Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program

The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

The role of regulation in the care of older people with depression living in long-term care: a systematic scoping review

Background

This aim of this study was to explore the role of regulation on the quality of care of older people living with depression in LTC, which in this paper is a domestic environment providing 24-h care for people with complex health needs and increased vulnerability.

Methods

We conducted a systematic scoping review. A peer reviewed search strategy was developed in consultation with a specialist librarian. Several databases were searched to identify relevant studies including: Embase (using the OVID platform); MEDLINE (using the OVID platform); Psych info (using the OVID platform); Ageline (using the EBSCO platform); and CINHAL (using the EBSCO platform). Articles were screened by three reviewers with conflicts resolved in consultation with authors. Data charting was completed by one reviewer, with a quality check performed by a second reviewer. Key themes were then derived from the included studies.

Results

The search yielded 778 unique articles, of which 20 were included. Articles were grouped by themes: regulatory requirements, funding issues, and organizational issues.

Conclusion

The highly regulated environment of LTC poses significant challenges which can influence the quality of care of residents with depression. Despite existing evidence around prevalence and improved treatment regimens, regulation appears to have failed to capture the best practice and contemporary knowledge available. This scoping review has identified a need for further empirical research to explore these issues.

Associations between psychiatric inpatient bed supply and the prevalence of serious mental illness in Veterans Affairs nursing homes

OBJECTIVES

We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA).

METHODS

We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings.

RESULTS

From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43,894-40,928), the average inpatient length of stay decreased (33.1-19.0 days), and the prevalence of SMI in nursing homes rose (29.4%-43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%).

CONCLUSIONS

These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.

Reasons for psychiatric medication prescription for new nursing home residents

OBJECTIVES

This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission.

METHOD

We extracted data from 73 charts drawn from a convenience sample of individuals who were residents of seven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conducted to explore rationales for psychoactive medication usage.

RESULTS

Eighty-nine percent of the residents who received psychoactive medications during the first three months of residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a written physician's order. Mental status was monitored by staff, and psychoactive medications were titrated based on changes in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review (PASRR) evaluations were completed during the admissions process. Further, while 73% had mental health diagnoses at admission, 85% of the NH residents were on a psychoactive medication three months after admission, and 19% were on four or more psychoactive medications. Although over half of the residents had notes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their number was eclipsed by the number receiving psychopharmacological treatment.

CONCLUSIONS

While the results suggest that NHs may be providing more mental health care than in the past, psychopharmacological treatment remains the dominant approach, perhaps because of limited mental health training of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals. A critical review of the role of the PASRR process is suggested.

Mental health service delivery in long-term care homes

BACKGROUND

The prevalence of mental disorders in long-term care (LTC) homes is high, but quality and availability of mental health services to assess and help in management of cases have been criticized.

METHOD

Literature concerning mental health problems in LTC homes was reviewed, especially regarding models of mental health service delivery and factors that affect development, persistence and reduction of symptoms and distress.

RESULTS

The advantages of consultation-liaison arrangements and of telepsychiatry were noted. Discussions led to development of recommendations aimed at improving mental health expertise and provision of assessment and intervention services in LTC homes in diverse countries. Prompt recognition of mental health problems among residents is required, with availability of a team working within the facility to deal with these problems. Commonly such multidisciplinary teams are formed by facility staff linking with visiting mental health professionals or services. Quality of care is also affected by the organization, attitudes and education within LTC facilities.

CONCLUSION

Provision of optimal mental health care in LTC settings is dependent on adequate funding, availability of expertise and education, positive and caring attitudes, recognition of needs, and supportive teamwork. The latter should include cooperative links between well-resourced and under-resourced regions.

Trends in mental health admissions to nursing homes, 1999-2005

OBJECTIVE

The study examined 1999-2005 data on first-time nursing home admissions of individuals with mental illness, dementia, or both to identify trends and characteristics.

METHODS

The Minimum Data Set was used to estimate the number and percentage of persons newly admitted to nursing homes who had mental illness (schizophrenia, bipolar disorder, depression, or an anxiety disorder), dementia, or both from 1999 to 2005. Data from 2005 were used to compare demographic characteristics and comorbid conditions of the three groups and treatments received.

RESULTS

The number of individuals admitted with mental illness increased from 168,721 in 1999 to 187,478 in 2005. The 2005 number is more than 50% higher than the number admitted with dementia only (118,290 in 2005). The increase was driven by growth in admissions of persons with depression--from 128,566 to 154,262 in 2005. Persons admitted with depression had higher rates of comorbid conditions than those admitted with dementia or with neither dementia nor mental illness. They also had high rates of antidepressant treatment and high rates of receipt of training in skills required to return to the community.

CONCLUSIONS

Current trends show that the proportion of nursing home admissions with mental illness, in particular depression, has overtaken the proportion with dementia. These changes may be related to increased recognition of depression, availability of alternatives to nursing homes for persons with dementia, and increased specialization among nursing homes in the care of postacute, rehabilitation residents. In light of these trends, it is critical to ensure that nursing homes have resources to adequately treat residents with mental illness to facilitate community reintegration.

Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions

The objective of this literature review was to evaluate the evidence pertaining to the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. A computerized search was conducted using MEDLINE, Cochrane Central Register of Control Trials, CINAHL, EMBASE, International Pharmaceutical Abstracts and PsycINFO, from January 1980 to April 2007. Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR = 0.57, 95% confidence intervals [CI] = 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR = 0.81, 95% CI = 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking.

Screening elderly patients in an outpatient ophthalmology clinic for dementia, depression, and functional impairment

PURPOSE

To determine the feasibility of screening for depression, dementia, and functional impairment in an ophthalmology outpatient clinic.

