A quiet but significant revolution is taking place in health care that primarily affects the nursing home industry. New clientele are being introduced to nursing homes, representing the chronically mentally ill, survivors of head trauma, terminally ill people with AIDS, brain damaged drug abusers, and the adult developmentally disabled and retarded.
On the surface, this seems to be the end result of changes in the marketplace. Closer examination, however, suggests the motivation to be shrinking state dollars for long-term care and the shining of costs from state to federal coffers. The shift to new payers will not be a smooth transition because current state and federal regulations were written to meet the needs of the physically ill elderly and do not encompass the special needs of these new populations.
The unplanned transfer of nongeriatric disabled clients to the nursing home is similar to inviting dinner guests but neglecting to prepare the meal. When young adults arrive in nursing homes, they will truly find empty plates: counselors, recreational and therapy programs oriented to younger patients, vocational rehabilitation, and other necessary services are neither required nor expected in today's nursing homes. Causes for this impending disaster may be partly rooted in the history of the relatively young nursing industry.
Before the nursing home, there was the county poor house. Its mission was to provide shelter and sustenance for orphans, widows, and the aging who had no families to "take them in." Not until the 1930s did American society begin to express its concerns over the inadequate treatment of these groups with the passage of the Social Security Act of 1935.
For the first time, federal monies were allocated to states for the care of needy women and children. Workers and employers began paying old age insurance premiums, and the elderly began to receive monthly old age benefits. These benefits allowed the aging to select and pay for room and board in homes instead of being admitted to the county poor house. Nursing care was neither a required nor an evident service in these early homes. As women, children, and those capable of relatively independent living moved out of the poor house, the sick and the very frail elderly were left as its occupants.
In the 1940s and 1950s, homes began to sort themselves according to their primary missions. Those that provided care for the sick began to be called nursing homes, while others provided retirement living for the well elderly. Some church homes saw their missions as providing for both populations. The county poor house left the scene.
Only about 30 years ago, in the mid 1950s, did requirements begin to include the presence of registered nurses in nursing homes located in or near metropolitan areas. One registered nurse present 8 hours per day, 5 days per week, regardless of the size of the facility, was considered to be generous coverage.
Solon reports that across the nation "in 1961 virtually no proprietary nursing home had a full time physician; only 44% had a full time registered nurse; and 14% had no trained nurses."1 The competence of nursing homes in the 1960s was in the care of physical illness and senility (or the dementias of old age). Patients with psychiatric diagnoses or psychoses were not admissible.
In 1965, Medicare legislation was passed with the intention of paying for acute care and rehabilitation of the ill and injured over 65 years of age. This brought about the upgrading of nursing homes into nursing and rehabilitation facilities with registered nursing services around the y clock and physical therapy available for the convalescent patient immediately following an acute hospital stay. Patients with psychiatric diagnoses were still neither welcome nor, in most instances, permitted in nursing homes by Medicare limitations. Fewer than 2% of all patient days nationally were paid for by Medicare by the late 1980s.2
Swann reminds us that "nursing homes are the centerpiece of a de facto mental health policy of deinstitutionalization."3 His comments reflect the effects of the federal Medicare/Medicaid reimbursement policy that refuses to pay for mental hospital care beyond 90 days in a lifetime, but will pay for endless numbers of days of care in a nursing home for the same individual with a geriatric diagnosis. Massive deinstitutionalization programs in the 1970s were an attractive solution for financially strapped state mental institutions. The 2,000-bed state hospital "warehouse" for the mentally ill in many states is being exchanged for the 200-bed "warehouse" in the community nursing home.
Unfortunately, nursing home care is not a substitute for inpatient psychiatric care because of a lack of appropriate specialty staff. The shifting of the psychiatric patient denies him a therapeutic milieu and treatment. It places him in a custodial environment devoid of psychiatrists and psychologists, as well as psychiatric nurses and social workers. In most states, nursing home licensure regulations do not require any psychiatrically prepared staff. Medicaid standards for nursing home certification, in most states, do not include costs of psychiatric care because the federal position is that primary psychiatric disease is excluded from Medicaid coverage in nursing homes. This position was upheld in the courts in the 1985 case of Connecticut v Heckler.
In an attempt to stop state shifting of psychiatric patients, federal Medicaid regulations proclaimed that institutions for mental disease are facilities with more than 50% of their patients having mental diagnoses requiring inpatient treatment. Federal guidelines use the receiving of psychopharmacological drugs as an indication of psychiatric illness.4 If a nursing home is found to have an excessive number of psychiatric patients, or patients receiving psychopharmacological drugs, it risks losing Medicaid reimbursement as a nursing home and reclassification as an institution for mental disease.
