February 15, 2002
NON-ELDERLY MENTALLY ILL AND ELDERLY PEOPLE IN NURSING HOMES
By: Saul Spigel, Chief Analyst
You asked for options to address the issue of non-elderly mentally ill nursing home residents (ages 22 to 64) harming elderly residents.
Both federal and state law require, with some exceptions, screening patients to determine if they need skilled nursing services before a nursing home can admit them. The state law applies to all chronic and convalescent homes and rest homes with nursing supervision; the federal law applies to Medicaid-certified facilities (most Connecticut nursing homes are Medicaid-certified).
The federal rules create two screening levels. Level I screening, conducted by the Department of Social Services (DSS), determines whether someone recommended for nursing home admission has a serious mental illness. The Level II screening, conducted by Advanced Behavioral Health (ABH) under contract to the Department of Mental Health and Addiction Services (DMHAS), determines whether someone with a serious mental illness (which does not include Alzheimer's or other forms of dementia) is appropriate for nursing home admission or whether he requires specialized mental health services (i.e., needs to be in a psychiatric hospital). Generally, someone who is psychiatrically stable can be admitted to a nursing home.
Once ABH determines that a person with serious mental illness can appropriately be placed in a nursing home, it sends an approval letter to the home. At this point, the home has the option of admitting the individual.
A home must notify DMHAS if any resident's mental condition changes. If this occurs, the person may be reevaluated, depending on whether he was previously identified as having a serious mental illness.
A recent report by the U.S. Health and Human Services Department found flaws in this system. It found that states did not know where non-elderly adults with severe mental illness were receiving treatment. It also found (1) that screenings were not being performed or were not included in residents' case records, (2) states have no systems to ensure that an individual receives the services that the Level II assessment recommended, and (3) states have no mechanism to ensure that Level II reassessments are appropriately triggered.
Connecticut could follow approaches used in other states to address some of these systemic problems. It could: (1) tie Medicaid reimbursement to a facility's assurance that all screenings have been completed or that reassessments are conducted as appropriate; (2) train nursing home licensure inspectors about appropriate assessment, care planning, and care for people with severe mental illness so they can better determine whether a facility is complying with state and federal laws; (3) develop staff training or ratio requirements for homes that care for residents with severe mental illness, or (4) provide resources for DMHAS to consult with homes on implementing the services ABH recommends as a result of the Level II screening.
SCREENING PEOPLE FOR MENTAL ILLNESS
Level I Screening. Federal law creates two screening levels. All candidates for nursing home admission must receive a Level I screening to determine if they have a serious mental illness. It is conducted by DSS' Alternate Care Unit based on physician, nurse, and hospital documents.
A person diagnosed with schizophrenia, bipolar disorder, major depression, delusional/paranoid disorder, or certain psychotic disorders is automatically considered seriously mentally ill. A person diagnosed with a lesser disorder such as adjustment, panic, obsessive compulsive, or depressive disorder is considered seriously mentally ill only if he has
1. within the past two years, been hospitalized as an inpatient or a partial patient or received electroconvulsive (shock) therapy or intensive psychiatric support in the community (e.g., case management or visiting nurse service) and
2. continuously or intermittently, experienced one or more limitations in functional areas such as complying with a medication regimen, asking for help in emergencies, maintaining personal hygiene, and interacting appropriately.
A person diagnosed with Alzheimer's disease or other form of dementia is not considered to have a serious mental illness.
Level II Screening. If the Level I screen indicates severe mental illness, the person must undergo a Level II screen. At this point, DSS appears to exit the screening process. A person seeking admission to the nursing home from a private hospital is screened by hospital staff; someone coming from a state mental health facility or the community, is screened by ABH personnel working under contract with DMHAS.
The Level II screening determines whether the individual with serious mental illness is appropriate for nursing home admission or whether he requires specialized mental health services (i.e., needs to be in a psychiatric hospital). Generally, someone who is psychiatrically stable can be admitted to a nursing home.
ABH looks at the Level I screening information and the patient's history and physical forms sent by the treating physician or hospital. Sometimes, the ABH evaluator will interview the individual. The Level II screen looks in more depth at the individual's appearance, attitude, and speech; current psychiatric symptoms and behavior; history of psychiatric treatment and dangerous symptoms and behavior; and current and past medication history among other items. The evaluator must fully explain how findings like hostile facial expression, provocative or uncooperative attitude, physically assaultive symptoms or behavior, and paranoid ideation relate to the client's functioning and potential danger to himself or others, particularly in a nursing home setting.
The Level II screening form requires ABH to indicate whether the individual's psychiatric symptoms and behavior potentially make him dangerous to other people. It also permits the evaluator to recommend various items for the client's nursing facility care plan. These include individual psychotherapy with a trained therapist, group therapy with a trained therapist, ongoing evaluation of the client's psychotropic medication regimen, and a treatment plan for problem behaviors.
The nursing home does not have to follow these recommendations, and there is little follow-up to determine if it does. ABH provides limited (perhaps two case per month) consultation services to nursing homes on implementing its recommendations, according to Jennifer Glick a nurse consultant in DMHAS' in Office of Behavioral Health who deals with nursing home issues. And, she says, Department of Public Health (DPH) inspectors conducting relicensing surveys will check to see if the home is providing recommended services if they find recommendations among the patient records they sample.
Once ABH determines that a person with serious mental illness can appropriately be placed in a nursing home, it sends a determination letter to the home. The home can admit the person only after it receives this letter. But the home does not have to admit him if it determines it cannot provide the type of treatment he needs. Some homes will get an opinion from their own consulting psychiatrist.