DESIGN

Prospective pilot survey study.

PARTICIPANTS

Fifty consecutive ophthalmology clinic outpatients.

METHODS

Consecutive patients more than 64 years of age with visits to the comprehensive eye clinic and the neuroophthalmology clinic at the University of Iowa were assessed. Suitable subjects were asked to complete a short questionnaire on instrumental activities of daily living, to answer a single question on depression, and to complete a clock drawing task in the office waiting room or examination room.

RESULTS

The 50 questionnaires reviewed showed that most respondents were functional (94%) in instrumental activities of daily living, had normal clock drawing results (80%), and were not depressed (80%). A significant minority, however, were identified by the screening to have functional impairment (6%), abnormal clock drawing results (20%), or depression (20%), and these patients were offered geriatric assessment. The tests were rapid (fewer than 5 minutes to perform) and easy to administer.

CONCLUSIONS

Screening for geriatric syndromes in the eye clinic was rapid, easy to perform, and detected a significant number of patients with functional disability, depression, and possible dementia.

The prevalence, diagnosis and treatment of depression in dementia patients in chronic care facilities in the last six months of life

OBJECTIVE

To assess the prevalence, diagnosis and treatment of depression among dementia patients and normal controls in chronic care facilities in the last six months of life.

METHOD

We reviewed perimortal data concerning dementia severity, depressive symptoms and diagnoses, and medication use for 279 dementia patients and 24 normal controls brought to autopsy through an Alzheimer's Disease Resource Center.

RESULTS

Major depression was highly prevalent among both dementia patients and normal controls in chronic care facilities in the last six months of life. This depression was under-diagnosed by physicians. Documentation of depressive symptoms by medical support staff has improved over time. However, physician diagnosis of depression has not improved. Recognition of depression was significantly lower for patients with severe dementia. Depression was under-treated in both dementia patients and normal controls, although treatment rates may be increasing. Anxiolytics and hypnotics were often used in lieu of, or in addition to, antidepressant therapy.

CONCLUSIONS

Major depression was highly prevalent in both dementia patients and normal controls, indicating that depression is an important issue for the elderly in the last six months of life irrespective of cognitive status. Under-diagnosis of depression may be an important clinical issue. As physician diagnosis of depression has not improved with time, further physician training and/or awareness initiatives may be warranted. Depression, a treatable cause of excess morbidity and mortality, was undertreated in all groups studied. However, treatment rates may be improving. The prevalent use of anxiolytics and hypnotics for depressed patients is problematic.

Assessment for depression among nursing home elders: evaluation of the MDS mood assessment

The 30-item Geriatric Depression Scale (GDS), the GDS Short Form, and the Mood Assessments from the Minimum Data Set versions 1 and 2 were completed for 50 nursing home elders. The purpose of the study was to evaluate agreement among these measures of depression, with the GDS considered the gold standard. Although the GDS Short Form performed highly consistently with the GDS, the correlations of the MDS mood assessments with the GDS were relatively low. The results are discussed in the context of the characteristics that surround the use of the MDS, and recommendations are made for improving methods of detecting depression among nursing home elders.

Nurse practitioner geropsychiatric consultation service to nursing homes

A nurse practitioner (NP) psychiatric consultation service was established to provide the residents of five nursing homes with on-site assessment and follow-up treatment for behavioral and psychiatric problems under OBRA and Medicare guidelines. During the 1-year project, 175 residents were referred by the nursing home (NH) staff for agitation, disruptive behavior, depressive symptoms, or decline in activities of daily living. An outcome evaluation documented that the NP recommendations resulted in positive behavioral changes in 62% of residents. Primary physicians, NH staff, and administrators validated that close monitoring of psychotropic medications and staff education in behavioral management strategies provided an effective, collaborative service. The practical aspects of establishing this consult service are addressed.

Use of the Iowa Self-Assessment Inventory with older hospitalized patients

This study examined the utility of the Iowa Self-Assessment Inventory (ISAI) as a multidimensional screening tool for older adults in the acute care hospital setting. A sample of 98 patients age 60 and older were administered the ISAI, the Short Geriatric Depression Scale, and the Mini-Mental State Examination. The findings suggest the ISAI is useful for screening for depression but does not detect differences in cognition. However, qualitative data and literature review support the continued search for a holistic, humanistic screening tool to increase the quality and effectiveness of patient care.

Compliance with PASARR recommendations for Medicaid recipients in nursing homes. Preadmission Screening and Annual Resident Review

OBJECTIVE

To determine the rate of compliance with placement and mental health recommendations of the preadmission screening and annual resident review (PASARR) program.

DESIGN

A retrospective observational study using PASARR screening forms to identify recommendations of inpatient psychiatric care for people needing more care than nursing homes provide, alternate disposition for individuals needing less than nursing home level care, and recommendations for new mental health services when needed but not provided. Service use as indicated in Medicaid billing data during the following year was used to determine receipt of service.

PARTICIPANTS

All Washington state Medicaid recipients screened from 1992 through 1993.

MAIN OUTCOME MEASUREMENTS

Compliance rates for placement and service recommendations.

RESULTS

Inpatient psychiatric care was recommended for four of the 523 Medicaid recipients (0.8%), all of whom received it. Screeners recommended alternate dispositions in 131 (25%) subjects, and compliance occurred in 29% of these. Recommendations for new services were made in 310 (59%) cases. Compliance rates averaged 35%, ranging from 73% for medication recommendations to 7% for consultation. Depressed individuals were less likely to receive recommended services.

CONCLUSIONS

Many individuals needed additional mental health services but did not receive them, and a significant minority of patients could have been given an alternate disposition but rarely were.