Admission and Care of Individuals with Mental Illness in Massachusetts Nursing Homes: An Exploratory Study

Abstract

Rising rates of mental illness in nursing homes (NHs) led Congress to pass the 1987 Pre-Admission Screening and Resident Review (PASRR) mandate, aimed at limiting inappropriate institutionalization of people with mental illness (MI) and ensuring appropriate service of NH residents with MI. The law’s flexibility results in significant cross-state variations. This study explores Massachusetts’ experiences with PASRR implementation, using semi-structured interviews (N=8) with key informants representing major stakeholders. Thematic Content Analysis was used for analysis.

Four themes emerged as follows: 1) PASRR screens MI, insufficient in ensuring services, 2) NHs face challenges implementing PASRR, 3) inadequate community-based services increase pressure on NHs, and 4) reactions to PASRR revisions were mixed. Participants agreed that PASRR’s first aim was met—avoiding inappropriate institutionalization—but not the second—ensuring appropriate services, and highlighted the limited community alternatives for serving people with MI. More research is needed to understand state variations in PASRR implementation.

Keywords

PASRR serious mental illness nursing homes long-term care

What this paper adds

• Reiterates previous research findings that PASRR may be more effective in identifying people with MI and thus achieving its first goal, but insufficient in ensuring services for them.

• Sheds light on the disparities in services for people with Intellectual and Developmental Disabilities (IDD) and services for those with MI.

• Identifies the lack of available resources for the growing number of NH residents with substance use disorders.

Applications of study findings

• PASRR should align with the needs of people with MI and substance use disorders to avail resources for services and address qualified staff shortage issues.

• Builds a case for a national study to understand the variations in the proportion of people with mental illness admitted and served in nursing homes across states.

The prevalence of mental illness (MI) in U.S. nursing homes (NHs) is on the rise, resulting in high costs for state as well as federal governments. On any given day, more than 500,000 individuals with mental illness (excluding dementia) reside in U.S. NHs (Fullerton et al., 2009). This number is larger than the total number of individuals with mental illness residing in all other health institutions. More recently, Hua et al. (2021) found that among Medicare beneficiaries the prevalence of Serious Mental Illness (SMI) in NHs increased from 10.5% in 2007 to 18.6% in 2017. Rising rates of MI in NHs are problematic for several reasons: NHs may not be suitable for people with MI because they lack resources to serve this population; a high population of residents with MI may impact the overall quality of care as pressure on limited resources increases; and a high proportion of residents with MI is associated with increased costs (Bartels et al., 2003; Office of Inspector General [OIG], 2001; Rahman et al., 2013). Moreover, the proportion of NH residents with MI varies widely across states, indicating geographical disparities in access to treatment (Fullerton et al., 2009). Newly admitted residents with MI tend to be younger, less likely to have family or other social supports, and are more likely to transition to long-term status (Aschbrenner et al., 2011; Grabowski et al., 2009; Simon et al., 2010). NHs are equipped to serve an older population and may not be a good fit for younger people with mental illness, who may be better served in other settings (Aschbrenner et al., 2011).

Increased pressure on NHs to serve people with MI began with the de-institutionalization movement of the 1960s and 1970s, which led to the downsizing and closing of state psychiatric hospitals (Aschbrenner et al., 2011; Koyanagi 2007). This increased demand created a need for federal policies to restrict the admission of people whose only need for support stems from their MI, and also to ensure that those with MI who are appropriately admitted receive the specialized mental health services they need. Thus, the Pre-Admission Screening and Resident Review (PASRR) was implemented under the Omnibus Budget Reconciliation Act (OBRA) of 1987 (Linkins et al., 2001). This legislation mandates two levels of screening: Level I and Level II. The Level I screen is required for all new residents prior to being admitted into Medicaid- or Medicare-certified NHs, irrespective of mental health status, to identify residents who may have a MI. A positive Level I indicate that a resident might have a mental illness; they are then referred to the second Level of screening. A positive Level II confirms diagnosis, assesses the appropriateness of NH placement, and/or determines the need for specialized services (Linkins et al., 2001, 2006; O’Connor et al., 2011). Thus, a positive Level II can indicate one of three things: a) an individual has a MI and can be admitted to a NH without additional mental health services; b) an individual has a MI and can only be admitted to a NH with additional specialized mental health services; c) an individual has a MI, and they will not be best served in a NH. The goals of the PASRR are therefore twofold: to reduce unnecessary NH admissions of people whose only need for support is due to a MI and to provide specialized services in the most integrated settings for those who are admitted to a NH based on their other support needs, but also have a MI.

