Skilled nursing facilities customarily have provided services to the elderly, addressing their physical and medical needs. However, over the past five years, these facilities have admitted a greater number of residents with mental health disorders, which may include younger individuals under 65 years old. This changing resident profile requires facilities to re-evaluate the safety and care needs of their residents.

This trend has been seen throughout the country. For example, in California, the population of its nursing home residents under the age of 65 grew by nearly 40% in a two-decade span from 1994 to 2014, and the state's rate of schizophrenia and bipolar disorder increased by 60% from 2000 to 2014, according to data sourced by the Brown University School of Public Health and reported by the Sacramento Bee. In Ohio, approximately 20% of nursing home residents are under the age of 65, compared to a national trend of 17.4%, according to a 2018 study from Miami University's Scripps Gerontology Center. This same study reports that severe mental illness is the primary reason for these early admissions.

Mental health disorders encompass schizophrenia, bipolar disorder, depression, anxiety disorders, suicidal ideation, and drug and/or other addictions.  Skilled nursing facilities that are considering admitting residents with mental health disorders should consider revising their enterprise risk management programs, in order to provide standards of care required for this population — while providing a safe environment for all residents. Here are seven actions that can help to mitigate this risk exposure:
 

1. Conduct a facility assessment. Many skilled nursing facilities have not been designed to care for younger residents with mental health disorders, who may require secure environments, one-on-one supervision and/or specialized behavioral health care. Prior to accepting residents with mental health disorders, a facility should consult with a qualified mental health professional to perform a facility assessment and recommend modifications to the facility's environment in order to mitigate risk exposures. Modifications could include secured units, suicide prevention measures, restrictions pertaining to medications and hazardous materials, or resident segregation.
     
2. Determine admission requirements. A facility's admission criteria should reflect the scope of services that can be safely delivered. Based upon the findings of the referenced facility assessment, in conjunction with staffing competencies, a skilled nursing facility can determine the range of mental health diagnoses it can safely manage and treat. For example, a facility may safely provide treatment to residents with long-standing, stable, mental health disorders, but unable to treat those with active addictions or suicidal ideation.
     
3. Evaluate staffing needs and competencies. Besides employing the appropriate number of staff, successfully managing residents with mental health disorders requires trained employees who understand the emotions and physical needs of residents with mental health issues. Skilled nursing facilities should provide both new employees and existing staff with skills and ongoing education, especially in the practice of non-pharmacologic interventions and de-escalation strategies. For each additional mental health disorder a facility chooses to manage, the greater specialization in staff skills and competencies will be required.
     
4. Monitor for staff burnout. Staff can become overwhelmed with high-acuity residents and behaviors that they are not equipped to manage. This stress can often be identified through exhibited behaviors, such as withdrawal, tardiness and absenteeism. Conduct an annual staff assessment to identify the frequency and causes of staff burnout. 
     
5. Understand the Centers for Medicare & Medicaid Services (CMS) guidelines for psychotropic medications and gradual dose reduction.  The scrutiny on the use of psychotropic medications has caused confusion on the appropriate use of these medications for residents with chronic mental health disorders. Establishing thresholds for medication use and a process to review diagnosis, dosage, and alternatives to psychotropic medications will ensure that these medications are used appropriately.
     
6. Determine resident compatibility. When residents share indoor and outdoor living spaces, tempers can escalate, even among friends. An altercation between an 80-year old dementia patient and a 40-year-old opioid dependent resident may result in unfavorable consequences, which can include verbal or physical altercations. As such, skilled nursing facilities that care for residents of various ages with mental health disorders should train staff on proven de-escalation techniques, while also considering resident compatibility.
     
7. Establish appropriate resident activities and programs. Programming needs will not be the same for elderly and younger populations. For example, younger residents require activities that maintain or restore their abilities to live independently, or activities appropriate for their entertainment preferences. Therefore, the holiday singalong — that elderly residents greatly enjoy — may not appeal to younger residents. 
     

As more individuals with mental health disorders are admitted into skilled nursing facilities, it is paramount that the quality of care and services are safe and effective for all residents. Before admitting residents with mental health disorders, consult with a Risk Control partner to evaluate facility risk exposures. A comprehensive strategy, executed by qualified behavioral health specialists, can help support a safe model of care for residents.