The use of specialty medical care drops steeply after a nursing home admission, with access to mental health care particularly affected, according to a new study from Harvard University and Beth Deaconess Medical Center in Boston.

Investigators used the Minimum Data Set and Medicare fee-for-service claims to track specialist outpatient visits for new residents before and after their transition to a long-term care facility from 2014 to 2018.

Among approximately 39,000 new residents admitted during 2016 and 2017, 45% had visited a specialist between one year and 24 months before their admission. In the 12 months after transition to an LTC facility, the proportion of visits fell across all medical specialties studied, David Grabowski, PhD, Michael Barnett, MD and colleagues reported.

In need of regular care

These findings held true even among residents with diseases that require regular specialty care, including for those with prior diagnoses of mental illness, the researchers found. For those with severe mental illness, specialist visits fell by 67%.

For other diseases and conditions, such as heart failure, Parkinson’s disease, cancer, arthritis and liver diseases, there also was significant loss of visits to specialist care, ranging from 25% to 42%. Although the study did not examine cause, Barnett and colleagues proposed that low staffing, transportation issues and the lack of caregiver involvement in coordinating visits may play a part in this substantial shift in care access.

Loss of psychiatric care

In an editorial accompanying the study, specialists from the University of Michigan decried the excessive loss of post-transition psychiatric care in nursing facility settings. It is unlikely that new residents with schizophrenia or bipolar disorder “become symptom-free upon admission,” wrote geriatric psychiatrists Lauren Gerlach DO, and MS, Donovan Maust MD, MS.

A shortage of physician specialists, care consolidation and the use of nurse practitioners to provide mental health care may have contributed to this drop in post-admission visits, they said. The larger problem, however, is that nursing homes have become a major institutional setting for adults with serious mental illness, without historical intent, they noted. 

The closing of psychiatric institutions starting in the 1950s was predicated on care being delivered in the community. Now, about 150,000 people with serious mental illness currently live in nursing homes, “a population that equals the entire supply of inpatient psychiatric beds for all conditions and ages across the United States,” they reported. Nursing facilities now are the most important setting of institutional care for adults with serious mental illness aside from prisons and jails, they added.

Telemedicine as a solution

Nursing homes not only should have the resources to provide this care, but “there should also be more emphasis on upstream policies and resources to support individuals with mental illness in community settings, should they wish to remain there,” Gerlach and Donovan wrote. 

Both they and study’s authors suggested that telemedicine could play an important role in connecting new nursing home residents to much-needed specialist care.

Telemedicine has become more widely accepted among senior care providers, and has been a necessary workaround for care delivery during COVID-19 pandemic shutdowns. In 2022, a group of mental health providers published guidance on telemedicine best practices for managing psychosis in long-term care settings.

The study was published in the Journal of the American Geriatrics Society.

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