As demand for behavioral health services continues to rise in the nursing home setting amid regulatory pressures and staffing shortages, one university-based program in the state of New York is looking to fill the gaps.

The digitally enabled behavioral health program, which first got off the ground back in 2017 with funding from the Centers for Medicare & Medicaid Services (CMS) Delivery System Reform Incentive Payment (DRISP) programs, has grown from 29 nursing homes at the beginning of the two-year demonstration — to most recently expanding the program to facilities across the state.

From 2017 to 2019, antipsychotic use among long-stay residents in the participating homes decreased by 37%, according to a case study published in NEJM Catalyst. During the pandemic the program’s services grew to 53 nursing homes.

The need for behavioral health services in nursing homes have only been exacerbated by the effects of Covid-19 but those services were required long before a global pandemic.

From 2007 to 2017, the prevalence of nursing home residents with serious mental illness increased by 77% — yet only 1 in 10 counties in the United States has a practicing geriatric psychiatrist, according to the case study.

Before the state’s office of mental health partnered with the University of Rochester program back in 2019 it had 500 or more residents waiting for nursing home placement. That number is now in or near the single digits, according to the case study.

“The pandemic has been devastating to the nursing homes. Many of our residents were confined to their rooms or to their units for many months during the pandemic and that had real tangible impacts on their mental health, a lot more anxiety and depression,” said Adam Simning, assistant professor in the Department of Psychiatry at the University of Rochester Medical Center.

And it’s also more than just zeroing in on mental illness, anxiety and depression — it’s also quality of life, according to Simning.

“We focus on mental illness, anxiety and depression, but there’s a flip side of that, there’s just quality of life, there’s well being. Sometimes just by focusing on the residents’ well-being will then in turn reduce anxiety, depression, so it’s really nice to be able to take a more holistic view of the residents in the context of their home,” he said.

Overall, those involved in the program believe they have demonstrated that a telehealth program that includes onsite nurse support, telepsychiatry, telepsychotherapy and telemonitoring can improve access to behavioral health services in nursing homes and improve both quality measures and outcomes, according to the case study.

Challenges faced

Researchers faced challenges involving nursing home credentialing, initial buy-in, continued engagement and program sustainability when getting the program up and running.

The case study noted that some nursing homes “quickly and enthusiastically” participated in the behavioral health program, while others expressed reservations about how the telepsychiatry visits would work and how this would change workflow.

Staffing also played a significant role in continued engagement with the program. Both the telepsychiatry and and onsite visits require the nursing home staff to be involved, and that proved challenging when staffing was limited due to ongoing industry shortages.

“Identifying a nursing home champion was essential to sustained engagement, and the monthly onsite program nurse visits were necessary to train new staff,” authors wrote.

In spite of those challenges, developing relationships with nursing home decision-makers and keeping track of quality metrics, while sharing those findings with potential funders, were all part of boosting the program’s sustainability.

Developing a similar program

Report authors noted that to create and implement a similar program to the one developed at the university, it should have: identified funders, selective partnerships with nursing homes, onsite implementation visits and the ability to track quality metrics.

On the topic of funding, while it was noted that telehealth has grown considerably over the course of the pandemic on a national scale, many of those efforts are temporary and creating a similar program would depend on telehealth payer support.

When picking nursing home partners, the report said working with facility social workers was “instrumental” in identifying and referring residents to such services.

While Simning believes the program could be replicated in other states, he does recognize the challenges presented in the realities of living in a largely fee-for-service health care world.

“For this program to spread to other states, it’s really important to look at ways of different funding mechanisms … Staff education isn’t really something that’s typically easy to reimburse,” he said.

Zhi-Yan Tsun, resident physician, department of psychiatry, University of Rochester Medical Center; Nirav Shah, senior scholar, clinical excellence research center, Stanford University School of Medicine; Elizabeth Santos, associate professor, department of psychiatry, University of Rochester Medical Center; Lara Press-Ellingham, senior health project coordinator, department of psychiatry, University of Rochester Medical Center; and Michael J. Hasselberg, chief digital health officer, associate professor, University of Rochester Medical Center were also involved in the program.