Scholars studying MI in NHs have used different definitions of MI, which exclude or include various diagnoses. When narrowly defined, MI can be limited to two mental disorders: schizophrenia and bipolar, which are often referred to as SMI (Grabowski et al., 2009). Alternately, MI can be more broadly defined to include mood disorders (e.g., depression), anxiety disorders, personality disorders, substance use disorders, and other diagnoses in addition to schizophrenia and bipolar disorders (Grabowski et al., 2009; Temkin-Greener et al., 2018). States can choose how they define MI for PASRR screening. In Massachusetts, the PASRR defines MI (which is used synonymously with SMI) to include any “major mental disorder, such as schizophrenic, paranoid, mood, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability” (Massachusetts Executive Office of Health and Human Services, 2019). In this paper, we follow the definitions used by PASRR in Massachusetts and use MI and SMI interchangeably to include a broad array of mental disorders.

PASRR has been somewhat successful in identifying individuals with MI, and yet the number of NH residents with MI continues to grow, and NHs struggle to provide appropriate and high-quality mental health services to them (Li, 2010; Linkins et al., 2006; Orth et al., 2019; O’Connor et al., 2009). In their study of PASRR implementation nationally, Linkins et al. (2006) collected survey data from the 50 state agencies responsible for PASRR implementation, reviewed PASRR program documents from 44 states, and conducted in-depth case studies in four states. The study found that passage of PASRR helped increase identification of MI in NHs. Yet, more than 50% of states failed to require NHs to use information from the PASRR to provide services to patients once admitted, with the exception of medication management. Similarly, Li (2010) found that the availability of mental health services in NHs did not improve significantly post-OBRA 1987 from 1995 to 2004. However, he found that certain facility characteristics—such as larger size, a greater Medicare census, and location (Northeast)—were associated with greater service availability. In a more recent survey of NH administrators and directors of nursing, Orth et al. (2019) found that behavioral health service needs were not met in a third of surveyed NHs; almost 40% of respondents regarded PASRR as an obstacle because it slowed down admissions; and more than 60% were worried that, once admitted, residents would not be able to access services and support. Difficulty obtaining mental health services for individuals with MI post-admission has been cited as a major reason for NHs’ reluctance to admit people with MI (Muramatsu & Goebert, 2011; Orth et al., 2019).

States vary in how they implement PASRR, what PASRR instruments they use, and how they define specialized services. Although all states must ensure that NHs complete PASRR screenings, they have considerable flexibility in implementing the federal requirements (Linkins et al., 2001). This flexibility has led to high statewide variation in estimates of the proportion of people with MI living in NHs, as well as considerable variation in access to specialized services. This may be due to the different tools that states use to identify MI and how they define MI, as discussed previously. Another potential source of variation lies in states’ interpretation of “specialized mental health services.” Thirty-eight states, including Massachusetts, define specialized services as limited to 24-hour inpatient psychiatric care (Linkins et al., 2006), while the remaining states include psychological consultations, rehabilitation, and crisis interventions (Linkins et al., 2006).

A major reason for poor coverage of these specialized services is the lack of a payment source. Medicare-funded mental health services are fairly limited. However, many NH residents also qualify for services under Medicaid, although these are also limited. According to Linkins et al. (2006), 38 of the 42 states studies reported that state Medicaid programs cover only basic services such as consultations and medication management services in NHs. States have struggled to finance specialized services under the PASRR mandate, and many maintain the bare minimum to comply with federal requirements (O’Connor et al., 2011).

