Even as Demand Rises, Nursing Homes Face Major Behavioral Health Hurdles

Adding behavioral health services has frequently been floated as a way that nursing homes can diversify their offerings and attract new residents — particularly as demand for the treatment of depression and other mental health issues continues to grow among older Americans.

But a significant swath of operators report persistent challenges in caring for residents with behavioral issues, with a third of facilities in a new nationwide study admitting an inability to completely meet their residents’ behavioral needs.

Providing even basic behavioral health (BH) services was rated as “difficult” or “very difficult” at 20% to 40% of all nursing facilities nationwide, a team from the University of Rochester School of Medicine and Dentistry found.


“Almost half reported that lacking appropriate staff education was an obstacle in providing BH services, and at least one third were not able to adequately meet residents’ BH needs,” the researchers wrote in a study published in the June issue of the Journal of the American Geriatrics Society.. “The ability to provide BH services also influenced NHs’ perceived impact on admissions.”

The University of Rochester team noted that surprisingly little has changed since the 1987 implementation of the Nursing Home Reform Act, better known in the industry as OBRA ’87 for its inclusion in the larger Omnibus Budget Reconciliation Act.

The sweeping OBRA regulatory overhaul included provisions designed to bolster behavioral health access in nursing homes, though multiple surveys conducted in the time since have shown meager improvements at best over the last 30 years — with the Rochester study just adding to the growing base of literature.


“This is troubling as the proportion of the NH population with BH conditions is large and increasing, driven largely by NH admission of residents diagnosed with depression,” the team noted.

Many of the 1,079 nursing homes included in the study identified the same issues when asked about the top concerns associated with admitting patients with behavioral needs: 88.8% cited the need to devote more staff to such residents, while 86.6% mentioned concern for resident and staff safety and 71.9% noted difficulties with sending behavioral health residents back to the hospital.

The researchers acknowledged that Medicaid funding issues represent a key hurdle to many operators.

“Since Medicaid reimbursement rates are generally low, there is little incentive for NHs to enhance these services to long-term care residents (who are largely funded by Medicaid),” they wrote. “Thus, it is not surprising that almost half of NHs reported access to specialized BH services or BH crisis interventions was difficult to very difficult to provide, if available at all.”

The solution for providers, however, may not be as complicated as the nagging nature of the problem could indicate. Jessica Orth, the study’s lead author and a Ph.D. candidate at the University of Rochester, told SNN that there were some clear connections among the SNFs that reported the best performance on behavioral health care.

“Our study found significant associations between the provision of behavioral health services in nursing homes and having behavioral health education and psychiatric training among nursing home staff,” Orth said via e-mail.

For instance, facilities with low turnover of registered nurses — as well as those with RNs who had previously received psychiatric training — were less likely to report issues with meeting residents’ behavioral health needs, while those with high certified nursing assistant (CNA) turnover had a greater chance of reporting difficulty with referrals and transporting residents to certain external services.

In addition, Orth said that the study was just as notable for what the team didn’t find.

“We did not find measures of nursing home quality to be significantly associated with the provision of behavioral health services in nursing homes —- these services were difficult to provide regardless of the nursing homes’ star rating, from one to five stars,” she said. “This calls for future research in understanding the barriers to providing behavioral health services in all nursing homes.”