In the recently announced rules for participation, the Centers for Medicare & Medicaid Services (CMS) included several updates related to behavioral health in nursing homes.
The agency aims to better address the rights and services available to residents with mental health needs, including focusing on situations where practitioners or facilities may have misdiagnosed or coded a resident.
It’s part of a broader push CMS is making to elevate clinical practices in a bid to improve the quality of care in nursing homes, industry leaders say.
Echoing one of the Biden administration’s initiatives announced in late February, another update to the rules for participation addresses the unnecessary use of non-psychotropic drugs and antipsychotics, defending the gradual reduction of doses for residents that might have come under these medications.
Devon Hiebert, administrator of the Kansas-based Catholic Care Center, said CMS is expanding its focus on behavioral health issues nationwide.
The spotlight doesn’t come too soon, as the nonprofit Continuing Care Retiree Community (CCRC) has seen a “significant increase” in mental illness-related diagnoses over the years, especially for those landing in long-term care facilities. Indeed, Catholic Care Center is adding a behavioral health center to its campus as part of a $13 million project.
Catholic Care Center CEO Cindy LaFleur calls behavioral health updates a ‘step in the right direction’ as industry improves in assessing related anxiety and depression at the age.
“The changes people go through and the losses people go through [as they age], it’s no wonder there are a lot of psychiatric issues as the aging population continues to live longer,” LaFleur said. “We have to be really well versed and experienced in this area as well as in physical function.”
While these new regulations appear to be harsh and sometimes punitive, the industry needs to focus on how it can cope as CMS continues to push the industry in a highly clinical, results-oriented direction.
“The angst is, how can we do it? The answer keeps staring us in the eye. What we need are better clinical outcomes and we are getting better clinical outcomes from committed physicians” “Said Dr. Jerry Wilborn, CEO of nursing home physician group GAPS Health. “It’s about engaged providers, really engaged, when we’re talking about antipsychotic use.
GAPS, based in Dallas, Texas, has worked for years with operator partners to reduce the use of antipsychotics in facilities – these efforts are part of its core mission.
An appropriate level of communication between behavioral health providers and primary care physicians for residents “barely exists,” Wilborn added, another major issue CMS is trying to address with its updated attendance rules.
The authors of a study published in July in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA) make the case for integrating behavioral health into nursing home care – untreated mental health issues in residents were linked to negative care outcomes, limited functional improvements, longer lengths of stay, high risk of rehospitalization and mortality.
Updates to Medicare and Medicaid participation requirements were originally released in 2016, most specific to visitor guidance and to clarify regulatory requirements, providing information on how compliance will be assessed.
“The feds are pushing a more clinical model. I think a lot of it will be paid through value-based initiatives that are tied to results, better results, potentially better revenue,” Wilborn added.
Many CMS initiatives, including those based on behavioral health, are clinically grounded. The problem is that such initiatives should be led by non-clinicians, Wilborn said, when the industry is understaffed.
The mismatch between CMS’s schedule and the availability of clinicians poses an “impossibility” for many operators, he added.
Answer to a need
Hiebert and LaFleur increasingly saw a need for behavioral health services in nursing homes because mental health facilities are unavailable.
Indeed, it is just one manifestation of a greater unmet need in the United States, as mental and behavioral health problems have increased. More than a third of Americans live in designated mental health professional shortage areas, the Biden administration noted when rolling out a mental and behavioral health strategy earlier this year.
“We need to be able to position our staff to serve residents, best meet their needs and identify what is happening with them so that we can make the appropriate interventions, make sure they feel at home them and they don’t feel at home. have to go to acute care hospitals,” Hiebert said.
Catholic Care Center, which has operated an Alzheimer’s Foundation of America certified program since 2007, has seen age-related anxiety and depression in all of its care settings, LaFleur said. CCRC has begun construction of a behavioral health addition to its senior living campus, as part of a $13 million project.
The 20-bed geriatric psychiatric unit is a defining aspect of the operator’s three-year strategic process, LaFleur said; renovations are expected to be completed in June 2023.
She calls for behavioral health updates in the necessary participation rules.
“We support these changes, most certainly. We believe that all of our staff can benefit from applying more acute behavioral health strategies. It will be a natural complement and a real complement to help our staff right here in our building,” said LaFleur. “It’s really necessary to give seniors the quality of life we want [provide] here.”
In the JAMDA study, the authors made a similar point, claiming that an “integrated behavioral health stepwise model of care for NFCs” can increase access to and engagement with behavioral health services, strengthen positive “biopsychosocial” outcomes in residents and preventing or improving behavioral health issues in families, partners and staff.
Pushing for better clinical outcomes
The use of medications related to mental and behavioral health has also long been a focus of nursing home quality improvement efforts, and CMS continues to focus on antipsychotic medications.
But there is a misconception that non-clinical staff can manage the use of antipsychotics in nursing homes, Wilborn said, and that needs to be dispelled — with regulations, if necessary.
“None of the care home staff has prescriptive power, and for good reason. No one is trained in pharmacology,” Wilborn said. “What has happened over the years is that the government, CMS and payers are trying to address the lack of clinician engagement, physician involvement.”
Instead, the industry has “taken care of itself,” as Wilborn puts it, taking responsibility for all things clinical.
“It may be shared, but that primary responsibility rests with the clinician with prescriptive authority,” WIlborn added. “The clinicians at the nursing home, unfortunately, have not been people with prescribing power. That’s not how it works, and that has to change.
Wilborn believes the industry is at an inflection point, in terms of transitioning to better clinical outcomes via more engaged physicians, rather than focusing on census.
Operators who are more concerned about the census, he said, are going to have a “much harder time coming,” as CMS and the Biden administration continue to push clinical outcomes and a more clinical model as part of the nursing homes.
Hiebert says staff education is another missing piece to serving this population that needs behavioral health services, along with Wilborn’s call for clinicians with prescriptive expertise.
Just knowing how to interact with residents who need behavioral health services can be a crucial part of education, Hiebert said — it’s the Center’s biggest goal following the announcement of the attendance rule.
“We are still working on all the other regulatory pieces for care planning and compliance,” Hiebert added.
Moving forward, LaFleur said she would like to see more educational support from CMS, as behavioral health training is not always taught to nursing home staff who are new to the industry. .
“Help us leverage our education, our training, our interventions, our crisis response pathways that we use, so that our staff across the country are highly trained and knowledgeable about the best way to care for and better settle these residents,” LaFleur added.