Severe Behavioral Health Manifestations in Nursing Homes: Associations with Service Availability?

BACKGROUND/OBJECTIVES: Despite high prevalence of behavioral health (BH) manifestations among nursing home (NH) residents, availability of BH services in this care setting is often inadequate. Our objective was to examine associations between availability of BH services and the presence of severe depression, suicidal ideation (SI), and severe aggressive behaviors (ABs) among NH residents. DESIGN: Cross-sectional. SETTING/PARTICIPANTS: This study used 2017 survey data about BH service availability obtained from 1,051 NHs. The Minimum Data Set (MDS) was used to identify long-stay residents in these facilities (N = 101,238) and the prevalence of BH manifestations. Descriptive statistics and multivariable logistic regressions were used. MEASUREMENTS: We constructed measures of three severe BH manifestations based on the MDS: presence of depression, SI, and ABs. Three independent measures of service availability based on survey items asked about degrees of inadequate (1) staff BH education, (2) coordination/collaboration between facility/community providers, and (3) facility infrastructure (ie, ability to make referrals/transport residents to services). RESULTS: Odds of severe depression were 21% higher (odds ratio [OR] = 1.21; P <.001) when NHs reported inadequate BH staff education. Residents with SI had 13% higher odds (OR = 1.13; P =.027) of living in NHs that reported inadequate coordination between facility and community providers. Severe ABs were 10% more likely among residents in NHs reporting inadequate facility infrastructure (OR = 1.10; P =.002) and 7% more likely in facilities with self-reported inadequate coordination between facility/community providers (OR = 1.07; P =.019). Several facilitylevel factors (eg, staffing, training, turnover) were also statistically significantly associated with these severe BH manifestations. CONCLUSION: Residents in NHs reporting inadequate BH services were more likely to experience adverse severe BH manifestations even after controlling for individual and facility-level risk factors. Higher nurse staffing and more staff psychiatric training were associated with lower prevalence of severe BH manifestations. Policy changes and modifications to Medicaid NH reimbursements may be warranted to better incentivize NHs to improve provision of BH services.