In a health care landscape full of challenges, staffing consistently ranks as the top concern for skilled nursing facilities. But the second-most prevalent concern is patients and residents who have mental health needs and substance use disorders, according to a top federal official — and there are no easy answers for how SNFs should cope.

“A lot of times we get the question of: CMS, what do you want us to do? If we didn’t take these people, they would have ended up on the street; you should be grateful that we’re taking them,” Evan Shulman, the director of the division of nursing homes at the Centers for Medicare & Medicaid Services, said in a Tuesday update to providers at the American Health Care Association (AHCA) annual convention and expo in Orlando, Fla. “Unfortunately, I don’t have a straight answer for you. It really depends.”

The issue of what to do with such patients and residents is a thorny one for SNFs. The provider Athena Health Care Systems reached a settlement with the federal government last month over claims that it discriminated against residents with opioid use disorder; it marked the second investigation into opioid-related denials by SNFs, and it highlighted some of the challenges that facilities face when dealing with these residents.

One study from the University of Rochester found that adding even basic behavioral health services was “difficult” or “very difficult” for 20% to 40% of all nursing facilities across the country, and the researchers noted that it tied into the top challenge for SNFS: staffing.

“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.

Though behavioral health issues can encompass more than substance use disorders or mental health issues, the number of seniors who have them is increasing, according to the University of Rochester study. For SNFs, there are some common trouble sports for patients who have mental health and substance use issues, which Shulman outlined in his presentation.

The first area relates to the information provided by hospitals about a given patient. In one case, a patient admitted to a SNF from the hospital had three missing pages of paperwork — pages that detailed the resident’s attempted suicide, Shulman said. But the lack of accurate information from the hospital is a widespread problem in many cases, he added.

“For hospitals, we’re going to need to hold them more accountable,” he acknowledged. “CMS just finalized a new discharge planning rule which does have new requirements related to discharges, and we hope that that will help.”

The second place where SNFs run into issues with patients who have mental health and substance use needs is harder to regulate: changes in the condition of the patients. In this case, when a resident is first admitted, their medical condition is the first and foremost issue being treated. After that problem is addressed, however, then the mental health or substance use disorder flares up.

In this situation, one of two things needs to happen, according to Shulman. The facility can either implement actions to meet the needs of the patient, or transfer the patient; the latter option comes with very specific requirements that the SNF has to meet.

“We’re not saying that the resident can’t be transferred or discharged, but we are saying the requirements for doing so need to be met,” Shulman emphasized. “This includes identifying and demonstrating the attempts that were made to meet the resident’s needs.”

The third scenario for such patients is that some facilities take them in knowing the risks the population represents. In some of those cases, the SNF should be providing more resources and delivering more care, Shulman said. But in other cases, the resident never should have been admitted in the first place.

That said, SNFs can’t get away with poor care by saying the patients would be on the street otherwise, Shulman stressed.

“That may be true, but that’s not going to cut it,” he said. “It gives the perception that because the alternative is worse, then we don’t have to deliver the quality of care that they need.”

But he also acknowledged the inherent difficulty SNFs face in treating this population, which tend to be “younger, more mobile, more tech savvy,” in his words. It’s a problem multiple providers have pointed out; Stephen Black, vice president of operations at Generations Healthcare, emphasized at the LTC 100 Conference earlier this year that this population is not, for the most part, appropriate for SNFs.

And it creates challenges when SNFs must deal with regulations that are geared toward another population entirely, Rick Destefane, the CEO of Reliant Care Management, said in an interview with Skilled Nursing News.

“We take care of people that suffer from mental illness,” he told SNN last year. “And that alone brings a lot of problems, because the regulations both from the state and the federal side are geared toward the general geriatric population. So we have to walk a fine line with the surveying process.”

Shulman also noted that regulators — not just providers — need to step up.

“It’s very easy for me to sit here and describe these different scenarios, so we’re all going to have to band together — including what we need to do here at CMS in terms of guidance,” he said.

There are concrete steps SNFs can take to better manage the population, Shulman pointed out in his AHCA presentation. Internally, SNFs can take a look at activities and try to gear some of them more toward their residents with mental and substance use issues — with an eye on the behaviors that might lead to problems, and the goal of developing activities to help them to a healthier lifestyle.

Externally, there are already several partnerships between nursing homes and addiction centers and mental health centers, and SNFs should continue to take advantage of them, Shulman said. Some might be able to provide training, while others might be able to consult when an episode occurs.

Shulman encouraged SNFs to continue building such relationships, and he praised the work that SNFs are already doing to address the needs of the SNF population with such problems.

“Many of you are already doing this,” he said. “As a matter of fact, I know that many of you are already sort of the silent saviors of this population … you have become sort of the unexpected caregivers.”