Nursing Home Operators Make Infrastructure, Staffing Changes to Meet Behavioral Health Needs

Some nursing home operators are increasingly finding ways to expand their behavioral health service offerings as need grows and federal oversight hones in on making such services available to long-term care residents.

Kansas-based nonprofit operator Catholic Care Center, for one, has doubled down on its pioneering efforts to make behavioral health readily available to its residents, as an increasing number of elderly people in the state make it harder to find care close by.

Senior care provider National HealthCare Corporation has opened two behavioral health hospitals in Missouri and one in Tennessee – the most recent being a 16-bed geriatric psychiatric hospital earlier this month.

Advertisement

In April, NHC opened a 64-bed psychiatric hospital in Knoxville, Tenn., and later in the year took over a 16-bed location in Osage Beach, Mo.

“We are experiencing a mental health crisis in America,” Shawna Nymeyer, NHC’s vice president of behavioral health, said in an emailed statement to Skilled Nursing News. “Nearly 50% of Americans will be diagnosed with a mental health problem in their lifetime. Our geriatric population is at risk of experiencing a mental health crisis when they have a diagnosis of dementia, Alzheimer’s or even depression.”

Behavioral health is a “new adventure” for NHC, Center for Behavioral Health-Maryland Heights CEO and administrator Sherrie Stafford said in a St. Louis Post-Dispatch article; NHC operates 75 skilled nursing facilities, 24 assisted living communities, five retirement communities, 34 home health agencies and 28 hospice agencies across 10 states, along with its most recent behavioral health hospital endeavors.

Advertisement

“We believe that our geriatric population will have better outcomes when we work with skilled nursing providers, hospitals and other post-acute providers to offer the appropriate level of care in our geriatric hospitals,” added Nymeyer. “We are proud to provide this much-needed care to patients in Missouri and Tennessee.”

Medical directorship company GAPS Health has also expanded its behavioral health offerings to new markets as well – the team will be adding Wisconsin to its existing service offerings in Utah, Idaho and Texas.

GAPS plans to roll out its new behavioral health services in the Wisconsin market in the next couple of months, in further efforts to break down silos between behavioral health clinicians and other experts that would provide medical care to residents.

“It made natural, logical sense for us to start adding behavioral health to some of the services that we do offer to the nursing care facilities,” said Dr. Sonali Wilborn, chief medical officer for GAPS. “We’ve seen a definite uptick in depression, definite uptick in behavioral issues.”

At this point in the pandemic, with staffing shortages to contend with, facilities have had to primarily focus on meeting the needs of residents from a clinical perspective, she said. GAPS is currently in the process of recruiting a psychiatrist or physician, along with advanced practice providers, to serve the rural Wisconsin market.

Niche expansion

Other operators have taken the opportunity to expand on what they’re known for, like Catholic Care Center and behavioral health services, to become a more specialized campus.

Catholic Care Center is developing a new acute care, senior behavioral health unit as part of a $13 million project, according to CEO Cindy LaFleur, along with a memory care unit. The two units are expected to go “hand in hand.”

Renovations will add 18 private rooms in the behavioral health unit for a total of 20 rooms. The Bel Aire, Kan., continuing care retirement community (CCRC) is licensed to offer 119 long-term and skilled beds, along with independent living unit homes, assisted living and memory care.

Once the first phase is complete, Catholic Care will focus on renovating its post-acute care short-term stay unit as well, LaFleur told Skilled Nursing News. Updates are part of a three-year strategic plan with a focus on what the Wichita area and surrounding markets need in terms of services.

Expansion plays on the center’s strengths as well – the team at Catholic Care Center is known for its behavioral health services.

The campus is known for its Alzheimer’s and dementia care as it has had one of the only Alzheimer’s Foundation of America-certified programs since 2007.

Still, during the pandemic Catholic Care’s residents were disrupted out of their living situation if they needed behavioral health services; they were either put on a waiting list or taken to an emergency room where there would be a waiting assessment area, LaFleur said.

