Behavioral Health a Barrier to High-Quality Nursing Care

As behavioral health becomes an increasing topic of national discussion, a new study reveals that patients with mental health issues are statistically less likely to be admitted at higher-quality skilled nursing facilities.

Led by Helena Temkin-Greener, professor emeritus at the University of Rochester’s Department of Public Health Sciences, a team of researchers set out to determine if a resident’s behavioral health status affected the kind of nursing care they could receive.

The group used data on 2.8 million admissions at more than 15,000 SNFs between 2012 and 2014, as well as the Centers for Medicare & Medicaid Services’ (CMS) Five-Star Quality Rating System data.


Of those total admissions, 43% were associated with some kind of mental health diagnosis, with more than a third exhibiting depression or anxiety during the study period. In general, the team found that patients with a behavioral health issue were younger than those who weren’t, and more likely to have dual Medicare and Medicaid eligibility.

But they were also more likely to find themselves in a one-star facility and less likely to end up at a five-star SNF, according to the findings: For instance, patents with schizophrenia or anxiety had a 10.7% shot at being admitted to a one-star SNF, as compared to 7.7% for other patients.

The researchers also discovered a slight uptick in the percentage of SNF residents with substance abuse issues, which sat at 1.08% in 2011-2012 gradually rose to 1.24% in 2013-2014.


While the disparities narrowed somewhat after controlling for other variables, the team still concluded that the gap exists — though they were unsure of the exact reasons for the trend. Because residents with behavioral health issues have generally lower socioeconomic status with less stable family lives, the authors speculate that income could play a role.

“Geography may be destiny — that is, patients with behavioral health conditions who are substantially more likely to be dually eligible and of lower socioeconomic status live in areas with fewer five-star [nursing homes],” the team wrote.

In addition, Temkin-Greener and her colleagues cited previous research showing that some nursing homes are more hesitant to admit patients with demonstrated behavioral issues, thus compounding the disparities over time.

“Nursing home administrators also may be concerned about potential behavioral problems and their ability to deal with such in these populations, making their ‘preferences’ clear to hospital discharge specialists,” they wrote.

The results were published in the American Journal of Geriatric Psychiatry.

Written by Alex Spanko

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