Nursing Homes Eye Behavioral Health, But the Service Line Can Come With a High Price Tag

Behavioral health has become an attractive — and sorely needed — service line for skilled nursing facilities, but operators often don’t have the resources for training, and reimbursements aren’t as good as serving higher acuity patients.

Isolation tied to the pandemic, and the Centers for Medicare and Medicaid Services (CMS) “crusade” several years ago to move away from psychotropic drugs in facilities, have pushed operators to invest more in the service line, according to Chaparral House Executive Director KJ Page.

The move translates to residents having greater access to therapy sessions with psychologists — who can’t prescribe medications, unlike psychiatrists.

Advertisement

Berkeley, Calif.-based Chaparral House does not have a psychiatrist on hand or prescribe psychotropic drugs to its residents, a move Page says is “rare” in the industry.

“Most places have a pretty high ratio of psychrotrophic [drugs] with dementia [patients],” Page said. “There are quite a few that took it seriously in 2016 and are working well … to keep the psychotropics [use] down. We have a special drive to do that and to not use benzodiazepines because they’re so dangerous to people. It’s something my board of directors and my medical director embraced and leadership took off with it. That’s part of our culture.”

Shift to therapy

Advertisement

Tiana Thompson, CEO of We Care Psychology Affiliates in Montclair, Calif., said her company finds and provides both psychiatrists and psychologists to nursing homes depending on the need.

“Sometimes [operators] need a diagnosis, they don’t have a diagnosis about what’s going on with the resident and so the psychologists, psychiatric nurse practitioners, psychiatric physician assistants … help in all areas, provide psychotherapy, along with some evaluations and dementia screening, cognitive screening,” said Thompson, who is also a former nursing home and assisted living administrator.

Thompson has seen a 30% increase in client need since she founded We Care three years ago, with operators more recently asking for psychologists as well as psychiatrists, “coupled” together as a team.

“We’ve always had psychiatry, but most [behavioral health vendors] haven’t really had psychologists to provide the therapy part,” said Thompson. “A lot of operators are knowing that it’s a need, that’s why they’re reaching out. That’s why we get referrals from other physicians.”

Page did mention that there are facilities that focus on geropsych residents — geriatric residents with a long history of psychiatric diagnoses — and that you’d expect psychotropic drug use to be higher in these places.

Facilities that prescribe psychotropic drugs to residents without the diagnosis of a mental illness might see a drop in quality measures, or a facility’s star ratings, Page said.

“By the same token, last week the New York Times had an article about how many people were diagnosed with schizophrenia in their eighth decade [of life] where it’s unlikely,” added Page. “If you’re over 40 and you’re not schizophrenic, you’re not going to develop it late in life. And so, people put on the diagnosis of schizophrenia so they could use the sedation and not have it trigger on their quality measures.”

The Times investigation found that at least 21% of nursing home residents are on psychotropic drugs in order to avoid hiring more staff at facilities.

Costly service line

Behavioral health services are a viable service line to add if an operator can afford it.

Reimbursements for behavioral services aren’t lucrative, compared to serving higher acuity patients. Medicare Part B, Page said, pays for higher acuity services like wound care, diabetics or dialysis.

Behavioral health is billed directly from the psychologist to CMS; the operator often doesn’t get involved at all, added Page, since there’s no billing codes available to them for behavioral interventions.

Chaparral House was able to use Provider Relief Funds to hire a psychologist to visit its residents with dementia, since they were isolated during the pandemic and unable to participate in social activities.

“You can’t do therapy on someone with dementia, so it wasn’t really billable as therapy, but what you can do is social interaction. That’s what we hired her to do, we paid her for the people you couldn’t bill Medicare for because clearly it’s not therapy, but it was therapeutic and it was social,” said Page.

It’s difficult to place, or get a referral for a resident with behavioral problems, Page said, because there’s no incentive to take them.

“The money is the same. That’s the problem right there. I can only take people for whom I can provide care, and there are certain types of behaviors I know right away I can’t, I just can’t keep them safe. I can’t keep other people safe, I can’t do it because of the layout of my building or because of the number of staff … there’s all sorts of reasons,” added Page.

Previous reports have indicated the shift to higher acuity patients in nursing homes, with assisted living and home care taking residents that don’t need as much skilled care. Higher acuity patients and those with behavioral health issues are two very different groups of potential residents however, Page said.

“The more physically sick someone is, the less likely they’re going to be walking around, having behavioral issues,” explained Page. “Most people with dementia are ending up in assisted living off their own expense and when they run out of money then they come into skilled nursing.”

It’s easier to train staff in acute care than behavioral health, Page added, since the principles are easier to teach and the cases don’t widely vary within a single diagnosis.

“A stage four wound is a stage four wound, there are some variations, diabetic and other complicating factors but it’s the same body of knowledge,” noted Page.

Behavioral health training, on the other hand, with its variability from person to person, is much more difficult to “train and learn and be good at,” said Page. In California, required behavioral health training just for dementia patients is usually 18 hours every two years for certified nursing assistants (CNAs), and facilities can choose from CMS-approved programs put out by the Alzheimer’s Association, among other organizations.

“It’s one of our strongest needs because of all the folks with dementia. We need a lot of training on [behavioral health practices] and there are not a lot of good solutions out there,” noted Page.

Companies featured in this article:

,