Beyond State Hospitals: Olmstead and Nursing Homes

1. Beyond State Hospitals:Olmstead and Nursing Homes Jeffrey A. Buck, Ph.D. SAMHSA/CMHS jeffrey.buck@samhsa.hhs.gov (after 9/20/04)

2. Disclaimer The content of this presentation does not necessarily reflect the views or policies of SAMHSA or DHHS

3. PASRR Study finding About 1/3 of states say that PASRR is not covered in their Olmstead planning

4. Preadmission Screening and Resident Review (PASRR) requirements • Designed to prevent inappropriate NH admission • With exceptions, requires that all NH applicants be screened for MI (level I) • If MI indicated, an independent evaluation

5. PASRR rqrmnts • If MI indicated, applicant must have an independent evaluation to determine if: • SMI • NH level of care required • If NH loc required, are specialized services also required

6. PASRR rqrmnts • Administered by SMHA; admission decisions may be delegated • Other living arrangements are supposed to be considered

7. (Mis)Perceptions supporting the exclusion of NHs from MH Olmstead planning • Nursing homes are a type of community placement, not “institutions” • Mental illness is only secondary to other physical disorders • Our responsibility is limited to SMHA-administered programs

8. #1 - Nursing homes are a type of community placement, not “institutions”

9. Medicaid definition “Institution” means an establishment that furnishes food, shelter, and some treatment or services to four or more persons unrelated to the proprietor

10. Nursing home facts • The average NH is over 100 beds • Avg length of time since admission is 892 days • 20% of NH residents are in facilities of 200 beds or more; avg length of time since admission for these is >1000 days

11. ADA perspective The ADA's integration regulation provides that a public entity must administer its services to individuals with disabilities in the most integrated setting appropriate to their needs. There is no ADA definition of institution, but describing how places are institutional is useful to describe how they are segregated and isolated from participation in mainstream society.Jennifer MathisBazelon Center for Mental Health Law

12. DOJ Civil Rights Div. Laguna Honda investigation • Laguna Honda – nursing facility owned by SF with an avg daily census >1000 • “Unusually high number” of residents under 55 yrs – 22% of total; this proportion is increasing • Found ADA violations

13. Laguna Honda • Major findings: • State did not perform adequate assessments when authorizing placements, leading to unnecessary segregation of residents • Individuals with MI were not screened adequately, contributing to improper placement • State did not enable informed decision-making by residents regarding community options • Olmstead plan lacked important data

14. #2 - Mental illness is only secondary to other physical disorders

15. NH news item [An] investigation of nursing home units shows residents with mental illness, many in their 30's and 40's and physically healthy, often "receive little in the way of rehabilitative therapy and are chiefly left to wander the halls or languish in their rooms.“ NY Times, 10/02

16. NH news item The federal government is widening its probe into whether Illinois is improperly warehousing mental patients in geriatric nursing homes, based on conditions found by federal investigations at a nursing home facility in Joliet Chicago Tribune, 6/01

17. NH news item Janet Wells, public policy director for the National Citizens' Coalition for Nursing Home Reform, said nursing homes had become the new dumping ground for psychiatric patients."These people should not be in nursing homes," she said. "They should be somewhere where they're getting treatment. Instead, they're just being cast aside." NY Times, 12/03

18. OIG study of younger MI residents • MDS data - 1.6 percent of States’ nursing facility populations (17,919). • OIG survey of 20 States indicates that this figure may be as high as 20 percent (10%=160,000; compare to state/county hosp – 60,000). • States do not know where younger individuals w/MI are receiving long-term care

19. #3 - Our responsibility is limited to SMHA-administered programs

20. If not you, who?

21. OIG – PASRR findings • States do not have a process to ensure that individuals get needed mental health services identified by PASRR • Little evidence that Level I PASRRs, which are screens to identify an individual’s mental illness, are completed. • Most nursing facilities responded that they never see the results of the Level II PASRRs.

22. OIG – PASRR findings • Most SMHAs do not consider it their responsibility to monitor or provide treatment for residents of nursing facilities with mental illness

23. Conclusions • Many if not all NHs are reasonably characterized as institutions, and subject to ADA/Olmstead • There are many NH residents with a primary or sole dx of MI; many are non-elderly • Due to PASSR, SMHAs play a major role in institutional placement in these facilities

24. Recommendations • Develop better information • Medicaid MIS reports • PASSR reports • Include NHs/PASSR in all Olmstead plans • Improve PASSR administration • Increase community-based alternatives • 1915c waivers