Use of mental health services by persons with a mental illness in nursing facilities: initial impacts of OBRA87.

OBJECTIVE: To identify mental health service use patterns in nursing facilities subsequent to nursing home reforms in the Omnibus Budget Reconciliation Act of 1987. METHODS: The study involves a retrospective analysis of Medicare Part B claims for mental health care for persons in a nursing facility in 1992 (N = 692) using the Medicare Current Beneficiary Survey. Mental health service use was described and analyzed using logistic regression. RESULTS: Only 26% of nursing facility residents and 36% of residents with a mental illness had a mental health visit in 1992. Logistic regression confirms analyses prior to 1987 showing older residents and those in rural areas remain less likely to receive mental health visits. DISCUSSION: Claims data collected after the passage of The Nursing Home Reform Act (NHRA) of 1987 indicate continued low levels of mental health treatment in nursing homes.

How many elders receive assistance? A cross-national comparison.

OBJECTIVES: To examine models of informal support received by elders in the United States and Sweden and to test whether differences in informal support appear to stem from demographic differences between the nations alone or whether cultural and historical differences must also be considered. METHODS: Samples with similar functional dependence, age 75 and older in the United States (n = 4,677) and Sweden (n = 1,378), were used to model cross-national differences in the association between country, age, sex, potential availability of kin support, and receipt of informal assistance. RESULTS: Patterns of informal help were higher in the United States than in Sweden but were qualified by higher order interactions among age, sex, and availability of kin support. DISCUSSION: Cultural differences predating current policies in both countries appear to influence informal support over and above what can be accounted for by demographic differences alone.

Childhood adoption: long-term effects in adulthood.

Clinicians and researchers have characterized early life experiences as permanent and stable influences on the personality and subsequent life experiences of an individual. Recent conceptualizations have suggested that personal and environmental factors influencing development are not deterministic. Multiple pathways into adulthood are possible. Adoption is one potential early life stressor that may illustrate the usefulness of such conceptualizations for assessing long-term effects in adulthood. Previous studies of adoption have characterized the effects of adoption into adolescence and young adulthood. The purpose of this study was to provide an initial assessment of the long-term impact of adoption. The participants were taken from the Swedish Adoption/Twin Study of Aging. From the original sample, we identified a subsample of 60 pairs of twins who were separated and reared apart, with one member being raised by a biological parent or parents and the other by an adoptive parent or parents with no biological relationship. A series of univariate and multivariate analyses were undertaken to assess the elements associated with being reared in either an adoptive home or the home of biological parent(s). The results suggest few significant effects of adoption on the adult adjustment of adoptees. In particular, the results reflect the important mediating role of childhood socioeconomic status, suggesting that the stress of adoption itself is mediated by the type of rearing environment provided by the adoption process.

Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment.

Data from 50 residents of a long-term care facility were used to examine the extent to which performance on a brief, objective inventory could predict a clinical psychologist's evaluation of competence to participate in decisions about medical care. Results indicate that the competence to participate in medical decisions of two-thirds of the residents could be accurately assessed using scores on a mental status instrument and two vignette-based measures of medical decision-making. These procedures could enable nursing home staff to objectively assess the competence of residents to participate in important decisions about their medical care.

Decision-making incapacity among nursing home residents: results from the 1987 NMES survey. National Medical Expenditure Survey.

Recent legislative and regulatory developments have focused attention on older adults' capacity for involvement in health care decision-making. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) focused attention on the rights of nursing home residents to be involved in health care decision-making to the fullest extent possible. This article uses data from the 1987 National Medical Expenditure Survey (NMES) to examine rates of incapacity for health care decision-making among nursing home residents. Elements of the Oklahoma statute were used to operationalize decision-making incapacity: disability or disorder, difficulty in decision-making or communicating decisions, and functional disability. Fifty-three percent of nursing home residents had a combination of either physical or mental impairment and an impairment in either self-care or money management. The discussion focuses on the policy and practice implications of significant rates of incapacity among nursing home residents.

Determinants of the use of specialist mental health services by nursing home residents.

OBJECTIVE: This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals. DATA SOURCES/STUDY SETTING: The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987. STUDY DESIGN: Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification. DATA COLLECTION/EXTRACTION METHODS: Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions. PRINCIPAL FINDINGS: Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment. CONCLUSIONS: Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.

The provision and use of mental health services in nursing homes: results from the National Medical Expenditure Survey.

Data from the Institutional Population Component of the National Medical Expenditure Survey were used to provide national estimates of annual mental health service provision and use in nursing homes. In addition, the relationship between service provision and setting characteristics such as ownership, size, Medicaid certification, and chain status was examined. Although more than three quarters of residents with a mental disorder resided at a nursing home that provided counseling services, fewer than one fifth actually received any mental health services within the year.

Mental health services for nursing home residents: what will it cost?

The Nursing Home Reform Act of 1987 requires nursing homes to provide basic mental health services for all residents and to give active mental health treatment, a set of specialized mental health services, to those residents who are admitted with a serious mental illness. This article examines the potential size of the nursing home population who will require mental health services, its demographic composition, and the facilities in which these individuals reside using the Institutional Population Component of the National Medical Expenditure Survey. Estimates of the potential costs of providing monthly psychotherapy and pharmacological management to this population in nursing homes indicate that the mandate will have significant financial effects on nursing facilities. Conclusions about how the requirements for maintaining the mental and psychosocial well-being of nursing home residents may affect the future of nursing home care and mental health care are considered.

