Report: People with Serious Mental Illness in Long-Term Care

In the past two decades, the proportion of nursing home residents with serious mental illness has risen significantly. One in five residents in long-term care facilities had a severe mental illness such as schizophrenia in 2019.

A recent article in the AMA Journal of Ethics highlights this issue. Titled “How Should We Address Warehousing Persons With Serious Mental Illness in Nursing Homes?,” the article describes the problems with using long-term care facilities to treat those with mental illness and presents recommendations for promoting community care.

Alternatives to placing people with mental illness in institutions has been evolving over the years. There has been an increase in advocacy for solutions such as community-based treatment, peer support, and supportive housing. However, an ongoing shortage of psychiatric beds in hospitals and other spaces for those with serious mental illness remains. In some cases, this has resulted in tragic outcomes for nursing home residents.

Screening People for Serious Mental Illness

More than 30 years ago, Congress established the Preadmission Screening and Resident Review (PASRR) process. With this process, lawmakers sought to address concerns about housing people with mental illness in nursing homes, PASRR requires facilities and hospital discharge planners to screen nursing home applicants for severe mental illnesses as well as intellectual disabilities. The state must then determine whether it is more suitable to place an individual in a nursing home placement or provide alternative, community-based services.

Research shows that this process has failed to curb the rise of individuals with severe mental illness in nursing homes. "Ill-equipped” to provide mental health care services, the report states, these types of facilities have become “an unwitting mental health provider – and not a very good one.”

In most states, PASRR only prevents a small number of individuals with serious mental illness from entering nursing homes. A loophole also exempts those expected to require less than 30 days of care. Yet many who meet this exemption end up staying in long-term care longer than 30 days. Later evaluations are less likely to result in their return to community living.

Report Recommendations

The report makes clear that physicians and hospitals have an ethical obligation to prevent discharges of individuals with severe mental illnesses to nursing homes.

• They need to be aware that lower-quality facilities may have a financial incentive to house residents with severe mental illness to fill beds.
• Health care providers also should be honest about the risks of nursing home care for a person with significant mental illness. They should emphasize that living in an institutional setting is typically not an appropriate long-term solution for this population. Home health agencies can provide more suitable, tailored care for patients who have stable housing. According to the report, hospitals should develop connections with home and community-based service providers, including Medicaid home and community-based services (HCBS).
• Clinicians should also consider referring individuals over age 55 to the Program of All-Inclusive Care for the Elderly (PACE). PACE receives capitated payments from Medicare and Medicaid to provide comprehensive services for those eligible for nursing home care but residing in the community. More than 40 percent of PACE participants have a mental illness diagnosis, according to the National PACE Association. A limitation of this program is that it often relies on community centers and is not under the same standards as Medicaid HCBS providers.

Possibilities for Reform

The report suggests the following reforms to keep those with serious mental illnesses out of nursing homes:

• Congress should repeal the PASRR process exemption for residents expected to stay less than 30 days.
• More alternatives to long-term care should be available. States should also have the ability to fund more community-based services. As the report states, Congress and the Centers for Medicare and Medicaid Services (CMS) may support this effort by clarifying the rules for Medicaid HCBS waivers. The rules currently in place prevents states from spending more on a patient’s community-based care than they would on care in an institution.
• In addition, the CMS should permit states more flexibility in testing out ways to transition people with serious mental illness into the community. This could include funding community housing for those with mental illness. The report suggests that such a solution could, for example, prove less costly than placing an individual in a nursing home.

Read the full report in the AMA Journal of Ethics.