Finally, states also differ in the extent to which they regulate MI in NHs (Street et al., 2013). Street et al. (2013) divided states into four categories: states with extensive MI regulations, states with a brief mention of MI, states lacking regulations related to MI management in NHs, and states with Alzheimer’s- or Dementia-specific regulations. The study found that only six states had specific NH regulations related to MI. Nine states had a passing mention of MI and 17 had regulations specific to dementia but had no mention of MI-specific regulations. The remaining 18 states, including Massachusetts, lacked specific regulations for either residents with MI or those with Alzheimer’s Disease and Related Dementias or any other mental disorders. It should be noted that although some studies include Alzheimer’s Disease and Dementia in their definition of MI (see Street et al. (2013)), this study excludes Alzheimer’s Disease and Related Dementias from its discussion of MI.

The literature shows that states vary considerably in their treatment of people with MI in NHs but does not address the source of these variations. Moreover, few studies examine whether the PASRR tool meets its goals—to control both the admission of people with MI to NHs and to ensure appropriate treatment of residents with MI once admitted—much less other factors that might influence these outcomes, such as a state’s support for people with MI outside of NHs.

The current exploratory study aimed to gather qualitative data to inform further research on these issues. It focused on one state’s (Massachusetts’) practices and regulations around the admission of people with MI into NHs. Massachusetts had 372 nursing facilities with about 36,675 residents in 2020, comprising 2.8% of all US NHs, mostly funded by the state’s Medicaid program (64%) (Kaiser Family Foundation, 2020a, 2020b, 2020c). Although data on the prevalence of MI in Massachusetts NHs is slim, one study (Grabowski et al., 2009) found that Massachusetts NHs admitted people with MI (defined as those with a schizophrenia, bipolar, depression, and anxiety disorders) at a higher-than-average rate—4.7% of all Massachusetts residents with MI, compared to the national average of 3.0% in 2005. The study also found that of the total new NH admissions in Massachusetts (34,352), 28.5% had a MI diagnosis—which, again, was higher than the national average of 27.4%. Correspondingly, Massachusetts has been found to have limited regulation of NH residents with MI (Street et al., 2013). Using a qualitative research design, the aim of this research was to explore the Commonwealth of Massachusetts’ policies around MI in NHs, specifically its regulations regarding the design and administration of PASRR, aiming to answer the following research questions:

Research Question 1: What are the policies, regulations, and processes in place in Massachusetts that govern the admission and care of NH residents with MI?

Research Question 2: What are the perceived barriers/challenges faced by stakeholders in providing needed care to residents with mental illness?

Methods

Study Design and Sample

This qualitative study used semi-structured phone interviews with eight key informants to understand the state of the PASRR implementation in Massachusetts. Key informants for this study included two NH administrators; a representative from the State Mental Health Authority (SMHA); a representative from the state Medicaid office; and an academic researcher involved in PASRR research. Participants also included two independent Department of Mental Health (DMH) contractors who work on behalf of the state mental health authority and the state Medicaid program (known as MassHealth) to conduct Level II screens and determine the appropriateness of NH placement, as well as a representative from the Technical Assistance Collaborative, a nonprofit organization contracted to provide technical assistance for the PASRR Technical Assistance Center (PTAC) (https://www.tacinc.org/project/pre-admission-screening-and-resident-review-pasrr-technical-assistance/). Interviewees were identified through snowball sampling, based on their knowledge of and engagement with the PASRR process. Key informants were directly contacted via e-mail to request study participation. Phone interviews were recorded and transcribed with subject verbal consent.

A semi-structured interview guide was designed to address the research questions (see Appendix 1). The interview guide drew from the works of Linkins et al. (2006) and O’Connor et. al. (2011). The interviews were conducted pre-COVID-19 between November 2018 and March 2019, used an open-ended format, and lasted from 20 to 60 minutes. They explored the interviewees’ understanding of the state PASRR process, state regulations around MI in NHs, initiatives to better address the needs of residents with MI, best practices, challenges in implementing PASRR, and recommendations identified by the key informants. Finally, the key informant interviews were used to understand how the different agencies communicate and collaborate to implement PASRR.

