Psychiatry in the Nursing Home

D. Peter Birkett

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135187477
• Topic: Medizin
• Subtopic: Krankenpflege

Get the vital clinical information you need with this comprehensive handbook!In the decade since the first edition of this book, dramatic changes have taken place in the field of geriatric psychiatry. Psychiatry in the Nursing Home, Second Edition, presents timely information on the newest trends in law, culture, and medications, while still offering essential advice on the fundamental concerns of caring for elderly patients with mental illnesses. The new edition of this essential handbook presents up-to-date information on psychiatric issues involving nursing home patients. Featuring helpful case histories and diagnostic criteria, Psychiatry in the Nursing Home, Second Edition, helps you effectively treat such difficult problems as noisy patients, sexual acting out, and incontinence. In addition, it offers help with such administrative concerns as financial issues, absent or warring families, and staffing problems. Psychiatry in the Nursing Home, Second Edition, presents incisive discussions of the changes in the field since the publication of the first edition, including:

• the effects of the new Prospective Payment System
• the use of newly released psychotropic medications
• the altered nomenclature of the DSM-IV
• the rise in assisted-living facilities
• the rapid development of the specialty of geriatric psychiatry

With its comprehensive scope and practical advice, Psychiatry in the Nursing Home, Second Edition, is a must-have for nursing-home administrators and staff. Policymakers, mental health professionals, and geriatricians will be fascinated by the book's wider considerations of the problems of housing and caring for the mentally ill and its provocative suggestions for future policy.

Part I:

The Places

Chapter 1

The History of Nursing Homes

Nursing homes in one guise or another had been around for many years before the 1960s.

Poorhouses, county homes, almshouses, and so forth have always existed in America. There were small homes for the aged financed by the residents’ Social Security payments. There were privately run nursing homes that took those who could pay for as long as they could pay. The state hospitals contained large numbers of the elderly, and in many states these institutions were willing to accept all comers, including victims of purely physical chronic illness.

In one state hospital in Connecticut where I worked, several of the wards contained long rows of closely spaced beds. The occupants of these suffered from disabling physical illnesses. The most unfortunate, perhaps, were those who were of perfectly sound mind apart from the distress caused by their circumstances. They were put there to stay until they died.

The advent of large numbers of efficient, privately run, Medicaid-funded nursing homes saved thousands from such situations in the government-run hospitals. The 1950 amendments to the 1935 Social Security Act provided an increased level of funding for Old Age Assistance. These amendments included federal matching funds for medical services in nursing homes, although they excluded such matching funds to state and county mental hospitals (Kidder, 1999). The modern American nursing home resulted from the Medicaid and Medicare programs established in 1965. The standards for the homes were largely set by Medicare, although it was Medicaid that became largely responsible for their funding and rapid expansion in the 1970s. In 1970, 10 percent of the population was over sixty-five years old, and of these, 7 percent lived in such institutions as nursing homes, mental hospitals, and homes for the aged (Stotsky, 1972). By 1997, 1.6 million people lived in the nation’s 17,168 nursing homes (Smith, 1998).

Medicaid was not intended to relieve states of the burden of caring for their mentally ill in the state hospitals. The law (Medicaid Transmittal, 1977) said that if over half the patients in a home were mentally ill then it should be designated as an Institution for Mental Disease (IMD). Guidelines were drawn up for the IMDs. Along with these guidelines went the stipulation that IMDs could not be supported by Medicaid. Naturally, no IMDs were set up (except for some in California).

The Community Mental Health Act of 1963 gave money to the states for psychiatry, but only for patients who were not in state hospitals. The states were supposed to go on paying for the state hospital patients out of state money. (There is some Medicaid and Medicare coverage in a state psychiatric hospital, but this is very limited and restricted.)

Omnibus Reconciliation Act of 1987

Hard-pressed though the state treasurers were, the feds remained suspicious that states were using some of this nursing home money to subsidize their state mental health systems. Evidence accumulated that, in spite of where federal law said the mentally ill belonged, they were put into nursing homes so that the money for their care would come from Medicaid, not out of the state mental health funds. This was one of the considerations that led to the new provisions of OBRA, the Omnibus Reconciliation Act of 1987. (OBRA Acts are passed frequently, but anyone who refers to “OBRA” in talking about nursing homes means the act of 1987.)

