating a negative environment among people who don’t understand mental illness.
- Alternatively, they may fade into the background because they’re not “causing problems.” They therefore don’t get the attention they need for their mental health issues.
- Because they tend to be relatively young, they may be looking at 10, 20 or even 30 years in a setting that isn’t the least restrictive environment for care.
Strategies for care
Aging families of SMI individuals are often relieved that their loved ones are in long-term care facilities, knowing that they’re safe after a lifetime of instability. Without regulation, appropriate alternative housing or family pressure to discharge SMI residents, it’s up to nursing homes themselves to address this problem.
Here are some ideas:
- Utilize consulting psychologists and psychiatrists consistently and early in admission.
- Train staff to recognize and manage mental illness.
- Develop therapeutic recreation programs that make use of the strengths of younger, stable SMI residents.
- Establish strong relationships with local psychiatric hospitals so that transfers result in meaningful care rather than an hour or so in the emergency department before a return to the facility.
- Become a crusader for local community resources such as adult homes equipped to treat mental health and physical illnesses.
- Encourage collaboration between LTC trade associations and advocates for mentally ill individuals to address the needs of aging SMI people.
We frequently hear about the tragedy of severely mentally ill inmates in jails and prisons. According to a 2016 report by the Treatment Advocacy Center, approximately 20% of inmates in jails and 15% of inmates in state prisons are estimated to have a serious mental illness. Based on the information gleaned from LTCfocus.org, long-term care is swiftly approaching those numbers.
A nursing home environment, while arguably more pleasant than a prison and not quite as confining, is also inappropriate for people with severe mental illness.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.