Are Nursing Homes Appropriate for Older Adults?
Are Nursing Homes Appropriate for Older Adults?
Objectives: In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs.
Design: Cross-sectional, descriptive, correlational study.
Setting: Ten community mental health centers and two state-funded nursing homes specializing in long-term care for older persons with SMI.
Participants: Consumers of mental health services in the community (n=115) and in nursing homes (n=106), aged 60 and older, with SMI. Sixty-four clinicians (51% registered nurses, 29% masters-level clinicians, and 20% certified social workers) conducted ratings.
Measurements: Consumers and their clinicians were independently asked to determine the most appropriate care setting for each consumer based on care needs from three alternatives: nursing home, congregate (group) living setting, or individual apartment/home. Clinical characteristics of participants with SMI were rated using the Mini-Mental State Examination, Brief Psychiatric Rating Scale, Specific Level of Function Scale, Cumulative Illness Rating Scale for Geriatrics, a modified memory and orientation subscale from the Clinical Dementia Rating Scale, and an item from the Minimum Data Set related to reasoning.
Results: Of nursing home residents with SMI who did not have severe cognitive impairment, 40% (n=42) and 51% (n=54) were considered by consumers or by their clinician, respectively, to be more appropriate for a community-based setting, but there was a low level of agreement (only 27.6%; no better than chance) between consumers and clinicians on which nursing home residents were most appropriate for living in the community. Determinations by clinicians were associated with clinical need (diagnosis and less-severe behavioral problems), whereas there was no association between clinical needs and level of care determinations by consumers. Finally, clinicians considered a group home necessary for 93.7% of nursing home residents judged to be more appropriate for a community-based setting, whereas 90.5% of consumers stated that an apartment or individual home was indicated.
Conclusion: State implementation of the Olmstead decision will need to consider major differences in perspectives between clinicians and consumers on the most appropriate long-term care setting for older persons with SMI.
In a landmark decision in June 1999, the United States Supreme Court ruled that it is discriminatory to institutionalize a disabled person who wishes to live in the community and is capable of benefiting from such a setting. Known as the Olmstead decision, this case established that unnecessary and undesired institutionalization constitutes discrimination for persons with mental disabilities because it severely diminishes the individual's ability to interact with family and friends, to work, and to make a life for him or herself. Perhaps the most daunting and challenging implication of the Olmstead decision pertains to the growing number of older persons with mental disorders. Nursing homes have become the primary institution-based setting for older persons with severe mental illness (SMI), accounting for 89% of all older persons with SMI in healthcare institutions, compared with 11% receiving services in hospitals.
Under the Olmstead decision, states must provide community placements for people with disabilities whenever the state's treatment professionals have determined that community placement is appropriate and the affected person wishes to live in the community, but little is known about professional and consumer perspectives on what constitutes appropriate community placement for aging persons with SMI.
To date, a limited literature describes clinical characteristics associated with institutional care for older persons with SMI. Older persons with SMI who reside in nursing homes have greater functional impairment in self-care skills and community living skills, worse general health, more-severe negative (deficit) psychotic symptoms and cognitive impairment, more aggressive behaviors, and less social support than those who live in the community. In addition, several studies suggest that older adults with SMI are at a substantially greater risk of institutionalization than other groups of older persons.
However, residential preferences of individuals with mental illness are poorly understood, and little is known about the preferences of older mentally ill individuals. A review of 26 studies of residential preferences of young mentally ill adults found that most consumers preferred to live in their own house or apartment, to live alone or with a spouse or romantic partner, and not to live with other mental health consumers. Group homes were among the least popular options. Nevertheless, at least one study has shown that mentally ill consumers may prefer to share housing with friends to avoid feelings of isolation. Higher perceived need for social support was related to housing preferences of homeless adults with mental illness, whereas diagnosis, symptoms, personality characteristics, and subjective quality of life were not. In addition, some state psychiatric hospital residents who had spent little time in the community expressed an attraction to institutional living. Finally, preferences of mentally ill nursing home residents (mean age 59.7) indicated that prior institutional living experience is associated with housing preferences and satisfaction. When given the choice to move to supported housing, 46% remained in the nursing home by preference 1 year later. This decision was associated with the consumer's perception of health, financial constraints, the wish to remain in one place, familiarity, and social support.
In summary, as states scramble to accommodate the Olmstead decision, major questions are unanswered with respect to important features of this federal directive. For example, what criteria should be used to determine the most appropriate long-term care setting for older adults with SMI? To what extent do older mentally ill nursing home residents view their long-term care setting as inappropriate, preferring instead to live in the community? Similarly, how do clinicians view the appropriateness of nursing homes for older persons with SMI? What clinical characteristics are associated with clinician determinations of the most appropriate level of long-term care? Finally, how do consumer and clinician perspectives compare? The purpose of this study was to help inform current deliberations by the states on implementing the Olmstead decision by addressing these questions through a descriptive analysis of a previously collected data set consisting of clinical ratings and surveys of older adults with SMI residing in community and nursing home settings.