Exceptions to Preadmission Screening Procedure. A Level II screen is not required in the following situations:
1. the patient is coming directly from a hospital after receiving acute inpatient medical (not psychiatric) care and requires convalescent care for that condition for less than 30 days,
2. the patient's physical condition or illness causes such severe symptoms that he cannot participate in psychiatric treatment,
3. the patient is too delirious to be evaluated until the delirium clears,
4. the patient needs nursing care for a terminal illness that makes his life expectancy less than six months, and
5. the patient's family or caregiver needs respite care.
Connecticut does not appear to have a formal mechanism for tracking and screening a person who is exempt from the initial Level II screening. Part of the problem arises from the hospital discharge process, in which a patient is often placed on the waiting list for several nursing homes at the same time. The Level I screening paperwork ABH receives from DSS may list all these homes, and it is up to the hospital to notify ABH where the patient goes. If the hospital does this, ABH can follow up to make sure the screening is done when the exception period ends. If the hospital does not provide this notice, ABH cannot follow up.
When a patient is admitted to a nursing home after a medical hospitalization (# 1, above), the hospital is supposed to notify ABH. ABH then contacts the nursing home after the 30-day exception ends and conducts a Level II screen if he is still there.
Until 1996, federal law previously required annual reviews to determine if residents with serious mental illness still required nursing home services. Michelle Parsons, head of DSS' Alternative Care Unit (ACU), reports that these reviews “only very infrequently resulted” in removing people from homes, and they required the services of 15 utilization review nurses.
In place of annual reviews, the screening process now requires nursing homes to notify DMHAS of changes in a patient's mental status (CGS §17b-359). Under DMHAS' guidelines, a resident's mental status is changed if a person diagnosed with serious mental illness displays acute or exacerbated symptoms or if a nursing home's physician determines that a previously undiagnosed person has a serious mental illness.
If the change in mental status leads the home to transfer a person not previously subject to a Level II screening to a hospital, that screening must be performed and ABH must issue an approval letter before the person can go back to the home. A rescreening and new letter is not needed for a person already diagnosed with a serious mental illness.
Critique of Preadmission Screening Process
The preadmission screening and resident review process suffers from several flaws, according to two recent evaluations by Health and Human Services Department's Office of Inspector General (OIG). The first found that many states were not able to determine where non-elderly adults with severe mental illness were receiving treatment.
This finding seems to hold for Connecticut. Neither DSS, DMHAS, nor DPH could provide data on the number of non-elderly nursing home residents with a primary diagnosis of a severe mental illness. DMHAS reports that in fiscal year 2000-01, ABH performed 1,093 Level II screenings. Of these, 955 validated a diagnosis of serious mental illness. But DMHAS does not track whether these patients were actually admitted to a nursing home following the screening or, if so, which ones.
The second report, published in January 2001 and based on OIG's review of 187 patient records in 19 facilities in five states, found:
1. little evidence that Level I screenings are being completed;
2. more than half of the case files reviewed contained only an approval letter, not a formal Level II screening;
3. states have no systematic process to ensure that someone receives the mental health services that were indicated as necessary or recommended on his Level II assessment;
4. states have no mechanism to ensure that Level II reassessments are appropriately triggered, many nursing facility and state agency officials indicate the definition of “significant change” (the trigger for a reassessment) is unclear, and, consequently, reassessments resulting from a change in a resident's mental health status rarely occur (OIG, Younger Nursing Facility Residents with Mental Illness, January 2001).
In Connecticut, no agency is explicitly required to ensure that the Level II screening documents are part of a nursing home resident's clinical record. DPH staff conducting nursing home relicensure evaluations sample patient records and report when they are missing, which could affect the home's relicensing. Nor does the state have a procedure to ensure that a nursing home provides the type of services the ABH evaluator recommended on the Level II screening.
Assuring Screenings, Rescreenings, and Record Keeping
Connecticut could attach monetary strings to nursing homes' compliance with screening record keeping and other requirements. Utah for example, specifically prohibits its Department of Human Services from reimbursing a nursing facility for a resident if the facility fails to assure that the resident's Level I or II evaluation is completed (UT Admin Code R414.503). North Carolina policy makes the nursing facility responsible for obtaining the appropriate screening for a resident who was admitted under one of the exceptions to the screening requirement (e.g., delirium, convalescing from hospital medical treatment, see above). The facility must notify the Medicaid administrator that the screening has approved the resident's continued stay in order for payment to continue (NC, PASARR Policy, ch. 5-3).
A 1999 Illinois law requires the Department of Public Health to train its nursing home licensure inspectors about appropriate assessment, care planning, and care for people with mental illness specifically to enable the inspectors to determine whether a facility is complying with relevant state and federal laws (210 ILCS 45/3-212).
Nursing Home Staff and Training
Nursing homes that accept non-elderly residents with serious mental illness are not required to have additional staff or specially trained staff to care for them. Connecticut could develop specific staffing requirements for homes with a certain threshold of these residents. Or it could require an agency to establish guidelines for services and staff training in homes that admit such individuals. A recently enacted Illinois law requires its Public Health Department to establish regulations on the provision of services by facilities that care for seriously mentally ill people. These must cover assessment, care and discharge planning, and treatment (210 ILCS 45/3-202.2).
Other options might be (1) to provide DMHAS with more resources to enable it or ABH to consult more frequently with nursing homes on implementing the services ABH recommends for clients as a result of the Level II screening or (2) require DSS, DMHAS, and DPH to examine the system for ways to better coordinate their various activities to assure that non-elderly residents with serious mental illness are receiving appropriate care.