Nursing home aides' work and family connections.

In order to maintain a productive workforce, organizations must acknowledge that many employees, particularly nurse aides, perform full-time care giving, both on and off the job. Competing demands between work and family can affect job performance, quality of care and bring on burnout.

The relationship of antipsychotic drug use, behavior, and diagnoses among nursing home residents.

Nursing homes have been criticized for frequent use and possible misuse of psychoactive agents. These issues are of clinical concern and policy relevance, especially since the passage of the Omnibus Budget Reconciliation Act (OBRA) of 1987. Using a sample of 419 residents, the authors examined the relationships among antipsychotic drug (AP) use, behavior, and mental health diagnoses. Only 23.2% of the residents were administered APs on a routine and/or "as-needed" basis. Based on the Multidimensional Observation Scale for Elderly Subjects (MOSES) ratings, AP users were more irritable, disoriented, and withdrawn than were nonusers. Also, AP users demonstrated agitated behaviors more frequently. Notably, AP users and nonusers differed significantly in terms of documented mental health diagnoses. Among AP users, 70.1% had documented dementia, 8.3% were psychotic or had other psychiatric disorders, and 21.6% had no mental health diagnoses. In contrast, the majority of nonusers had no mental health disorders. Logistic regression revealed that diagnostic factors, frequency of agitation, level of withdrawal, and marital status were significant predictors of AP use.

The mental health system and older adults in the 1990s.

Trends in mental health services for older adults during the past decade were used to predict salient issues for the current decade. These include overreliance on inpatient treatment, increased use of general hospitals as treatment sites, inadequate integration with the nursing-home industry, and insufficient mental health referrals from general medical providers. In the decade ahead, the mental health needs of older adults are unlikely to be an identified focus; rather the issues will overlap with other priorities (e.g., biomedical research on brain functioning, alternative treatment programs for the chronically mentally ill, and containing health care costs). Advocates for the elderly will be successful to the extent that they cast aging services within the context of these other concerns.

Strategies for improving nursing home care: a research roundtable.

The findings reported here are from a group of researchers identified by the authors for their leadership in the advancement of knowledge about nursing homes as organizations. Three themes were identified from the current research presented at the Roundtable. The first was a recognition of the pervasive which society's conflicting expectations about nursing homes create for those who staff them. The second related to the central, at times unsupervisable, role of non-professional staff. The third theme called attention to the reinforcement power of supervision and leadership in bringing about positive change in care giving staff. These issues and the research described had implications for both policy and practice. While far from a comprehensive treatment of organizational and managerial issues, the observations reported here represent new research interest in nursing homes be considered simple organizations with stable and predictable inputs. The processes of care and the way those processes are implemented vary from one facility to another and, indeed, among nursing units within the same facility. Broadbased practitioner-researcher collaborations are needed to promote usable research on the internal processes of nursing homes. Future collaborations will probably focus on how and why some procedures and structures produce better results for residents and others. Policy makers and administrators will benefit as the tools and methods of organizational research are used to identify the best structures and practices in the nursing home industry. Similarly, the knowledge base of long-term care administration will be enriched by contemporary reconsideration of the structure and processes of nursing homes as organizations.

Assessing nursing assistants' knowledge of behavioral approaches to mental health problems.

Nurse's aides are the primary caregivers in nursing homes, a major receiving site for elders with behavioral and psychiatric problems. We describe the development, psychometric properties, and utility of a brief instrument designed to assess aides' knowledge of three specific mental health problems (depression, agitation, and disorientation) and behavioral approaches to them. The instrument was administered to 191 nurse's aides and 21 clinicians with training in behavioral management and experience with older residents. The nurse's aides averaged 11 of 17 correct answers, and the clinicians averaged 15 of 17 correct answers. Implications for staff training and consultation activities in nursing homes are discussed.

State pharmaceutical assistance for the elderly and disabled: planning issues for program and nonprogram states.

The Medicare Catastrophic Coverage Act (MCCA) would have mandated federal assistance for Medicare beneficiaries who have high annual prescription medication costs. High national expenditures for such drugs have encouraged the development of private and state insurance programs to help with these costs. Ten state pharmaceutical assistance programs (SPAPs), designed to help certain elderly, low income, or disabled people, exist for those ineligible for Medicaid or unable to purchase coverage privately. Coordination of state and federal benefits was a consideration for established programs, and programs being planned needed to determine the feasibility of integration of federal assistance. But the enactment and subsequent appeal of the Act affected both planning and policy implications for these SPAPs. All U.S. states and territories were surveyed before the bill's repeal to collect data on the effects of MCCA for those with prescription drug programs and those without. The repeal of the federal program places pressure on the nonprogram states to proceed, perhaps more cautiously, to initiate programs for their own residents, given increasing out-of-pocket and insurance costs, and no federal program.

The experience of micro- and macroevents. A life span analysis.

This study investigated how individuals retrospectively construe their lives in terms of major life events. Ninety-nine participants sorted a set of personal and historical events in terms of perceived importance for their lives. Analyses of variance with repeated measures and rank comparisons were computed. Overall findings revealed no cohort differences with regard to the perception of life events. However, within-cohort differences were found, indicating that more life events were recalled from the young adult years. Those experiences were also perceived as having been more important in the participants' lives than events from other age segments. With regard to historical events, war-related experiences were among the highest ranked. Analyses of variance revealed intracohort differences but not intercohort differences, indicating higher scores for the time between 1930 and 1948 relative to other historical periods.