Objectives: In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs.
Design: Cross-sectional, descriptive, correlational study.
Setting: Ten community mental health centers and two state-funded nursing homes specializing in long-term care for older persons with SMI.
Participants: Consumers of mental health services in the community (n=115) and in nursing homes (n=106), aged 60 and older, with SMI. Sixty-four clinicians (51% registered nurses, 29% masters-level clinicians, and 20% certified social workers) conducted ratings.
Measurements: Consumers and their clinicians were independently asked to determine the most appropriate care setting for each consumer based on care needs from three alternatives: nursing home, congregate (group) living setting, or individual apartment/home. Clinical characteristics of participants with SMI were rated using the Mini-Mental State Examination, Brief Psychiatric Rating Scale, Specific Level of Function Scale, Cumulative Illness Rating Scale for Geriatrics, a modified memory and orientation subscale from the Clinical Dementia Rating Scale, and an item from the Minimum Data Set related to reasoning.
Results: Of nursing home residents with SMI who did not have severe cognitive impairment, 40% (n=42) and 51% (n=54) were considered by consumers or by their clinician, respectively, to be more appropriate for a community-based setting, but there was a low level of agreement (only 27.6%; no better than chance) between consumers and clinicians on which nursing home residents were most appropriate for living in the community. Determinations by clinicians were associated with clinical need (diagnosis and less-severe behavioral problems), whereas there was no association between clinical needs and level of care determinations by consumers. Finally, clinicians considered a group home necessary for 93.7% of nursing home residents judged to be more appropriate for a community-based setting, whereas 90.5% of consumers stated that an apartment or individual home was indicated.
Conclusion: State implementation of the Olmstead decision will need to consider major differences in perspectives between clinicians and consumers on the most appropriate long-term care setting for older persons with SMI.
In a landmark decision in June 1999, the United States Supreme Court ruled that it is discriminatory to institutionalize a disabled person who wishes to live in the community and is capable of benefiting from such a setting. Known as the Olmstead decision, this case established that unnecessary and undesired institutionalization constitutes discrimination for persons with mental disabilities because it severely diminishes the individual's ability to interact with family and friends, to work, and to make a life for him or herself. Perhaps the most daunting and challenging implication of the Olmstead decision pertains to the growing number of older persons with mental disorders. Nursing homes have become the primary institution-based setting for older persons with severe mental illness (SMI), accounting for 89% of all older persons with SMI in healthcare institutions, compared with 11% receiving services in hospitals.
Under the Olmstead decision, states must provide community placements for people with disabilities whenever the state's treatment professionals have determined that community placement is appropriate and the affected person wishes to live in the community, but little is known about professional and consumer perspectives on what constitutes appropriate community placement for aging persons with SMI.
To date, a limited literature describes clinical characteristics associated with institutional care for older persons with SMI. Older persons with SMI who reside in nursing homes have greater functional impairment in self-care skills and community living skills, worse general health, more-severe negative (deficit) psychotic symptoms and cognitive impairment, more aggressive behaviors, and less social support than those who live in the community. In addition, several studies suggest that older adults with SMI are at a substantially greater risk of institutionalization than other groups of older persons.
However, residential preferences of individuals with mental illness are poorly understood, and little is known about the preferences of older mentally ill individuals. A review of 26 studies of residential preferences of young mentally ill adults found that most consumers preferred to live in their own house or apartment, to live alone or with a spouse or romantic partner, and not to live with other mental health consumers. Group homes were among the least popular options. Nevertheless, at least one study has shown that mentally ill consumers may prefer to share housing with friends to avoid feelings of isolation. Higher perceived need for social support was related to housing preferences of homeless adults with mental illness, whereas diagnosis, symptoms, personality characteristics, and subjective quality of life were not. In addition, some state psychiatric hospital residents who had spent little time in the community expressed an attraction to institutional living. Finally, preferences of mentally ill nursing home residents (mean age 59.7) indicated that prior institutional living experience is associated with housing preferences and satisfaction. When given the choice to move to supported housing, 46% remained in the nursing home by preference 1 year later. This decision was associated with the consumer's perception of health, financial constraints, the wish to remain in one place, familiarity, and social support.
In summary, as states scramble to accommodate the Olmstead decision, major questions are unanswered with respect to important features of this federal directive. For example, what criteria should be used to determine the most appropriate long-term care setting for older adults with SMI? To what extent do older mentally ill nursing home residents view their long-term care setting as inappropriate, preferring instead to live in the community? Similarly, how do clinicians view the appropriateness of nursing homes for older persons with SMI? What clinical characteristics are associated with clinician determinations of the most appropriate level of long-term care? Finally, how do consumer and clinician perspectives compare? The purpose of this study was to help inform current deliberations by the states on implementing the Olmstead decision by addressing these questions through a descriptive analysis of a previously collected data set consisting of clinical ratings and surveys of older adults with SMI residing in community and nursing home settings.
Source...