As the demand for behavioral health services continues to grow in the nursing home setting amid regulatory pressures and staffing shortages, a New York State university program is looking to fill the gaps.
The digitally enabled behavioral health program, which first launched in 2017 with funding from the Centers for Medicare and Medicaid Services Reform Incentive Payment Programs (DRISP), has grown from 29 nursing homes at the start of a two-year demonstration — until the latest expansion of the program to facilities across the state.
From 2017 to 2019, the use of antipsychotics among long-term residents in participating homes decreased by 37 percent, according to a case study published in NEJM Catalyst. During the pandemic, the program’s services grew to 53 nursing homes.
The need for behavioral health services in nursing homes has only been exacerbated by the effects of Covid-19, but these services were needed long before the global pandemic.
From 2007 to 2017, the prevalence of nursing home residents with serious mental illness increased by 77% — but only 1 in 10 counties in the United States has a practicing geriatric psychiatrist, according to the case study.
Before the state mental health service partnered with the University of Rochester program in 2019, there were 500 or more residents waiting to be placed in a nursing home. That number is now in the single digits or close to it, according to the case study.
“The pandemic has been devastating for nursing homes. Many of our residents were confined to their rooms or wards for many months during the pandemic, and that had real tangible impacts on their mental health, much more anxiety and depression,” said Adam Simning, assistant professor of psychiatry at the medical center. of the University of Rochester.
And it’s also more than just focusing on mental illness, anxiety and depression — it’s also quality of life, according to Simning.
“We focus on mental illness, anxiety and depression, but there’s a flip side to that, there’s just quality of life, there’s wellbeing. “Sometimes just focusing on residents’ well-being will in turn reduce anxiety and depression, so it’s really nice to be able to take a more holistic view of residents in the context of their home,” he said.
Overall, program participants believe they have shown that a telehealth program that includes on-site nursing, telepsychiatry, telepsychotherapy, and telemonitoring can improve access to behavioral health services in nursing homes and improve both quality measures and the results, according to the case study.
The researchers faced challenges including nursing home accreditation, initial participation, continued commitment, and program sustainability when they started the program.
The case study notes that some nursing homes “quickly and enthusiastically” participated in the behavioral health program, while others expressed reservations about how telepsychiatry visits would work and how it would change the workflow.
Staff also played a significant role in continuing commitment to the program. Both telepsychiatry and on-site visits require the participation of nursing home staff, and this proved challenging when staffing was limited due to ongoing industry shortages.
“Identifying a nursing home champion was essential for ongoing engagement, and monthly on-site nursing visits were necessary to train new staff,” the authors wrote.
Despite these challenges, developing relationships with nursing home decision makers and monitoring quality metrics while sharing these findings with potential funders were part of increasing program sustainability.
Developing a similar program
The authors of the report note that in order to create and implement a program similar to the one developed at the university, it must have: identified donors, selective partnerships with nursing homes, site visits for implementation and the ability to track quality indicators .
On the topic of funding, although it has been noted that telehealth has grown significantly over the course of the pandemic nationally, many of these efforts are temporary and establishing such a program will depend on payer support for telehealth.
In selecting nursing home partners, the report said working with social workers at the facility was “instrumental” in identifying and referring residents to such services.
Although Simning believes the program can be replicated in other states, he acknowledges the challenges presented by the realities of living in a largely fee-for-service health care world.
“In order for this program to roll out to other states, it’s really important to look for ways to have different funding mechanisms … Staff training is not really something that’s usually easy to recover from,” he said.
Zhi-Yan Tsun, Resident Physician, Department of Psychiatry, University of Rochester Medical Center; Nirav Shah, senior scientist, Clinical Excellence Research Center, Stanford University School of Medicine; Elizabeth Santos, Associate Professor, Department of Psychiatry, University of Rochester Medical Center; Lara Press-Ellingham, Senior Health Project Coordinator, Department of Psychiatry, University of Rochester Medical Center; and Michael J. Hasselberg, chief digital health specialist, associate professor, University of Rochester Medical Center were also involved in the program.