Patients in skilled nursing facilities need more than just physical care — and SNFs are wisely delivering it. The inclusion of behavioral care with primary care in the skilled nursing setting is an essential development for SNFs. The question, of course, is how best to integrate behavioral health into the care continuum.
According to one expert, the path to success is in three pillars. Behavioral health care in skilled nursing must be:
- Holistic and proactive
- Delivering consistency in medication management
- Communicated with clear objectives
“Primary care providers have a lot on their plate. They have to spend a lot of time dealing with multiple other medical conditions, and psychiatry takes a lot of time, and a lot of discovery and resources that they really don’t have, frankly,” says Dr. Jim Horst of TeamHealth, the nation’s leading integrated physician practice and provider of post-acute services. “If it is just up to them, they’ve got to go beyond just the monthly gradual dose reductions that are presented by the pharmacist. They need to take a holistic and global view of what is the possibility for reductions in the patient’s medications and/or limiting the medications overall.”
With the right approach to behavioral health, skilled care providers can gain three key benefits:
- Reduced hospital readmissions
- Reduced fall risk
- A new model for staff-appropriate approaches to behavioral health patients
Reduce hospital readmissions
According to new research from the National Council on Aging (NCOA), nearly 95% of adults 60 or older have at least one chronic health condition, while nearly 80% have two or more. That’s a lot of medication to manage, and hence a big risk that something can go wrong.
“The number one reason for readmission from a nursing home is a change in mental status, and the number one reason for change in mental status is generally a delirium state,” Horst says. “The most common cause of a delirium state is usually something that happens with a patient’s medication, be it a drug, drug interaction, a side effect, an allergy, and so on.”
While medication management isn’t new in skilled care, viewing it through a behavioral health lens can enhance a skilled nursing provider’s understanding of the inherent risks for patients who are on multiple medications. SNFs utilizing a Chronic Care Management program goes a long way to keeping their patients exactly where they need to be.
“Not having a holistic, proactive approach to understanding the nuances of the medications and their potential for interactions and side effects can lead to readmissions,” Horst says. “SNFs should seek to use the least amount of medication that’s most effective, limit the overall number of medications and reduce polypharmacy.”
Reduce fall risk
When a SNF patient experiences an error in medication management, fall risk rises. And falls are literally a killer, resulting in more than 32,000 deaths annually according to the CDC. Each year, about three million older adults end up in an emergency department due to a fall. Those are residents who are leaving a SNF, and doing so with a variety of injuries that make life more difficult after their hospitalization.
While a change in medication, or negative drug interactions, won’t lead to grogginess or a possible fall for all SNF patients, it will for some. An integrated behavioral health program can help SNFs recognize which patients are most at risk. More broadly, a behavioral health specialist can map a broader history of each patient to show why they need a certain medication to begin with, or why they once did and no longer do.
“As you look at the landscape of long-term care, there are 2.5 psychiatric medications per resident, which is extreme. Of those, only 10% have seen a behavioral health specialist. They’ve been prescribed by their neurologist, their primary care, their OB-GYN, you name it,” Horst says. A behavioral health specialist can help primary care providers in a SNF understand a patient’s history, which can lead to better decisions around medication and a pre-emptive correction against falls.
“Just understanding the history allows us to move the path forward, and in understanding that we can have the staff, again, be on the front lines and understanding when these patients are on certain medications and why they’re on it,” Horst says. “A study by a large national provider in North Carolina showed a 20% reduction of falls and readmissions when there was an IBH (integrated behavioral health) consultant who had regular rounding in those facilities.”
How behavioral health care can help reduce staff turnover
As Dr. Horst notes, long-term care is one of the top three areas of impact for psychology and psychiatry pathology after correctional institutions and the unhoused. This is often a strain on post-acute care staff members who might not enter the field to handle behavioral health challenges.
“When people come in the front door and realize that this is now the long-term care solution for the chronically mentally ill — not just the elderly — it can be a little jarring,” he says. “Most often when I have discussions with the frontline staff, they say, ‘I did not sign up for this.’ They truly expected little old ladies. Just having that perspective gives them a bias against their population, so really trying to reorient and reeducate is the key to that success.”
Specifically, Horst says an integrated behavioral health plan allows SNFs to re-direct staff members into three staff-appropriate approaches to behavioral health patients:
- To learn how to adjust your expectations and meet the patients where they are, something he calls “check yourself first”
- To learn how to be consistent by setting limits and boundaries with patients
- To execute on the 3 S’s: smile, sound, stance. That is: smile, control the sound of your voice by staying calm, and take an even stance physically with patients
“As a consultant that goes into nursing homes, I can’t tell you how many times I have had the frontline staff say to me, ‘Oh, they’re worse than they ever were.’ Then I go to the chart, and their behavior charting are all zeros,” he says. “You just become, if you will, broken down on putting in your 100% effort into treating these patients, and part of the treatment of the patients is appropriate documentation. Just aligning that will help everyone.”
This Views article is sponsored by TeamHealth. To learn more about how TeamHealth can help your facility improve your behavioral health offering, visit TeamHealth.com.