Mental Health Services in Illinois Nursing Homes: What Do I Need to Know?

By Steven C. Greenwald, MSW, LCSW and David J. Beard, MSW, LCSW

The Council Connections thanks Steven C. Greenwald, MSW, LCSW, and David J. Beard, MSW, LCSW, from SocialWork Consultation Group, for writing this article about Subpart S (the state's version of psychiatric rehabilitation services) and F406 (the federal version of psychiatric rehabilitation). This article will clarify the programs and systems facilities and staff need to provide to meet the needs of residents with Serious Mental Illness.

There has been much discussion and sporadic training done across Illinois regarding Subpart S in the Illinois regulations and F406 found in OBRA. These regulations deal with the programs, services, and systems mandated to meet the needs of persons with mental illness living in long term care facilities.

Hearing criticism and receiving deficiencies during a survey is never a pleasant experience, but you can turn this negative into a positive by learning from the experience. This article will identify what programs, services, and systems facilities need to have in place to avoid receiving this F-tag in the future.

The key to success is developing a comprehensive system offering three types of interventions:

• interventions offered inside the facility by licensed professionals (i.e., psychiatrists, psychologists, clinical social workers, mental health counselors)

• interventions offered outside the facility by licensed professionals and appropriately educated and certified professionals (i.e., a certified addictions counselor, vocational trainer)

• interventions provided by qualified facility staff (i.e., psycho-educational groups, support groups, one-to-one counseling, goal-directed counseling)

If a facility has a population of mentally ill and/or mentally ill substance abusers and these interventions are not occurring, the nursing home may find itself engaging in unnecessary risk taking. Managing the mentally ill clients is under the Illinois Department of Public Health (IDPH) microscope and probably will stay under the microscope in the near future.

Management Involves Structure

Structure involves rules, controls, policies, well-trained staff, supervision, restrictions (i.e., regarding smoking, substance abuse, pass privileges) and consequences. Remember, there is substantial chaos and disorganization in the adult mentally ill population. This is why they need the level of care a nursing home provides.

The majority of residents with serious mental illness do not typically do well with flexibility and freedom. Given multiple choices and liberties, these individuals often self-destruct. Self care neglect, not taking medications, and engaging in "high risk" behavior leads to destruction, decompensation, and eventually an emergency hospital admission. Sometimes our duty is to save the person from himself/herself.

The nursing homes having success with meeting the needs of mentally ill residents (and mentally ill substance abusers) use an organized system with firm rules and controls. In short, it is a no nonsense approach and it helps balance the client's anxieties and insecurities. Each individual has the opportunity to follow the rules, gain additional privileges, and advance on the psychiatric rehabilitation continuum.

Things Change Over Time

If residents refuse programming, deny their illness, and spend their time engaged in non-productive (or even self-destructive) tasks/events, it is no longer acceptable to document that "we offered, he refused, end of story."

It is important to show on-going interventions and even different types of strategies to confront destructive behaviors. There is now an expectation that not following the rules results in a meaningful consequence.

In the past, there was no expectation that nursing home staff visit outside day programs. These were viewed as independent supportive environments. Today, IDPH requires the nursing home to know more about the resident's outside day programs, i.e., where the resident is, what he/she is engaged in, and (if the client is mentally ill) what type of psychiatric rehabilitation services he/she is receiving.

Day programs should be conducting joint staffings/case conferences with facility staff and providing professionally written progress notes on a regular basis. Qualified individuals should provide the interventions. The resident should be engaged in a therapeutic and rehabilitation focused series of interventions.

If your facility has individuals with alcohol and drug dependency disorders, it is wise to contact programs such as Alcoholics Anonymous, Cocaine Anonymous and Narcotics Anonymous to see if they can offer programs within your facility. Experience has taught us that often when residents leave the facility to participate in these support groups, problems occur. Sometimes "temptation" is too challenging for the resident to cope with.

It is important for facility staff to invest in learning how to best communicate with mentally ill adults, i.e., the question, "Hey, you got fifty cents for a pop?" can be answered therapeutically or non-therapeutically. The problematic answer is, "No, I don't have any money," which is typically not truthful and shows that the staff member has failed to use this opportunity to impose a limit. The therapeutic answer is, "Yes, I do have fifty cents, but I don't give my money away. What can you do to earn fifty cents?" This response communicates "limit setting," specifically, it is not appropriate to panhandle and gives the person an opportunity to work on "problem solving." This approach helps the person improve logical thinking, communicates the value of work (or at least creativity) and promotes psychiatric rehabilitation.

F406 and Subpart S

F406 remains the heart of deficiencies lately while Subpart S remains slow out of the gate. IDPH maintains they will start enforcement by looking at three Subpart S related issues:

• facility assessment of which residents meet Subpart S criteria

• psychiatric rehabilitation services available for residents within the facility and community

• screening of high risk behavior (see the September 2003 memo from IDPH)

Our advice is to be prepared, while not going overboard. This remains an unfunded mandate at present. The University of Chicago (U. of C.) receives grant money from the Illinois Department of Public Aid (IDPA) to provide long term care staff with psychiatric rehabilitation training. U. of C. has a training program scheduled in February. If you are not already on their mailing list, contact Candace Aronowitz at 708/614-4783, or caronowi@uchicago.edu).

In order to better prepare for F406, the staff needs to recognize that surveyors are asking questions such as:

• What does the resident's pre-admission screening (PAS) say? Did you review it and implement recommendations? Know about these mandated screens and where they are located. Social service staff should retain a copy of the OBRA-1 and PAS MH-1 (second level screening for mental illness).

• How did you assess/learn about his/her psychiatric problems/mental health needs?

• How do you evaluate residents for programming?

• What types of programs (groups) are provided in the building?

• What outside programs are your residents involved in?

• How many people attend in-house programs/outside programs?

• Do you have a roster showing who goes where and when?

• Has anyone been discharged to the community in the past year or so? Do you have their names?

• How do you handle difficult (i.e., aggressive, non-compliant) residents?

• How do you assess and screen suicidal/homicidal/dangerous behavior?

• How do you discharge a resident who is a threat to himself or others?

• What are the program director's qualifications?

• What are the qualifications of each staff member?

• How often does the consultant come in?

• What are the consultant's credentials?

• What training is the consultant currently providing to staff?

• How do you assess the person's discharge planning needs?

• Are you working on helping some resident with discharge planning now?

It is important to have confident answers to all of these questions.