Top Nursing Homes May Exclude Mentally Ill

Top Nursing Homes May Exclude Mentally Ill

Even people with common and often treatable mental health problems like depression and anxiety may have a harder time than patients without these diagnoses getting admitted to a high-quality nursing home, a U.S. study suggests.
Researchers examined data on more than 3.7 million admissions to 15,600 facilities nationwide from 2012 to 2014. By the last year of the study, people with depression and anxiety were 8 percent less likely to gain admission to a nursing home with the highest Medicare quality rating of five stars than individuals without mental health problems, the study found.

The odds of admission to top nursing homes were longer with more severe mental health issues. With bipolar disorder, patients were 11 percent less likely to go to a five-star facility than people without mental health problems; the odds were 28 percent lower with schizophrenia, 27 percent lower with a substance abuse problem and 32 percent lower with personality disorders.

“It appears that nursing homes shy away from accepting patients diagnosed with any behavioral health conditions,” said lead study author Helena Temkin-Greener, a public health researcher at the University of Rochester School of Medicine and Dentistry in New York.

“Whether this is due to misconceptions about these conditions or lack of mental health resources in these facilities or geographic mal-distribution of higher quality nursing homes in lower income neighborhoods where patients with these conditions are more likely to reside, or all of the above, is not clear,” Temkin-Greener said by email.

The U.S. Centers for Medicare and Medicaid Services rates nursing homes on a scale of one to five stars based on staffing levels, quality benchmarks and results from health inspections.

Even after excluding dementia and Alzheimer’s disease, which are a common causes of nursing home admissions, people with behavioral health issues account for about half of all residents, researchers note in the American Journal of Geriatric Psychiatry.

While severe behavioral problems have long been linked to slim chances of admission to a high quality nursing home, the current study offers fresh evidence that even people with common and comparatively easy to manage mental illnesses like depression and anxiety may be rejected by top facilities, Temkin-Greener said.

With behavioral health problems, patients were also more likely to be sent to one-star homes, the lowest quality facilities, the study also found.

Compared to people without mental illness, patients with depression and anxiety were just one percent more likely to go to one-star nursing homes by the last year of the study.

But patients with bipolar disorder were 11 percent more likely to wind up in a one-star facility, and the odds were 15 percent higher with a substance abuse problem, 18 percent higher with personality disorders and 28 percent higher with schizophrenia.

The study wasn’t a controlled experiment designed to prove whether or how a behavioral health problem diagnosis might directly affect admission to very high- or low-quality nursing homes. Researchers also lacked data on what factors nursing homes might have used to make admissions decisions.

Still, the results add to evidence of widespread disparities in who can access top quality nursing homes, said Stephen Crystal, a researcher at Rutgers University in New Brunswick, New Jersey, who wasn’t involved in the study.

“We already know that there is a substantial level of disparity access to higher quality nursing home care across a broad range of patient characteristics – notably, by socioeconomic status, race, ethnicity, education, income and the degree of family involvement and support in negotiating the system,” Crystal said by email.

Because not enough facilities can handle patients with multiple chronic, complex physical and mental health problems, families need to advocate for their loved ones, Crystal said.

“This is a difficult problem with no easy answers,” Crystal added. “It takes a lot of vigilance, visiting and researching facilities, being ready to act quickly when a hospital is pressing to discharge a patient to post-acute care, and when necessary pushing back against the first placement offered if it is not a good facility.”

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