Coming out of three-plus years of isolation and uncertainty during the worst of the pandemic, perhaps it’s not a surprise that the nation’s nursing homes residents are suffering from increased indications of anxiety and depression.
The number of residents that show clear signs of behavioral health challenges is coupled with, in some cases, a severe lack of licensed psychologists and social workers for the setting, according to Dr. Daniel Heiser, senior vice president of behavioral health and clinical psychologist at GuideStar Eldercare.
In other words, the workload has increased with less staff to take it on.
The gap in behavioral health services and staff was exacerbated during the pandemic like many other aspects in the sector, but Heiser is glad the service line is getting attention now.
GuideStar, based in Indiana, provides on-site neurobehavioral and psychiatric services to nursing homes in Texas, Michigan, Ohio, Kentucky and Illinois.
There’s a growing awareness from federal and state agencies that residents need stimulation in order to forego worsening cognitive levels, according to Heiser. Residents need interaction with staff, activities and professionals coming into the building to see them, talk to them and assess them.
“There’s a growing need in terms of residents who are struggling, and then I think there’s an increased appreciation for how residents in nursing homes benefit when they are receiving different levels of interaction and assessment,” noted Heiser.
Facilities draw post-pandemic parameters
While LifeSource Inc., another behavioral health service provider based in North Carolina, has not experienced tight staff reductions like GuideStar has, the team has noticed a difference in the level of care nursing homes are asking for from behavioral health providers.
“It’s strange because prior to the pandemic, there were a lot of rules for us, of how much and how often we could see [residents] despite diagnoses or despite concerns and behaviors,” said Dr. Lori Tirado, a psychologist and consultant with LifeSource. “When the pandemic came around it opened up a little bit.”
Now that Covid’s impact on the sector has lessened, she has seen facilities revert back to behavioral health visits on a much more limited basis.
“I always say therapy is not meant to be forever, but only having so many sessions – I think that’s hard,” Tirado said.
Facilities, mental health providers and government agencies are still trying to strike a balance between what residents need and what can be provided based on the resources available, she said.
“After all these years, we’re still struggling with trying to stand up for mental health. I hoped what we were seeing during Covid would continue. We were allowed to do our job and to help out; it felt good to be a support,” Tirado said.
Educating staff for holistic care
Heiser has been providing behavioral health services to the long-term care space for more than a decade – early in his career, he saw a lot of “confusing diagnoses” in the nursing home setting by clinicians outside of the behavioral health speciality.
One example of many, he said, was a misdiagnosis of obsessive compulsive disorder. In this case, the resident ended up having dementia and didn’t have the cognitive capacity to have obsessive thoughts, he said.
Misdiagnoses pointed toward the solution – more behavioral health specialists in the nursing home space, first, and also more education on the part of LPNs, RNs and CNAs.
The Centers for Medicare and Medicaid Services (CMS), as part of its Phase 3 conditions of participation, added a requirement for behavioral health training including trauma-informed care. Heiser believes the agency will continue to focus on behavioral health in this way.
“When we’re looking at psychotropic reductions, our nurse practitioner needs to be at that meeting, needs to bring the [GuideStar] team’s notes, impressions. I think you’re going to hear more and more of a fully integrated model including the primary care physician as much as possible,” he said.
Trauma-informed care especially is a collaborative effort, Tirado added, both within the context of the pandemic and outside of it.
“I’m gathering information from the nurses and CNAs, even the activities department,” Tirado said. “During Covid, [collaboration] was really difficult with staffing shortages, you had agency staff.”
There were a lot of false starts as residents had to be continually introduced to new faces and become comfortable with agency staff coming in or new hires.
What legislators can do next to increase the pool of behavioral health staff
Social workers and nurse practitioners have helped fill the gap to a degree especially in rural settings, but Heiser feels CMS needs to open up Medicare reimbursement even more to other positions like licensed mental health counselors.
Waivers tied to the public health emergency, specifically those dealing with telehealth, could help behavioral health providers continue to deliver care, although GuideStar prefers to serve residents in person, Heiser said.
“There are a lot of behavioral health folks with that training and with that background who I think would be a good fit but currently, Medicare does not pay for them,” he said. “That reduces the pool of behavioral health folks that you’re going to see providing clinical services.”
GuideStar is 40-50% below where they’d like to be in terms of behavioral health staffing.
“We have a very strong philosophy that diagnosis drives treatment. As we grew, it really became a recruiting issue – we simply could not find and hire enough psychologists to keep up with the growing patients we’re taking care of in nursing homes,” he said.
Heiser said their company would need to bring on 15-20 more psychologists and social workers just to bring their staffing ratio up to where it needs to be, to consistently provide care under its internal clinical model.
“It’s still hard to find folks who either understand the need or are aware of the need … in nursing homes,” he added. “It’s helpful if somebody has geriatric experience, but it has never been a requirement for any of our staff. I think that would significantly limit the number of people that would join our company.”
Some state Medicaid programs, including Ohio, allow behavioral health groups to hire behavioral health clinicians without a master of social work license, he said — something that is a requirement in other states.
In order to get reimbursed by Medicare though, licensed psychologists, social workers and nurse practitioners must make up a BH team at the nursing home. GuideStar’s primary source of funding is Medicare, he added.
The potential good news is there was a bipartisan bill introduced in Congress in March 2021 to change the reimbursement rate for social workers in the nursing home, but it hasn’t moved past committee since that time. The role currently gets reimbursed at 75% of what Medicare Part B would pay for a licensed psychologist.
Heiser hopes such legislation, if passed, will open the door for more types of counselors to be able to practice in the nursing home.
“I think that would do nothing more than enlarge the pool of possible candidates to bring in to work in this setting,” he said.
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