BACKGROUND/RATIONALE:
Little is known about the prevalence, characteristics, or quality of care for VA Community Living Center (CLC; formerly known as nursing homes) residents with serious mental illness (SMI). In general, researchers have questioned whether nursing home staffs have adequate mental health resources, training, and experience to meet the care needs of residents with SMI. There is also little information regarding the distribution of individuals with SMI across facilities, or how this relates to treatment capacities, processes, or resident outcomes.

OBJECTIVE(S):
This study assessed whether and how CLC facility structural elements and treatment processes influence risks of adverse outcomes for patients with and without SMI.
Study objectives were to: 1) Describe the prevalence, characteristics, and services use of VA CLC residents with SMI; 2) Determine whether risks of adverse health outcomes differ by resident SMI status; 3) Determine whether individuals with SMI are less likely to experience adverse health outcomes if their CLC has a high prevalence of SMI; 4) Assess resources and perceptions related to delivery of CLC care to patients with SMI.

METHODS:
The study used a retrospective cohort design for secondary data analysis that included National Death Index, Minimum Data Set (MDS) and national VA administrative data from FY01-FY07. For bivariate analyses, the study identified residents in VA CLCs in each year, FY01-07. Resident characteristics and services utilization, by SMI status, were assessed. We also evaluated trends in the prevalence of SMI. We also conducted separate multivariable survival analyses for specific outcome measures (e.g., behavioral decline, functional decline, pressure ulcers) except for mortality and receipt of antipsychotics, which were examined using generalized estimating equations. Analyses evaluated whether resident SMI status is associated with risks of adverse outcomes. We also examined the influence of structure and process indicators on risks of adverse outcomes. These were assessed at of the start of FY01 and then at 6-month intervals. Structure measures included facility SMI specialization, assessed using a measure of sustained high prevalence and admission volume.
For primary data collection, the study also administered a national survey of all VA CLCs to nurse managers at 130 CLCs. The survey collected information on resources and perceptions related to delivery of care for residents with SMI.

FINDINGS/RESULTS:
Prevalence of SMI among CLC residents is increasing over time, as is the percent of CLCs that are categorized as SMI specialized. SMI status was associated with increased likelihood of antipsychotic receipt, discharge to inpatient psychiatric settings, and behavioral declines over time. Individuals with greater reported disruptive behavior were more likely to have SMI, to have been admitted to a CLC that was more geographically distant from their zip code of residence, and to die during their CLC stay or up to 6 months following CLC discharge. Residents' SMI status was not a significant predictor of functional decline, mortality, ambulatory care sensitive hospitalizations, or suicide. SMI status was associated with reduced likelihood of pressure ulcer development.
However, CLC SMI specialization status was associated with greater risk of pressure ulcer development and of behavioral declines.
National CLC survey reports suggest that improvements to CLCs' physical environments and the amount of recreational activities have had a positive impact on care for residents with SMI. Survey respondents also noted concerns regarding delivering care to residents with SMI. These included safety, increased complexity of care, and the need for greater resources, training, and consultations with specialty mental health.

IMPACT:
Greater access to long-term care for patients with SMI is needed, as this population in the CLC is growing. In addition to the need for increased capacity, CLCs may also benefit from more specialized training for staff and from more involvement by specialty mental health.

Study investigators have contributed study information in the context of the national and VISN level Geriatrics and Extended Care review and the VISN 11 Nursing Home Mental Health Task Force.

Bowersox NW, Szymanski BR, Barry KL, Valenstein M, McCarthy JF. VHA Inpatient Psychiatric Bed Capacity and Prevalence of Serious Mental Illness in Long-Term Care Facilities, 1999-2007. Poster session presented at VA HSR&D National Meeting; 2011 February 16-18. National Harbor, MD.

McCarthy JF, Mach JM, Kim HM, Blow FC, Kales H. Prevalence and Predictors of Receipt of Antipsychotic Medications in VA Community Living Centers. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD.

McCarthy JF, Mach JM, KIM HM, Blow FC, Kales HC. Prevalence and Predictors of Receipt of Antipsychotic Medications in VA Community Living Centers. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.

McCarthy JF, Szymanski B, Kales HC, Blow FC. Indications of Appropriateness of Admissions for Individuals with Serious Mental Illness in VA Community Living Centers. Poster session presented at: Academy Health 2010 June 28; Boston, MA.

McCarthy JF, Szymanski B, Mach JJ, Blow FC, Rosen A, Valenstein M, Kales HC. Serious Mental Illness in VA community Living Centers and Risk Factors for Disruptive Behaviors. Poster session presented at: VA Mental Health Annual Conference; 2009 Jul 22; Baltimore, MD.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kim HM, Banaszak-Holl J, Kales H, Mach J, Blow F, McCarthy JF. Trends and predictors of quality of care in VA nursing homes related to serious mental illness. Medical care. 2013 Aug 1; 51(8):659-65. [view]

Conference Presentations

1. McCarthy JF, Szymanski B, Kales HC, Kim HM, Blow FC. Assessing the Appropriateness of Admissions for Individuals with Serious Mental Illness in VA Community Living Centers. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA. [view]
2. McCarthy JF. Disruptive Behaviors Among Nursing Home Residents With Vs: Without Serious Mental Illness. Paper presented at: National Association of PASRR (Pre-admission, Screening & Resident Review) Professionals Annual Conference; 2009 Oct 27; Baltimore, MD. [view]
3. McCarthy JF, Mach JM, Kim HM, Blow FC, Kales H. Prevalence and Predictors of Receipt of Antipsychotic Medications in VA Community Living Centers. Paper presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 27; Baltimore, MD. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care
DRE: none
Keywords: Behavior (patient), Behavior (provider), Severe mental illness
MeSH Terms: none