The interviews were transcribed verbatim, and Atlas.ti software was used for qualitative data analysis. The analysis combined a priori codes derived from the interview protocol as well as inductive codes arising from the interview text, which were analyzed using Thematic Content Analysis. Thematic Analysis (TA), as the name suggests, is a qualitative method of discovering themes or commonalities in data and using these commonalities to interpret data (Braun & Clarke, 2006). All interviews and documents were read thoroughly, coded, and recoded until no new themes emerged. Two coders were involved in the coding and recoding process, and they discussed, clarified, and refined the codes multiple times. Any coding difficulties and disagreements were resolved through discussion to achieve consensus. The study did not use respondent validation due to the explorative nature of this research.

Results

The timing of this study’s interviews was fortuitous. Many interview participants had recently thought through issues around PASRR implementation because, in 2018, Massachusetts had revised its PASRR Level I screen and the overall PASRR process to better comply with federal regulations. A detailed description of the current PASRR screening process in MA is included in the Appendix, along with a flowchart (See Appendices 2 and 3).

Four key themes were identified as follows: 1) PASRR screens MI but insufficient in ensuring services, 2) NHs face challenges in implementing PASRR, 3) inadequacy of community-based services leads to increased pressure on NHs, and 4) mixed reactions to PASRR revisions.

Pre-Admission Screening and Resident Review Screens MI but is Insufficient in Ensuring Services.

Respondents agreed that although the revised PASRR process was reasonably efficient in identifying and screening out people with MI, it was insufficient in ensuing appropriate services for people with MI living in NHs. Most study participants pointed out that NH residents in Massachusetts rarely qualify for specialized services, which in Massachusetts are limited to inpatient psychiatric care. One NH administrator said that they witness a total of two to three Level II positive screens a year, out of roughly 600–700 admissions a year. The other administrator reported that although the facility had multiple Level II positive screenings, most did not result in any specialized services. Those who need specialized services, as determined by the independent contractor, would need to leave the NH for a psychiatric hospital to receive those services. However, given that positive Level II screens are a rarity, most NH residents with MI continue living in NHs.

The two NH administrators emphasized that Massachusetts’ limited definition of specialized services (that is, as comprising inpatient hospital care only) restricts their NH’s ability to meet resident needs and limits the usefulness of the PASRR. States are responsible for meeting specialized service needs for residents with MI, but Massachusetts NHs are required to provide any additional non-specialized mental health services to residents as part of their service plan. One of the administrators stated, “You can identify all you want, but if there aren’t any services you can bring, why bother doing it in the first place?” Another stated,

“The tool is fine. We collect all this information. We have auditors that come in to make sure that the information is correct, but what are we doing with all of this information? The provision of services after we collect it, we are left up to our own intent to provide those services, whether to find a psychiatric provider, to meet the patient’s needs, we are the ones that do all that.”

The two NH administrators also pointed out that the number of residents with substance use disorders has risen. In Massachusetts, the PASRR includes substance use disorder as an MI. However, the NH administrators reported feeling unprepared to support this population. One stated that “not everybody is qualified to come in and start working on those issues.”

NHs Face Challenges in Implementing PASRR

Three key challenges that NHs face were identified as follows: a) NHs lacking guidance, b) NHs lacking the essential information needed to complete Level I, and c) changes in the nature of MI and required services. First, NH administrators indicated that they receive insufficient guidance from the state regarding PASRR compliance. NHs often received unclear feedback because of the disconnect between the state and the federal government: “the facilities need a greater degree of consistency in what the state expects to be present in the service plan. But because the federal regulations do not say (clearly), the state will often take the position of we won’t tell you what to do, we will just tell you what you are doing wrong when we see it.” Written guidelines are available but not helpful. “The regulations are certainly voluminous. There are 700 pages of them, but they talk about it in generalities, you have got to have the services that the person needs, well what does that mean?” Although NHs periodically received PASRR training from MassHealth, the scope of these trainings is limited. “It is really more about ensuring compliance with getting the Level I done properly and seeing that the Level II are followed through when they are necessary. It is not so much about bringing the services together.” Thus, PASRR has become more of an administrative hurdle that needs to be cleared to avoid penalties, and less of an opportunity to address the mental health care needs of residents with MI.

