Evaluation of Outcomes for a Skilled Nursing Facility for Persons Who are Difficult to Place

摘要

Individuals with serious mental illness, prisoners, and ex-offenders needing skilled nursing facility (SNF)–level care are difficult to place in traditional SNFs. SNFs accepting these historically marginalized individuals may offer them a more appropriate level of care. We compared health services use (emergency room (ER) visits, acute hospitalizations), total number of antipsychotic medications prescribed, and quality-of-life indicators (depressive symptoms, cognition, resident behaviors), before and after admission, among 86 individuals admitted to a Connecticut SNF for persons difficult to place. Residents were racially diverse, primarily male (89%), and 58.4 (±12.5) years of age; 56 percent were transferred from state psychiatric facilities. Twelve-month hospitalization rates decreased from 36.5 to 10.6 percent, 27 percent of those taking an antipsychotic medication at admission experienced a reduction in total number of antipsychotics prescribed by six months, and 13 residents transitioned into the community. Quality-of-life indicators did not change between admission and first quarterly assessment. A SNF for persons difficult to place may help prevent hospitalizations, optimize antipsychotic medication use, and serve as an intermediate step into the community. These findings may inform development of an evidence-based model for establishing SNFs in other states for persons who are difficult to place. With the aging of the U.S. population, an unprecedented number of older adults will meet preadmission criteria for requiring skilled nursing facility (SNF)–level care in coming years.sup 1 /sup Included among the growing number of aging individuals requiring SNF care are historically marginalized persons who are regarded as difficult to place in Medicaid-paid SNF settings: those with severe mental illness (e.g., schizophrenia and bipolar disorder) and inmates and ex-offenders. The U.S. Supreme Court decision in Olmstead v. L.C. (527 U.S. 581 (1999)) largely initiated a push toward deinstitutionalization of people with mental illness and admission to community and residential care settings.sup 2 /sup However, residents with severe mental illness (SMI) in state-run psychiatric facilities who have a history of behavioral symptoms or have frequent exacerbations of their illness thereby requiring hospitalization, may benefit from a higher level of care than complete deinstitutionalization.sup 3 , 4 /sup As these individuals age and acquire chronic conditions that limit function, they also may need SNF–level care. Yet, an unintended consequence of the Olmstead decision has been that individuals with SMI are more likely to be admitted to SNFs that have government-issued deficiency citations for both overall and clinical care quality.sup 5 /sup The growing need for SNF-level care may permit nursing home administrators at high-quality facilities to deny admission to selective individuals with SMI, given concerns about disruptive and potentially dangerous behaviors.sup 6 , 7 /sup As a result of this selectivity, if SNF placement for a person with SMI is found, the facility is likely to have more lenient admission standards, which translates to more quality deficiencies and a lack of an appropriate level of nursing and psychiatric care for these complex residents.sup 8 /sup In addition, over the past two decades, a large number of psychiatric hospitals in the United States have closed. Inadequate development of community-based health services to offset these closures has contributed to a disproportionate number of people with mental illnesses who are incarcerated.sup 9 /sup The criminalization of those with SMI who are now aging in prison, together with factors including minimum sentencing laws, more arrests at later ages, and population aging in general, have resulted in a 500 percent increase since 1990 in the population of U.S. inmates age 50 and older.sup 10