Challenges providing care for nursing home patients with mental health and behavioral health issues are adding to discharge bottlenecks for hospitals, and the demand for such care has led some facilities to set up specialized units with additional staff just for those patients.
Older adults are suffering from higher rates of mental health and behavioral health problems, which can complicate their recovery from surgery or illness. But accepting those patients for rehabilitation following a hospital stay can be complicated for nursing homes because they can be harder to care for, facilities need to ensure the right staff is available and billing Medicare for behavioral health services can be difficult.The challenge is exacerbating problems hospitals face discharging patients to post-acute care due to staffing shortages.
Related: Nursing homes limiting admissions amid staffing shortages: AHCA
"This really reflects another complex set of challenges hospitals and health systems are facing with respect to moving patients through the care continuum," said Akin Demehin, the American Hospital Association's senior director of quality and safety policy.
Until nursing homes can be properly reimbursed for the additional care patients with mental health and behavioral health disorders require, nursing homes won’t be incentivized to take them, said Jodi Eyigor, director of nursing home quality and policy at LeadingAge, a trade group representing nonprofit nursing homes.
“You have a duty to make sure the resident gets the care that they need and if they can’t get that care at your nursing home, you are doing a complete disservice by admitting them,” Eyigor said.
Rates of anxiety, depression and substance abuse among Americans have been rising since before the COVID-19 pandemic, according to a study published in April by Fair Health, a nonprofit that analyzes healthcare data. The study found the number of patients with mental health diagnoses increased nearly 40% across all age groups between 2019 and 2023 and increased 57.4% among people over age 65.
Mental health and behavioral health are different. Mental health refers to a person’s psychological state and how it impacts wellbeing. Mental health disorders include depression, anxiety, bipolar disorder and schizophrenia. Behavioral health is related to the way an individual’s actions affect their mental and physical health. Behavioral health disorders include substance abuse and eating disorders.
Older adults with mental health or behavioral health issues hospitalized for a medical condition can be more costly to hospitals. A 2020 study from the Massachusetts Center for Health Information and Analysis found those patients remained in acute care for at least a day longer than other patients and were twice as likely to be rehospitalized.
Treatment for mental health disorders and behavioral health disorders differ, but both present unique challenges to post-acute care providers, including longer rehabilitatiion, said Dr. Jeremy Cauwels, chief medical officer for Sanford Health. The Sioux Falls, South Dakota-based nonprofit health system operates 45 medical centers and 132 Good Samaritan Society nursing homes in nine states.
“Many nursing homes have a hard time caring for someone whose body may be very quick to heal, but whose mind is being taken, if you will, in a different direction due to chronic mental illness,” Cauwels said. “Those patients don’t get out of the hospital until they have a place able to accept them and those beds are in very short supply.”
Good Samaritan Society operates a 15-bed behavioral health unit at a 45-bed skilled nursing facility in Canistota, South Dakota. The nonprofit contracts with a behavioral health company to provide care to patients in the unit and also trains staff on non-crisis intervention. Sanford Health staff psychiatrists can provide care to patients at other Good Samaritan Society nursing homes who have a mental health or behavioral health problem.
Taking care of patients with mental health and behavioral health problems adds an extra layer of complexity for nursing homes. For instance, many patients with behavioral health or mental health problems are prescribed antipsychotic drugs, which are more highly regulated and require more clinical oversight, according to DeeAndra Sandgren, Good Samaritan Society’s chief nursing officer.
Patients taking antipsychotic drugs in addition to other medications are also at greater risk for falls, said Dr. Jim Horst, national medical director and chief clinical officer of behavioral health for TeamHealth, which provides clinical staffing to hospital and post-acute providers.
“The drug interactions are really amplified when it comes to fall risk,” Horst said. “These are patients that are in a confused state, they try to get up and go to the bathroom by themselves and then they are on the floor.”
Patients with behavioral health and mental health problems can also be disruptive or intimidating to other patients when integrated into the nursing home, according to some operators.
To prevent that, iCare Health Network separates patients with secondary mental health and behavioral health issues from other patients in secure units at seven of the eleven nursing homes the Manchester, Connecticut-based company operates across Connecticut and Massachusetts.
The units have up to 30 beds and are staffed with a behavioral health director, clinicians that specialize in behavioral health and psychiatrists who round several times a week, according to David Skoczulek, vice president of business development and communications at iCare.
Skoczulek said the company gets referrals from hospitals and even other nursing homes around the Northeast because many operators don’t have the staff or expertise to handle patients with behavioral health issues.
“To effectively and safely care for these residents and ensure quality outcomes, you have to invest in resources, programs and people to do it correctly, which means you must be fully committed,” Skoczulek said. “You can’t just do it with three or five patients. You have to have a whole unit.”
Reimbursment for behavioral heath services for a patient receiving short-term care at a nursing home can also complicate staffing. Medicare Part A, which covers nursing home stays after certain hospitalizations, does not cover behavioral health services provided by clinical social workers that many nursing homes have on staff. However, those services can be provided by licensed mental health counselors and billed separately through Medicare Part B. That usually requires skilled nursing facilities to contract with outside providers for those services.
Both the American Hospital Association and LeadingAge want Congress and the Centers for Medicare and Medicaid Services to develop a holistic reimbursement model that would cover wrap-around services, including behavioral health, for nursing home patients.