These new provisions made a further effort to keep the mentally ill out of the nursing homes. Compliance with OBRA occupied the attention of those concerned with nursing home care for several years thereafter. Nursing homes were not prohibited from taking psychiatric patients. It was merely mandated that the patient was to get active treatment (the term “active treatment” for mental illness was later replaced by “specialized services”) and that treatment was not covered by Medicaid. Thus, it was up to the nursing homes to ensure that they did not get stuck with psychiatric patients.

The Final Rule issued by the Health Care Financing Administration (HCFA) in September 1991, made a distinction between “rehabilitative services” for mental illness (which the nursing home is supposed to be able to provide) and “specialized services” (which are “outside the scope of nursing facility mental health services.”) An example of the former would be treatment for mild depression. Making fine Talmudic distinctions of this kind can be of practical importance in the nursing home business because of the need to comply with such government regulations. The 1991 Final Rule said, “We believe that specialized services can only be ordinarily delivered in the NF setting with difficulty because the overall level of services in NFs is not as intense as needed to address these needs.” The Rule went on to say that a state’s Preadmission Screening and Annual Resident Review (PASARR) program (see Chapter 2) could determine that an individual with mental illness or mental retardation “may enter or continue to reside in the NF, even though he or she needs specialized services” but warned that “if the individual does so, then the State must provide or arrange for the provision of additional services to raise the level of intensity of services to the level needed by the resident” (Comment on §483.45(a)).

OBRA Exemptions

Several exemptions provided loopholes for admission of the mentally ill. For example, presence of a medical illness may get a mentally ill patient into a nursing home. This “medical override” can come into effect if the patient is terminally ill or comatose, is convalescing from a recoverable condition following hospitalization, or has severe lung or heart disease, or certain progressive neurological diseases. Another exemption is for dementia due to Alzheimer’s disease and related conditions, but if the diagnosis of dementia is made, it has to be substantiated by investigations and consultations.

It is difficult to diagnose dementia in the mentally retarded. For this reason Alzheimer’s disease is not given any specific mention in the sections on mental retardation (Federal Register, 1989). The prohibition against admission to a nursing home presumably applies to the mentally retarded even if “dementia” is also diagnosed. However, the “ICF-MR” category (see Chapter 11) has been retained so that Medicaid can fund care for the mentally retarded in certain institutions.

OBRA and Psychotropic Medication

OBRA took a definite stand against antipsychotic drugs and recommended that they should be used only to treat a specific condition. It recommended attempts to reduce their use, such as trials of dose reduction and of stopping the drugs (drug holidays) and substitution of behavioral programming.

The federal law apparently stigmatized the use of psychotropic drugs as “chemical restraint,” which aroused the indignation of ardent psychopharmacologists. The exact wording as published in the Federal Register, Vol 54, February 2, 1989, was:

§ 483.13 Level A requirement: Resident behavior and facility practices.

(a) Level B requirement: Restraints. The resident has the right to be free from any physical restraint imposed or psychoactive drug administered for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.

Some further federal regulations are as follows:

Code of Federal Regulations; 483.25(1)

(2) Antipsychotic drugs. Based on a comprehensive assessment of a resident, the facility must ensure that:

(i) Residents who have not used anti-psychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record and

(ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

This wording did allow for a nonpsychiatric physician or other practitioner to do the documentation, but in practice, for better or for worse, most nursing homes find it easiest to get a psychiatrist to meet the requirements.

Section 1819 and 1919(c)(1)(D) of OBRA 1987 says that “psycho-pharmacologic drugs” can be prescribed “only if, at least annually, an independent external consultant reviews the appropriateness of the drug plan of each resident receiving such drugs.” The qualifications of this external consultant have not been defined (Kidder, 1999). The problems arising from these drug use regulations are further discussed in Chapter 10.

Did OBRA Improve Things?

The start-up date for the OBRA requirements was October 1, 1990, but it took a long time for anything to happen. The implementation rules and “interpretive guidelines” are the work of the Health Care Financing Administration (HCFA) in the Department of Health and Human Services, which performs for mystic writings of Congress the functions of Daniel before Nebuchadnezzar. Some of these rules and guidelines continue to be changed.

In the next two chapters, we shall examine some of the mountains of paperwork the regulations produced and the evidence that they failed to reduce the number of mentally ill in the nursing homes.

Chapter 2

Paper, Paper, Paper

A set of nursing home records may be several inches thick, and the staff will complain that most of their time is spent on paperwork. To what extent is psychiatry responsible for this, and what can psychiatry do about it?