So as not to jeopardize federal Medicaid certification and reimbursement, nursing homes have limited the admission of patients with overt psychiatric diagnoses. Therefore, the patient with a diagnosis of "dementia of old age" or "chronic brain syndrome" can more easily locate a nursing home bed than a patient with a diagnosis of schizophrenia or Alzheimer's disease. To protect state mental health budgets and to shift coste to Medicaid, one state is granting certificates of need to nursing homes based on their willingness to develop designated mental health (geropsychiatric) beds for patients transferred from state psychiatric hospitals. It was intended that a 6-month increase in patient reimbursement would be used for specialized programs.5
Advocates for the other nongeriatric disabled populations have noted the success of mental health bureaucrats in shifting scarce public dollars from state treasuries to federal matching Medicaid funds, and are attempting to follow the same course. AIDS patients and brain damaged drug abusers comprise populations with new diseases that have not yet been included in the planning of health resources. Both require lifetime care, some shorter than others. The impact of AIDS creates massive numbers of patients who will need highly technical nursing and other support services for an episodic period of perhaps 6 months to a year. The care requirements of brain damaged drug abusers, as well as the adult developmentally disabled and retarded, are not those of highly technical services, but are the psychiatric, restorative, and cognitive therapies offered by an array of health disciplines for the remaining 40 to 60 or more years of their lives.
Most long-term care health plans are based on the needs of a target population 60 years of age and over. The admission of new and younger populations to the nursing home will create severe competition for already scarce beds. Many states have attempted to control Medicaid costs by capping bed construction and increasing family fiscal responsibility. Cost containment measures in general do not take into account the need for increased numbers of beds based on the Census Bureau's projected increase in the geriatric population from 13% of the total population in the year 2000 to 20% in 2025.6 Nor do these "hold the line" measures provide for the increased need for nursing home beds resulting from today's emphasis on early hospital discharge of sicker patients since the institution of diagnosis related group limitations. The planning basis for nursing home care is thus nullified before adding the burden of unforeseen use by new population groups. The need for upwardly revised bed estimates, additional health disciplines, and different specialty programs in the nursing home must be addressed before new clientele are admitted.
The Nursing Home Reform Act (NHRA), that portion of the Omnibus Budget Reconciliation Act of 1987 that pertains to nursing homes, specifically prohibited admission of the mentally ill and retarded to nursing homes as of January 1, 1989.7 At least part of the problem should have been solved, but not necessarily. Implemented with Draft Federal Guidelines, this now restricts only those in need of "active treatment" for psychiatric conditions or retardation, not those with chronic conditions requiring ongoing or maintenance therapy.8
In practice, psychiatric patients are being treated in acute general hospitals for 21 to 30 days, then released to nursing homes on the assumption that additional benefit or behavior change will not be obtainable by prolonged treatment. The issue of "manageability" is seldom confronted. Chronic care psychiatric patients are still streaming into the nursing home, and will continue to do so until the definition of "requiring active treatment" is better and more broadly defined. For this population, the NHRA has only slowed the admission process and increased the paperwork of both nursing homes and governmental regulators. Some states may abide by the spirit of the NHRA, whereas others take full advantage of this loophole in the law.
The NHRA also allows for persons who have been in a nursing home 30 ^ months or longer and require active treatment to elect to remain in the home as long as the active treatment can be arranged. As soon as the nursing home begins to import elements of active psychiatric and retardation care, a question arises about the medical or philosophical basis for restriction of future admissions.
Perhaps the nursing home of the future will be required to specialize as have hospitals in the past. Separate facilities may be developed for the elderly, those with communicable diseases, the terminally ill, the retarded and head injured, and those requiring convalescent care. Successful planning for current and future long-term care must provide for appropriate and medically sound residential care for the frail elderly, mentally ill, survivors of trauma services (head injuries), retarded and physically disabled, brain damaged from drug abuse, people with AIDS, and terminally ill, regardless of age. Coincident with this revolution is the need for a convention of state nursing home licensing authorities and advocacy groups to draft programmatic standards to meet the needs of the varied users of the future nursing home.
- 1. Solon JA . Nursing home and medical care . In: DeGroot LG, ed. Medical Care: Social and Organizational Aspects. Springfield, Ul: Charles Thomas; 1966:198.
- 2. Medicaid and Nursing Home Care: Cost Increase and the Need for Services are Creating Problems for the States and the Elderly. Washington, DC: LTS General Accounting Office; 1983:4.
- 3. Swan JH. The substitution of nursing home for inpatient psychiatric care. Community Ment Health J. I987;23(l):3.
- 4. Services Transmittal No. 20. In: State Medicaid Manual, Part 4. Washington, DC: US Department of Health and Human Services, Health Care Financing Administration; Sept 1986.
- 5. The public-private partnership for mental health. In: Maryland Legislative Briefing. Annapolis, Md; Jan 1988.
- 6. Governor's Task R)rce on Alzheimer's Disease and Related Disorders. Maryland Report on Alzheimer's Disease and Related Disorders. Annapolis, Md; 1985: V-2.
- 7. Public Law 100-203, Budget Reconciliation Act, US, 1987: Sec 421 1:C:7.
- 8. Draft Federal Guidelines, State Medicaid Manual. Part 4: Services. Washington, DC; 1988: Sec 4250-4253.