Amina Dubuisson, vice president of clinical services at Ventura Services in Florida, who has been working in health care leadership for over a decade, has noticed a significant change in the skilled nursing provider’s patient population.

As the dust settled after the first three years of the pandemic, she began to notice long-term care residents were being discharged to nursing homes with more complex conditions, and at younger ages. And more patients, some of whom also had dementia, also needed mental health care.

Last year, Ventura Services, which operates 12 facilities across the Sunshine State, underwent a staffing model modernization which Dubuisson said allowed her to have more flexibility in hiring staff that have the expertise specific to the services needed at any given facility.

Specifically, she hired behavioral technicians at two facilities with the highest concentration of younger, ambulatory patients with significant behavioral diagnosis.

“With those residents, we need to focus on the medical issues and the care and services that they need, but their mental health issues also need to be addressed and people need to know how to care for them,” she said.

She said the behavioral technicians help train staff to understand what might trigger patients and how to de-escalate harmful situations.

She also added that offering mental health care benefits a patient’s overall health and can decrease hospitalizations.

“If a patient has a mental health disorder that is not taken care of, it is very hard for them to get the medical care that they need,” she said.

Across the United States, more nursing home operators are confronting the same behavioral health issues among residents that Dubuisson is trying to address. Indeed, 85% of nursing home residents have a mental and behavioral health diagnosis, according to data released in fall 2022 by NORC at the University of Chicago, in conjunction with the National Investment Center for Seniors Housing & Care (NIC).

And as the behavioral health needs of nursing home residents come to the fore, operators not only need to elevate the care they provide, but should brace for more regulatory scrutiny.

“Seeing the way that behavioral units have materialized, memory care units have materialized – patients that are truly long term, their behavioral health needs have risen to the surface. Behavioral health is something that nursing homes are definitely going to be paying attention to, and are paying much more close attention to, as time moves forward,” Joel VanEaton, Broad River Rehab’s EVP of post-acute care regulatory affairs and education, said during a recent appearance on Skilled Nursing News’ Rethink podcast.

Increased mental health awareness

Dan MacDonald, vice president of marketing and communications at American Health Care Partners, said the one “silver lining” of the pandemic was that it brought conversations about mental health to the forefront because isolation rules were so strict.

“You couldn’t have family members come in and visit, and we would do Zoom meetings and stuff like that so people could see their family members, but that whole situation took such a toll on people psychologically and from a mental health perspective,” he said.

American Health Partners provides long-term care and rehab in American Health Communities buildings, and also operates acute-care psychiatric hospitals for older adults.

Lisa Hogan is a psychiatric nurse practitioner and the regional director for seven of American’s nursing homes. She said that patients today are generally living longer with more chronic medical illnesses, and those who have less severe conditions are opting for at-home care. This means that nursing homes are left to cater to a population with tougher mental health needs.

“The ones that are coming to the facilities are much sicker with multiple comorbid conditions,” she said.

For patients with multiple conditions, such as Alzheimer’s and bi-polar disorder, Hogan said it is important to come up with an individualized treatment plan and for staff to understand how the various conditions manifest.

Hogan is also seeing a rise in substance abuse among nursing home residents, and that complicates treatment plans.

“Of those behaviors that we treat in a skilled facility [are] depression, cognitive impairment, and anxiety. Something else we’re seeing is an increase of substance abuse,” she said.

She said that if a patient is admitted with a substance abuse disorder, they can also have comorbidities – such as anxiety or a heart condition – that can drive further medical complexities.

“These comorbidities require closer observation, medications, especially if their plan is to go from the skilled nursing facility to a lower level of care or even to the home setting,” she said. “It would be really important to ensure that they’re connected or on the right treatment plan.”

Hogan said a multi-disciplinary approach can be used to formulate a care plan, decide what the monitoring process is going to be, and conduct meetings to discuss how treatment is progressing.

“So, it’s not necessarily just your direct frontline staff… their care encompasses social services, dietary, certainly clinical, but also from a provider perspective,” she said, that can enhance treatment.

Dubuisson said that the increased emphasis on mental health care can also provide a career path for CNAs. She is currently looking into classes and training requirements for her CNAs who want to become mental health technicians.

“It’s a career ladder from within, retaining your staff because you help them grow,” she said.

Increased regulatory oversight

In January, the Centers for Medicare & Medicaid Services (CMS) announced a plan for targeted, off-site audits focused on whether nursing homes are accurately assessing and coding individuals diagnosed with schizophrenia.

Erroneous schizophrenia diagnoses can lead to inappropriate use of antipsychotic medication. Facilities that are found to have a pattern of inaccurate coding related to schizophrenia will see their Quality Measure ratings dropped to one star, affecting their overall Star Rating.

Such actions from industry watchdogs and regulators could increase in the years ahead, given the prevalence of behavioral health conditions in SNFs. But Dubuisson said that beyond increased regulatory oversight, there is simply more willingness among providers to ensure the highest quality of mental health care. In her additional role as Chair for the Florida Health Care Association, she finds that providers are often interested in learning about how to improve their programming.

“As a health care provider, being a patient and resident advocate, I already see some people that are willing,” she said.

And as regulators increasingly push for nursing home staffing minimums, the provision of behavioral health is also under consideration. In 2022, the Florida Legislature modernized Florida’s staffing standards to allow services provided by behavioral health techs to count toward a daily minimum for hands-on care.

“Mental health service workers play a key role in that process,” Kristen Knapp, Senior Director of Strategy and Communications for the Florida Health Care Association. “These staff members are specially trained to provide the appropriate interventions to better understand what triggers a behavior.”

Knapp added that when facilities improve patient’s mental health, they can reduce their use of antipsychotic medications, enhance their quality of life and improve their clinical and physical outcomes.

“When these staff members deliver treatment that can help residents become less agitated, it helps improve their sleep patterns and emotional well-being,” she said.

Hogan said that at American Health Communities, they are also keeping a close eye on CMS guidelines. “We have a really good open line of communication so that we’re able to just stay current,” she said. “And I think we all want the same thing. We are all striving to achieve the highest level of care and keep the patient as independent as possible.”