Nursing homes have only reached the tip of the iceberg when it comes to mental health challenges in the sector, with such challenges affecting quality metrics (QMs) and reimbursement amid renewed monitoring of antipsychotics use in facilities.
Operators must start preparing now for behavioral health needs in residents, equipping themselves to handle multiple patient populations. Screening for complex behavioral needs prior to admissions, extended activities hours and in-depth training on crisis intervention and de-escalation skills are all good places to start, Cory Woods, chief clinical officer for California-based Rockport Healthcare Services, told Skilled Nursing News.
Lisa Chubb, chief nursing officer for Venza Care, echoed these thoughts on rising behavioral health challenges needs in the sector, saying that she expects a “tsunami” of challenges linked to unprepared operators and an aversion to taking on complex diagnoses.
Meanwhile, the Centers for Medicare and Medicaid Services (CMS) has a schizophrenia audit focused on potential misdiagnoses in the nursing home, or in the hospital where there are less stringent rules around prescribing antipsychotic medications, among other policy tied to behavioral health needs.
Moreover, misuse of antipsychotics was the focus of an Office of the Inspector General’s (OIG) work plan in March. And given that the presence of work plans could signal future scrutiny, with auditors frequently beginning their review of providers for targeted areas around eight months to a year earlier, addressing mental health challenges is even more urgent now.
“If you have residents that were deemed to not be appropriate for that diagnosis, you ultimately can have your QM suppressed,” said Woods. “If [surveyors] actually audit and find residents that they determine to be misdiagnosed, that in itself impacts the quality metrics, to where it suppresses your QMs in totality.”
Rockport, which operates 70-plus nursing homes in the state, has seen an increase in residents that need behavioral health services in their facilities. Sometimes they are younger patients with psychiatric conditions, and other times it’s older residents with dementia that have behavioral symptoms or a patient with a substance abuse disorder.
And the more challenging a behavior is, the more likely it is to impact other areas, Woods said. If a resident has a psychiatric condition, they may be more likely to get up in the middle of the night and not have good balance.
“Then you’re more likely to see more falls or potentially more falls with injuries,” said Woods. “That really is where that comprehensive care planning process, from an interprofessional perspective, really comes into play to make sure that you’re really putting a solid plan in place for those types of patients.”
Far-reaching effects of behavioral health challenges
In addition to QMs, having a certain amount of schizophrenia diagnoses in a nursing home bars that facility from participating in the recently introduced risk-based audit program.
When it comes to the financial impact of behavioral health challenges, Woods said it’s important to have the right resources to care for residents with a mental health diagnosis.
Rockport uses state resources including Cal Aim, a multi-year initiative led by the state Department of Health Care Services to support the behavioral health of MediCal beneficiaries.
“Reimbursement plays a primary role in providing the necessary resources to really oversee and manage residents with complex behavioral symptoms,” said Woods. “That was the real reason we went back to our payers to say, we’re happy to better support you in getting patients to the right level of care, but we really need the resources in order to do that.”
Increased complex behaviors require increased oversight, one-on-one support and staffing at a very costly level, at least until such behaviors can be stabilized and residents can get to a baseline where they feel safe.
Operators must also consider residents with complex behavioral health needs that fly under the radar – they don’t require one-on-one support, but there might be a triggering event that causes them to lash out or create a situation where there is a high level or high scope and severity deficiency, Woods said.
“You could be facing denial of payment, civil money penalties, fines from the state, and then obviously you go through the process of them coming back in to evaluate whether or not systems and processes have improved to prevent reoccurrence,” said Woods. “That in itself is resource intensive.”
Preparing through education, skills training
Behavioral health preparation will likely involve more education on crisis intervention and de-escalation skills as the need for such services rises, Woods and Chubb said.
Better supporting behavioral health needs starts before admission, Woods said, screening referrals for complex behavioral backgrounds, trauma or substance use, psychiatric conditions. In other words, really understanding what their needs are and being clear about resident-facility compatibility.
Rockport in January also launched a behavioral management training series, recognizing that not all caregivers are equipped to care for more challenging behaviors.
“Our training was comprehensive, identifying resident triggers and teaching the team what escalation looks like and how to de-escalate a situation, how to approach a resident, different types of interventions that you can deploy for residents who have more challenging behaviors, and then when to essentially summon help,” said Woods.
But staff come and go, Woods said, making it difficult for that training to stick in certain buildings. Rockport has started adding the training series as part of onboarding, to get an idea of what’s expected before they hit the floor.
Activities that connect residents with the wider community act as a management tool for complex behavioral needs too, Woods said, mentioning Rockport’s Heart to Serve program as a good example; residents make food for the homeless in their communities, and in turn keep their minds and bodies busy.
“Part of stabilizing residents with behavioral health symptoms is to try to mitigate boredom. When you’re sitting around doing nothing, your brain starts to wander,” said Woods. “We extended our activity hours and made a more robust activities program.”
A change in clinical team makeup might change too, as operators get more comfortable admitting residents with dual diagnoses, Woods and Chubb said.
Across Rockport’s footprint, some nursing homes cater more to behavioral health needs in the community, and so the staff makeup is different, Woods said. These facilities have hallway monitors and increased rounding from psychologists, psychiatrists and in-house, advanced-degree social workers.
“There’s niche populations in some of the centers. In our more focused behavioral health buildings, we have additional resources, additional staff on the floor, hallway monitors, you know degree professionals, and increased rounding from psychologists and psychiatrists to really meet the needs of those patients,” said Woods.
The medical director might be joined by psychiatric providers, social workers and counselors depending on the patient case mix, added Chubb.
Specializing in behavioral health, or at the very least training staff in how to properly care for residents with behavioral health diagnoses, helps people along the care continuum as well, Chubb and Woods said.
“We’re finding niches in every market to take care of those patients and to offload our hospital partners,” said Chubb. “We know that we have to absorb some of that care. A lot of these patients are ending up in our arms.”
Residents that would be best served in a nursing home are sitting in the hospital longer because of their behavioral health needs, added Woods.
“They don’t really need that level of care,” said Woods. “They’re more appropriate for this new space, but they’re more challenging on the behavioral health side. So, they sit longer, which creates a backlog of patients in the hospital that need to move to a lower level.”
Companies featured in this article:
Centers for Medicare & Medicaid Services, CMS, Rockport Healthcare Services, Venza Care