Catholic Care needed to find a way to transport residents sometimes 30 miles out of the area to meet these needs.

“There was such a great need for acute senior behavioral health in this community,” LaFleur said. “We began to look at how we could do that within our current environment and do it in a more homelike setting, in a more compassionate way to serve their behavioral health needs.”

As part of its strategic plan, LaFleur worked with board members and community stakeholders throughout Wichita and the state of Kansas to compile a clinical team to specialize in the psychiatric care of seniors in the nursing home environment.

“For the last three years, with all of our community and board stakeholders, we’ve been defining what this step needed to look like. We finally got board approval to move forward with this renovated construction,” added LaFleur.

Catholic Care conducted a comprehensive market study prior to getting the green light for expansion; the data showed there was a definite need in the area. LaFleur worked with local and regional hospitals to understand what was and wasn’t working.

“We took all of that into consideration as well as working with our state agencies, who identified this as a huge need in this area of Kansas as well,” she said.

Looking ahead, Catholic Care has support from its community partners, including nearby hospital systems that have their own behavioral health services.

Behavioral Health: ‘If we won’t, who will?’

It’s very important that operators across the country address age-related anxiety and depression seen in facilities, LaFleur said. Catholic Care’s clinical team seeks to be a continued leader in such services, and that means not shying away from taking referrals from other behavioral health acute units.

“Our team constantly discusses that mantra of, ‘if we won’t, who will?’ We’re going to get expertise in it, and we’re going to say yes,” said LaFleur.

It’s “no wonder” that there is an increasing number of psychiatric issues for people as they age, especially as the aging population continues to live longer, she said. Nursing homes need to be well versed in this area as well as more traditional areas of post-acute and long-term care.

“This is a nationwide problem. It’s not local to one state at this point. This is a trend that is everywhere, and prevalent for sure in rural markets just because of the availability of these specialist providers,” said Jeff Winter, senior vice president of strategic partnerships at GAPS.

Allison Rizer, principal at ATI Advisory, said the nation is experiencing a workforce shortage in the behavioral health space at the same time, as demand outpaces supply. Stigma associated with mental health makes supply and access “even worse,” she said.

Coverage for behavioral health services, meanwhile, is less than stellar. Medicare services aren’t covered until a person needs treatment, rather than prevention, Rizer said. Dual-eligible beneficiaries — when Medicaid is the payer — face “guardrails” on behavioral health services that can be reimbursed in an impatient stay, Rizer added.

The Patient-Driven Payment Model (PDPM) bumped up rates for patients with depression diagnoses, according to Fred Bentley, managing director at ATI, but it’s unclear if the boost translates to improved treatment and management of depression, along with related behavioral health challenges.

The need for behavioral health services spans the care continuum as well – skilled nursing facility turned assisted living center Tekoa Care Center has had to increase staffing and education as behavioral needs become more frequent.

Madison Flake, administrator at Washington-based Tekoa Care Center, said one of the facility’s aides is a specialized support staff member, training to provide one-on-one care when behavioral issues arise.

“They’re helping with 15-minute checks, to check on the residents, and then spend a little bit more time with them one-on-one conversing and helping de-escalate … for more of these behaviors and psychosocial needs,” Flake said.

Tekoa, a center owned by Noble Healthcare, gets behavioral health referrals from all over the state – the 59-bed facility is sought out for this specialization.

The Biden administration and Centers for Medicare & Medicaid Services (CMS) plan to focus on behavioral health services through reform initiatives and, most recently, updates to rules of participation for nursing homes.

CMS 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.

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 Catholic Care Center, said such updates will ultimately help the industry grow in serving this sector of mental health.

“The rules really start to hone in on [the] education of your staff, which honestly, it’s a missing piece in a lot of long-term care,” Hiebert said.

A lot of the work will fall around destigmatizing the perception of behavioral health needs for staff and residents, he added. Administration must make staff feel comfortable in taking on a resident with behavioral health needs.