NH respondents identified some issues with the Level I screen. One respondent reported that it had too many questions and that the data, once collected, were not well-utilized. Both NH informants felt that NHs sometimes lacked adequate information to complete the Level I screen, given that these were conducted pre-admission and data were obtained from hospitals, medical charts and/or reviews. One recommendation was to require hospitals to complete the Level I screen, given their more thorough knowledge of resident needs. In some states, hospitals can complete the level I screen and then pass on the information to the NHs. This speeds up the process and eliminates the redundancies inherent in the Massachusetts system, where prospective residents may be referred to (and screened by) as many as four NHs, but are admitted to only one. This happens because regulations place ultimate responsibility for Level I screenings on NHs, even though hospitals and Aging Services Access Points (ASAPs) are permitted to complete Level I screenings.

According to the NH administrators, the population of people with MI entering NHs has changed over the years, and so have their care needs. They are more likely to be male, younger and have significantly more acute psychiatric or substance use disorders. NHs struggle to serve this population; in particular, NHs face difficulty in finding staff qualified to work with the issues these residents present. One administrator reported, “Most often NHs have consulting arrangements with agencies that will bring in a team that would include individual counseling, services of a psychologist or a psychiatric nurse practitioner. But again, they have a hard time with staffing. Facilities do not have as much available as need might really demand.”

Inadequate community-based services increase pressure on NHs

Although Massachusetts, like many states, aims to return NH residents to the community—and, indeed, includes provisions for community diversion in its PASRR instruments—it has difficulty discharging residents with MI due to a lack of appropriate community-based services and supports. One DMH contractor reported,

“There is a section in our Level II where there are services, such as alcohol rehabilitation, adaptive equipment needs that are recommended in the NH, and there are community referral opportunities or other types of services that people could look at community-based Medicaid services, integrated care plan through Medicaid, HCBS waivers, non-Medicaid services.”

Four out of the eight respondents expressed concern about placing people with MI into the community, given the lack of home and community-based services (HCBS) such as group homes, and other needed supports such as affordable housing. One stated, “the availability of mental health services is lacking everywhere, so if they do not belong in the NH where do they belong?” The HCBS are not only limited but also unreliable: “There is a degree of security in staying in the NH and some of them who have been in the community-based systems in the past fear that even if they have something very solid when they first go, that it won’t stay that way and then they are left vulnerable.” Another respondent pointed out that, due to waiting lists for services, it can take years before community options become available—long after residents may have adapted to life in NHs.

The PASRR’s ability to facilitate services for people with MI and people with intellectual or developmental disabilities (IDD) varies, given the differences in service delivery systems for the two groups. Several study participants reported that the Department of Developmental Services (DDS), the primary agency responsible for meeting the needs of individuals with IDD, had a greater capacity to meet the service needs of individuals with IDD and help them to age in place. However, one participant acknowledged that the IDD population was smaller, and the DDS had more resources at their disposal. A NH administrator reported:

“We see a lot more (specialized services) with people who have a developmental disability. They are approved to go to a day program, or they will have somebody to come into provide one-on-one…We have had cases, somebody who has a DD has some sort of work program at home and they would provide that service in the NH as well.”

Compared to people with IDD, people with MI are less likely to be denied admission into NHs because of their MI and less likely to transition into the community.

Reactions to PASRR Revisions were Mixed

The PASRR revisions instituted by Massachusetts received mixed reactions, with state respondents (DMH, DMH contractors, and MassHealth) differing from NH respondents. The NH administrators reported that the 2018 changes had not been well-received by the NH community; they saw the changes as a way for the state to get more information from NHs without a clear-cut strategy for making more services available to residents. In contrast, the other participants were hopeful about the new instruments and changes. One of the DMH contractors stated: “The new Level I is creating more false positives, which is what you want. You want to bring in more people and then bring them out. I think that it is doing its job.” The higher number of false positives, they felt, ensures that individuals with MI are not underdiagnosed and thus are not falling through the cracks.

