A Natural Fit: New CMS Requirements Elevate Nursing Homes’ Behavioral Health Role

In recently announced rules of participation, the Centers for Medicare & Medicaid Services (CMS) included several updates related to behavioral health in nursing homes.

The agency aims to further address the rights and available services for residents with mental health needs, including a focus on situations where practitioners or facilities may have inaccurately diagnosed or coded a resident.

This is part of a larger push that CMS is making to elevate clinical practices in an effort to improve quality of care at nursing homes, industry leaders say.


Echoing one of the Biden administration’s initiatives announced at the end of February, another rules of participation update addresses unnecessary use of non-psychotropic drugs and antipsychotics, championing gradual dose reduction for residents that may have come into the setting on such medications.

Devon Hiebert, administrator for Kansas-based Catholic Care Center, said CMS is expanding its focus on behavioral health issues at a national level.

The spotlight comes none too soon, as the nonprofit continuing care retirement community (CCRC) has seen a “significant increase” in mental illness-related diagnoses over the years, especially for those landing in long-term care facilities. Indeed, Catholic Care Center is adding a behavioral health center to its campus as part of a $13 million project.


Catholic Care Center CEO Cindy LaFleur sees the behavioral health updates as a “step in the right direction,” as the industry gets better at assessing age-related anxiety and depression.

“The changes people go through and the losses people go through [as they age], it’s no wonder that there are a lot of psychiatric issues as the aging population continues to live longer,” said LaFleur. “We’ve got to be really well versed and well experienced in this area as well as the physical function.”

While these new regulations appear to be tough and at times punitive, the industry must focus on how they can meet the moment as CMS continues to push the industry in an outcome-driven, highly clinical direction.

“The angst is, how do we do it? The answer continues to stare us right in the face. What we need is better clinical outcomes and we get better clinical outcomes from engaged physicians,” said Dr. Jerry Wilborn, CEO of nursing home physician group GAPS Health. “It’s about engaged providers, truly engaged, when we’re talking about antipsychotic use.”

Dallas, Texas-based GAPS has been working with operator partners to reduce antipsychotic use in facilities for years now – such efforts are part of its central mission.

An appropriate level of communication between behavioral health providers and primary care physicians for residents “hardly exists,” added Wilborn, another major issue CMS is trying to address with its updated rules of participation.

Authors of a July study published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA) make the case for integrating behavioral health in nursing home care – untreated mental health issues in residents was linked to negative care outcomes, limited functional improvements, longer lengths of stay, elevated risk of rehospitalization and mortality.

Updates to the Medicare and Medicaid requirements of participation were originally published in 2016, most being specific to surveyor guidance and to clarify regulatory requirements, providing information on how compliance will be assessed.

“The Feds are pushing a more clinical model. I think a lot of it’s going to be paid for through value-based initiatives that are linked up with outcomes, better outcomes, potentially better revenue,” added Wilborn.

A lot of CMS initiatives, including those that are behavioral health-based, are clinically founded. The problem is, such initiatives are expected to be carried out by non clinicians, Wilborn said, all while the industry is short staffed.

The mismatch between CMS’ agenda and clinician availability poses an “impossibility” for a lot of operators, he added.

Meeting a need

Hiebert and LaFleur have increasingly seen a need for behavioral health services in nursing homes, as mental health facilities are unavailable.

Indeed, this is just one manifestation of a larger unmet need across the United States as mental and behavioral health conditions have increased. More than one-third of Americans live in designated Mental Health Professional Shortage Areas, the Biden Administration noted when rolling out a mental and behavioral health strategy earlier this year.

“We need to be able to position our staff in a way that serves the residents, best address their needs and identify what’s going on with them so we can make appropriate interventions, make sure they’re feeling at home and that they don’t have to go to acute care hospitals,” Hiebert said.

Catholic Care Center, which has operated an Alzheimer’s Foundation of America-certified program since 2007, has seen age-related anxiety and depression at all of their care settings, LaFleur said. The CCRC began construction on a behavioral health addition to its senior living campus, as part of a $13 million project.

The 20-bed geriatric psych unit is a defining aspect of the operator’s three-year strategic process, LaFleur said; renovations are due to be completed June 2023.

She calls the behavioral health updates within rules of participation necessary.

“We support these changes, most definitely. We believe that all of our staff can benefit from applying more of the acute behavioral health strategies. It’s going to be a natural fit and a real supplement to help our staff right here in our building,” said LaFleur. “It’s very much needed to give the quality of life for seniors that we’re wanting to [provide] here.”

In the JAMDA study, authors made a similar point, arguing that a “stepped-care model of integrated behavioral health for SNFs” can increase access to and engagement with behavioral health services, strengthen positive “biopsychosocial” outcomes among residents, and prevent or improve behavioral health concerns among families, partners and staff.

Push for better clinical outcomes

Medication use related to mental and behavioral health has also long been a focus of nursing home quality improvement efforts, and CMS continues to focus on antipsychotic drugs.

But there is a mistaken notion that non-clinical staff can manage antipsychotic use in nursing homes, Wilborn said, and this must be dispelled – with regulations, if necessary.

“No one on the nursing home staff has prescriptive authority, and for good reason. No one’s trained in pharmacology,” said Wilborn. “What’s happened over the years is that the government, CMS and the payers are trying to remedy that there hasn’t been adequate clinician engagement, physician involvement.”

Instead, the industry has been “taking care of its own,” as Wilborn puts it, assuming responsibility for all things clinical.

“It can be shared, but that primary responsibility rests upon the clinician with prescriptive authority,” added WIlborn. “Clinicians in the nursing home, unfortunately, have not been people with prescriptive authority. That’s not how it’s worked, and it needs to change.”

Wilborn feels the industry is at an inflection point, in terms of shifting toward better clinical outcomes via more engaged physicians, rather than focusing on census.

Operators that are more concerned with census, he said, are going to have a “much harder time ahead,” as CMS and the Biden administration continue to push clinical outcomes and a more clinical model in the nursing home setting.

Hiebert says education among staff is another missing component to serving this population that needs behavioral health services, along with Wilborn’s call for clinicians with prescriptive expertise.

Simply knowing how to interact with residents who need behavioral health services can be a crucial piece of education, Hiebert said – this is the Center’s biggest focus as a result of the rule of participation announcement.

“We’re still working through all the other regulatory pieces for care planning and compliance-wise,” added Hiebert.

Moving ahead, LaFleur said she’d like to see more educational support from CMS, as behavioral health training isn’t always taught to nursing home staff just starting in the industry.

“Help us build on our education, our training, our interventions, our crisis intervention pathways that we use, so that our staff across the nation are very well trained and well versed on how to best care for and how to best settle these residents,” added LaFleur.

Companies featured in this article:

, ,