How Integrative Care Improves Life for Nursing Home Patients With Mental Health Diagnoses
Natalie Truesdell is a consultant with John Snow, Inc, which has been providing evaluation services to the MeHAF Integration Initiative since 2009.
Mental illness, dementia and other behavioral health conditions in the nursing home are well-recognized challenges in both the clinical and policy arenas. It is estimated that 65-91% of adults in a nursing home have a significant mental disorder, such as depression or dementia.
As one of MeHAF's 43 Integration Initiative grants, the Northeast Integrated Geriatrics Care project focused on changing the way mental health care is provided to elderly people, both in the nursing home and in the hospital. The Rosscare Nursing Homes led the project in its network of four homes, partnering with Eastern Maine Medical Center and the Acadia Hospital.
Rosscare found that older adults with mental health or dementia diagnoses were staying in the hospital for extended periods of time, even after their acute medical needs had been met. For example,from October 2008 through June 2009 there were 14 geriatric extended-stay patients who were in the hospital a total of 557 days with an average cost of stay for each patient of $724,100. To make matters worse, their mental health deteriorated as a result of staying in the disorienting hospital environment.
Often the reason these patients were not discharged to nursing homes was because nursing home staff did not feel prepared to care for patients with behavioral health conditions. Of course, many of these homes already had patients with mental health needs, for whom there was a lack of ongoing psychiatric evaluation and care.
Through effective collaboration between the hospitals and the nursing homes, The Northeast Integrated Geriatrics Care project focused on changes to effectively address these ongoing challenges.
At the Hospital
Eastern Maine Medical Center (EMMC) developed a new unit designed and staffed specifically for older adults with acute behavioral health needs. It includes:
- an interdisciplinary geriatrics consult team supported by Acadia Hospital, the inpatient psychiatric hospital affiliated with EMMC;
- training provided by Acadia Hospital to help all nursing home staff work more effectively with patients living with mental and behavioral disorders;
- regular rounds by a geriatric psychiatrist from Acadia;
- addition of a licensed clinical social worker (LCSW) to smooth transitions to the nursing home; and
- redesign of the environment with color cues to reduce disorientation.
At the Nursing Home
Changes at the nursing home include:
- continuity of care provided by the LCSW;
- frequent geriatric psychiatric evaluations andfollow-up care;
- frequent evaluations accessible through telemedicine; and
- additional training of nursing facility staffon behavior management, mental health conditions, and strategies to serve residents with more complex needs.
The program increased the number of adults who could be appropriately cared for in a nursing home, reducing the average length of stay for adults with behavioral health conditions in the hospital from an average of 45 days to 6 days. Patient satisfaction in the geriatric inpatient unit improved substantially, and the need for antipsychotics was reduced.
Patients receiving integrated behavioral health services at the four participating nursing homes showed an improvement in both mood and behavior. Emergency room visits due to behavioral needs were eliminated. Nursing homes now accept patients they previously would have denied. For example, a patient who had been at Acadia Hospital for over 100 days because no facility would accept him was successfully transitioned to a Rosscare nursing home with the support of the LCSW. Eventually, he was able to return to community care.
Often, small things can help patients feel more at ease in a nursing home. One role of the LCSW is finding ways to accommodate patients and support their often unsettling transitions to a new environment. For example, one woman had a favorite TV show that was not available on the television channels at the nursing home. The LCSW worked with administrative staff to obtain recordings of the patient's favorite show, making the patient happier and, ultimately, helping her to heal.
The Northeast Integrated Geriatrics Care program has made significant improvements for the staff and older adult patients of EMHS. The full report offers guidance for other health systems seeking to incorporate the innovations shown to be effective at EMHS.