Additionally, the MassHealth representative noted that, although NHs continue to be penalized if found non-compliant with PASRR regulations, there are now benefits to compliance. NHs that meet PASRR regulations receive an add-on to their NH daily rate. The MassHealth representative and the independent contractors also saw the revised logic behind a positive screen as a step in the right direction. Positive screens are now based, not simply on a MI diagnosis, but on the impact of that diagnosis, and specifically, on whether an individual experiences significant impairment due to MI and has received services for their MI. Finally, the MassHealth respondent also pointed out that the state plans to set up an online portal for submitting completed Level I forms, which would enable the state to better monitor NHs and identify trends in the MI service needs of NHs and NH residents.

Discussion

Our study finds that Massachusetts’ implementation of the PASRR, along with recent changes to its implementation, has been successful in ensuring that those with MI who are admitted to NHs are accurately identified, which meets the first goal of the PASRR. However, the second goal of the PASRR is yet to be fully met. NH residents in Massachusetts are reportedly not receiving appropriate services, which is a problem not with the PASRR tool or process, but rather with the overall system of supportive care in MA. Our findings are in line with previous studies showing that PASRR successfully screens people for MI but fails to ensure that they receive mental health services in NHs or elsewhere (Linkins et al., 2006; Orth et al., 2019; O’Connor et al., 2011). Previous literature and our findings show that NHs perceived PASRR as a compliance requirement rather than a way to ensure that NH residents appropriately access quality mental health care (O’Connor et al., 2009). Indeed, NH administrators in a previous study described PASRR as a “government mandated stumbling block” (Molinari et al., 2011, p.18). NHs can struggle to provide appropriate mental health care for several reasons; states can choose how broadly they define specialized services, and in Massachusetts specialized services are narrowly defined and only include inpatient psychiatric hospitalization. Thus, NHs are left to their own devices to meet most of their residents’ mental health service needs. Additionally, the lack of adequate community services and the unreliability of such services means that NHs become the de facto primary site of care for many individuals with MI.

Our study findings were also in line with previous studies that showed that NHs feel unprepared to meet the growing needs of residents with MI (Muramatsu & Goebert, 2011). The two NH administrators in our study stated that they lacked guidance on how to serve this population adequately. According to them, most of the written guidelines from the state focused on ensuring compliance with federal requirements. The participants in our study also recognized that the population of residents with MI has changed over the years and is younger, more likely to be male, and has more acute psychiatric and substance use disorders. So, now more than ever, NHs need additional support and training to better serve the changing population of people with MI.

Massachusetts had recently revised its PASRR tools and processes to better meet federal requirements. At the time of the study, it was still too early to determine how well the revisions were working, but the recent changes appear to be a step in the right direction. Further research should assess the impact of the 2018 PASRR revisions in Massachusetts.

This study has significant limitations due to its function as an exploratory study and its goal of identifying issues for future investigation. Additionally, the study did not use respondent validation to confirm the accuracy of the findings. Most importantly, the study sample was small and only involved PASRR policies in one state, Massachusetts. It is not known how typical Massachusetts is in its implementation of PASRR; hence, the study results may not be generalizable. Future studies should focus on national-level data to understand how PASRR implementation varies across states, resulting in variations in the proportion of people with mental illness admitted and served in NHs.

Supplemental Material

Supplemental Material - Admission and Care of Individuals with Mental Illness in Massachusetts Nursing Homes: An Exploratory Study

Supplemental Material for Admission and Care of Individuals with Mental Illness in Massachusetts Nursing Homes: An Exploratory Study by Adrita Barooah, and Pamela Nadash in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Statement

The research does not qualify as human research and therefore did not require IRB review. The key informant interviews were conducted with respondents in their professional capacities alone. The study is not about living individuals but the processes and regulations around the admission of people with mental illness into Massachusetts nursing homes

ORCID iDs

Adrita Barooah

Pamela Nadash

Supplemental Material

Supplemental material for this article is available online.

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