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Mental Health Services in Nursing Homes

Finding the residential facility that fits your needs or your loved one is a difficult task. A lot of emphasis is placed on how the facility provides for the physical needs of its residents. However, another very important but overlooked question is how does it care for mental or behavioral needs? Studies say that 18-25 percent of older adults in the community have mental health needs. In nursing care and personal care facilities the number increases. Some studies show that 50 percent of older adults in nursing homes suffer with depression.

Questions to Ask

Here are 17 questions to ask of every skilled nursing facility about providing for mental health needs.

1. Do you have a geriatric psychiatrist or geriatric psychologist on staff or as a consultant? How often do they come to your facility?

Psychiatrists are able to perform services such as diagnosing disorders, checking medication, counseling, and training staff. Geriatric psychiatrists and geriatric psychologists are specially trained to help older adults.

Some facilities say that they have a consultant psychiatrist, but the key is how often he/she comes to the facility. This is especially important if the resident is on psychotropic medication. Side effects from the drugs need to be monitored closely.

2. Does the facility contract with or hire psychologists to do individual therapy when needed?

If your loved one develops major depression, anxiety or other mental health needs, the facility should have resources available to provide a professional assessment and treatment. It is insufficient to just have a physician prescribe medication and not provide follow up care. For instance, some cognitive impairments may be caused by dementia and be irreversible or may be the result of depression that is treatable. It is important to know ask if they will arrange for neuropsychological evaluations if there is a question of a cognitive disorder.

3. What kind of emergency coverage do they have?

If someone has an emergency psychiatric problem, you should know if they have to go to the emergency room of the local hospital for help or if they have resources that will be available right in the home.

4. Do you have a behavior team/committee? If yes, how often does it meet?

A behavior committee focuses on problem behaviors in the residence. It helps staff assess reasons for the behavior and develop appropriate responses to behavior. It can also promote staff education on dealing with problem behaviors.

The committee should meet on a regular basis as well as in an emergency.

5. Do your residents utilize partial hospitalization? How do you help them get that resource?

Partial hospitalization is the most intensive form of mental health treatment besides inpatient hospitalization. It is usually provided to consumers several times per week for the entire day. It can be a valuable resource for caring for the mental health needs of older adults. Ask if the partial hospitalization program serves the unique needs of older adults. Its staff should be trained in geriatric mental health care.

Transportation to and from the treatment center must be reliable and punctual if the consumer is going to benefit. Some centers have their own transportation, others rely on para transit systems or volunteers. Make sure there is a regular schedule.

6. Do you routinely inservice your staff about the mental health commitment process, 201, 302, and mobile psyche units?

Staff should be trained in the kinds of voluntary and involuntary commitment that may be needed in case of a mental health emergency. They should also be able to know what resources to call to get help.

7. Does the facility provide group therapy?

Group therapy can be a valuable way to help older adults deal with stress, anxiety adjustment problems and depression. Ask if the group is led by a qualified facilitator.

8. What kind of activities program do they have? How much of it depends on volunteers, how much on staff?

For good mental health, older adults need stimulation just like anyone younger. The facility should have reliable, interesting and consistent activities for the residents. BINGO is not enough.

9. Do they have a special unit for dementia? How do they handle declines in cognitive functioning? Do they reserve the right to discharge patients because of dementia?

At age 85 almost half of older adults have some form of dementia. The facility should have plans to care for older adults. Know what the provisions are for people who develop cognitive disabilities. Is there an appeal process if you think your loved one is being discharged inappropriately?

10. Does your psychiatrist or pharmacy inservice your staff on psycho-active drugs? Does the facility monitor psycho-active drug use?

Psychotropic drugs are very powerful and can have numerous good effects. Yet they can also have many side effects. Reactions from drugs, improper doses, drug combinations, can cause serious impairment, falls, or even death. Staff need to be trained to notice undesirable side effects and know who to report them to.

Monitoring psycho-tropic drug use is important to determine if a drug is working or not and what are its side effects. Written records should be available to the attending physician.

11. Do you have a restraint policy? What percentage of residents are in restraints?

Restraints are a failure of treatment. Make sure that the facility has a written policy on restraints and that it is monitored. Restraints should never be used as punishments or because the facility is short staffed. The state keeps statistics on the use of restraints and you could compare the facility with others.

12. Do you have a wanderguard system?

Wanderguard programs are designed for residents with dementia. It helps prevent people from wandering away from the facility and locating them if they do.

13. Does your staff receive inservice on dealing with behavior problems?

Working with people who have mental illness or dementia requires special knowledge and skills including: listening, observing, communicating and redirecting. Staff need to learn these skills in order to help older adults with behavior problems get their needs met and prevent further problems from occurring. Untrained staff may misunderstand behavior and respond inappropriately leading to further in agitation, use of restraints and greater stress for staff and residents.

14. Is your staff trained in detecting and treating elder abuse?

Behavior problems can be caused by a number of factors including present or past elder abuse. Staff should be aware of signs of elder abuse and know what to do if they suspect it has occurred.

15. Are family members invited into meetings on a regular basis to ask questions of assembled staff? What other access to staff do families with concerns have?

Good homes work to inform families and develop a working relationship with the families of their residents.

16. How will they advocate for residents in Medicare-managed care if the insurance won't underwrite mental health services, or requires that the resident leave the facility for evaluation or treatment?

In the era of managed care, there may be need for someone to advocate for the mental health needs of older adults. Facilities should have someone knowledgeable and skillful in how to make the system work for their residents.

17. Do they have an ethics team so that there is a place to bring disputes about care, resident transfers, and so on? What are the appeals and grievance procedures?

Sometimes there will be conflicts with regard to treatment and care. Every home should have a written policy on how it works to resolve conflicts. Consumers and their family members should be informed of what appeals and grievance processes are available to them.

Federal law specifies permissible reasons for transfer from the facility and establishes protections such as advanced notice the right to appeal transfer and the right to return to the nursing home. A home can't discharge a consumer who is away for treatment. Ask for the federal and state guidelines.

Mental Health/Aging Advocacy Project | a project of the Mental Health Association of SE PA | 1211 Chestnut Street | Philadelphia, PA 19107 | 215-751-1800, ext. 266 | e-mail: tvolkert@mhasp.org | www.mhaging.org
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