Some of the work is psychiatric. Nursing home charts are required by law to have a comprehensive assessment of the patient’s psychosocial needs on the chart. This is usually done by the social worker (see Chapter 8), although that is not mandatory. It is supposed to document such things as outside contacts, frequency of visitors, use of free time, preinstitutional hobbies and interests, participation in activities, communication, orientation, and behavior. This is often the most useful document in the chart for telling what is really going on with the patient, and why he or she is in a nursing home. It is more extensive and more legible than the doctor’s history and physical examination (which, to be fair to my colleagues, has to be on the chart within two days of admission, whereas the social worker has two weeks from the admission date).

Care Plans

A comprehensive care plan, mandated by OBRA and already in place as a requirement in many states, is supposed to be developed after the comprehensive assessment and updated at intervals. It must be prepared by an interdisciplinary team that includes the attending physician, a registered nurse, and other staff, plus, if possible, the patient or the patient’s representative.

Sometimes a multidisciplinary care plan is produced without a genuine meeting ever taking place. The plan contains formulaic phrases, and is passed around for different professionals to sign, none of whom had any real input. It is then kept for a required period of time and discarded without having served a useful purpose.

A multidisciplinary care plan (MCP) can be useful and can actually save time if correctly carried out. Circumventing it can increase work. Once the plan is agreed to at the meeting, it can be referenced to avoid prolonged misunderstandings and arguments at the nursing station or over the telephone. Formulating care plans requires mastery of a certain jargon that may be unfamiliar to the medically trained. Traditional medical care planning consisted of the patient’s complaints or symptoms, followed by a diagnosis and then by treatment, hopefully based on the diagnosis. Currently, fashionable care planning consists of problems, goals, and interventions. It always sounds good to interpolate the magic phrases “evidenced by” and “related to,” and to use MCP terminology. The “problem” can be stated in various ways. It can be a disability such as inability to walk, or a symptom such as pain, or a medical diagnosis such as “hip fracture.”

Nursing staff often have trouble complying with documentation of behavioral interventions for problem behaviors (Llorente et al., 1998):

An eighteen-year-old mentally retarded diplegic cerebral palsy victim with no understandable speech was showing signs of agitation and distress. At a care plan meeting staff members said, “We try to show him we love him. Some of us come in to see him on our time off. We bring him toys and pictures to look at. We hug him and talk to him.” However, they said they could not document a care plan because, “There’s nothing we can do for him.”

Acronyms

RUG, RAP, MDS, and RAI stand for Resource Utilization Group, Resident Assessment Protocol, Minimum Data Set, and Resident Assessment Instrument. MDS and RAP are long and involved questionnaires about the patient.

The MDS “triggers” the RAP. MDS and RAP (plus some others) taken together comprise the RAI. (Outcome Assessment Information Set [OASIS] is the home care equivalent of the RAI.) Digits and signs may be added to these after the manner of software manufacturers, as new and improved versions are introduced, so that RAI has become RAI2. PASARR (Preadmission Screening and Annual Resident Review) is done on every potential resident whose MDS shows evidence of mental illness other than dementia. If such evidence is confirmed the review is to be repeated annually.

Resource Utilization Group (RUG)

The RAI determines the RUG classification, which decides if the nursing home can get paid for the patient. The RUG classification system is of the “sicker the better” type. Mental status enters very little into the equation (Beckwith, 1998).

Minimum Data Set (MDS)

It used to be possible for a patient to be in a nursing home with a diagnosis listed as congestive heart failure when the real problems were incontinence and inability to walk. The record stated that the patient had “CHF due to ASHD (congestive heart failure due to arteriosclerotic heart disease)” and that the treatment was cardiac medication.

This still occurs to a large extent, reflecting the concept of the nursing home as a kind, albeit an inferior kind, of general hospital. The new Minimum Data Set was intended to give a more rational and comprehensive picture of the patient.

The MDS is in many ways a superb instrument. It was devised by the prestigious Institute of Medicine (a quasigovemmental organization appointed by the National Academy of Science to which the federal government gives money to conduct inquiries and issue reports). It possesses excellent psychometric properties of reliability and validity (Lawton et al., 1998; Casten et al., 1998) and is even used outside the United States (Finne-Soveri and Tilvis, 1998).

It is a monument of intellectual achievement but resembles other monuments erected by governments, such as the pyramids, in taking...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• Part I: The Places
• Part II: The People
• Part III: The Problems
• Part IV: The Future
• References
• Index