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The SNF mental health revolution

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Consider the following scenario: A 78-year-old woman is admitted to a long-term care unit following a stroke, and after an unsuccessful 21 day stay on the facility’s subacute rehab unit. Confronted by the loss of her physical health, ambulation, home, church, dog, friends and hobbies in the community, she presents with anxiety, depression and insomnia. She also had an episode of delirium while in the hospital, for which she was prescribed the anti-psychotic medication Seroquel. Unfortunately, the Seroquel was not discontinued despite the fact that the condition that caused the delirium — dehydration — was quickly resolved.

Now, grappling with the loss of independence and control that are often part of a SNF admission, she is also prescribed Xanax, Zoloft and Ambien to combat the symptoms of anxiety, depression and insomnia. Tranquilized and sedated, she winds up on a total of 23 medications and quickly loses cognition and energy. She loses the resources she would have needed to confront the main challenge that she is facing — the task of creating a new life for herself in long-term care.

At continual risk for drug-induced cognitive impairment, deleterious drug interactions, confusion, hallucinations and delirium, she loses the opportunity for a successful adjustment to the SNF.

This scenario is unfortunately not unusual in the post-acute arena. The imperative to aggressively treat the symptoms of mental illness, typically with pills, often leaves the person underneath the symptoms essentially ignored.

In this and similar cases, SNF administrators must ask themselves, “Did we provide the kind of care the resident really needed to maximize her ‘whole emotional and mental well-being?’” That, in a nutshell, is the manifesto behind the revolution and the mandate from the Centers for Medicare & Medicaid Services, and we have a long way to go before it is realized. Right now the overwhelming majority of Medicare expenditures and provider attention in post-acute settings go toward medical, as opposed to mental health conditions, despite these facts:

  • Psychiatric illness in SNFs is the norm, rather than the exception.
  • Untreated mental health conditions, especially depression, lead to higher health care costs.
  • Many psychotropics, especially anti-psychotics, are extremely expensive — more expensive in the long run than the cost of providing evidence-based, non-pharmacologic care and staff training.

The role that skilled nursing facilities are currently being asked to play has changed drastically as sicker, more cognitively impaired and more psychiatricly-compromised residents are now the norm. With older people with moderate infirmities now much more likely to reside in assisted living facilities or at home than in a nursing home, SNFs are being asked to care for older residents with high levels of medical acuity as well as the significantly mentally ill and many younger residents with conditions such as ALS, multiple sclerosis, traumatic brain injury, post-traumatic stress disorder and addictions. According to a study published in the Journal of Aging & Social Policy in 2011, the percentage of new nursing home admissions with mental illness now exceeds the percentage presenting with dementia only.

For the full text of this article by Richard Juman, Psy.D., click here to visit the McKnight’s Long-Term Care News website.