SALT LAKE CITY – Geriatric psychiatrist consultants can relieve some of the burden on nursing homes and help provide optimal care, the medical director of a large system of senior-living facilities said.
Good geriatric psychiatrists are hard to find, but it's important to convince administrators that timely psychiatric consultations and appropriate recommendations may reduce litigation risks and help nursing homes with risk management, Dr. Jeffrey B. Burl, medical director of Overlook Masonic Health System in Charlton, Mass., said at the annual symposium of the American Medical Directors Association.
Today, up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. “We're all seeing these types of patients admitted to our facilities [from] assisted living programs,” Dr. Burl said. “They nurture these people until it finally reaches the point where the behavior is so untenable that they are admitted to a nursing home.”
He noted that mental health issues are some of the most difficult problems in the nursing home setting. Lack of good research, potential adverse effects of medications such as atypical antipsychotics, and difficult-to-quantify end points for progress with patients “make care of these issues problematic,” he said. “Provider and staffing issues may complicate the picture.”
Dr. Burl said he is aware of a few skilled nursing facilities that offer a stipend to consultant psychiatrists and assign them the title of associate director of dementia units. Duties include educating staff about behavioral problems, reviewing policies, and developing behavior plans for residents.
“It took a little bit of effort to convince these nursing homes to pay for the stipend, but once they saw the number of antipsychotic medications going down and the number of psychoactive medications going down [after psychiatrists' interventions], that got their attention,” said Dr. Burl, whose system offers a continuum of services that includes independent housing, assisted living, a skilled nursing facility, subacute care, a visiting nurse association, and hospice care.
Other facilities have used the services of specially trained nurse practitioners with skills and expertise in geriatric mental health. They usually collaborate with consultant psychiatrists in providing timely care in facilities.
Overlook Masonic Health Care recognizes six indications for a geriatric psychiatry consultation: recurrent depression or being nonresponsive to medications for depression, suicidal ideation or hopelessness, depression with psychotic features, aggressive behaviors that result in harm to staff or to other residents, refusal to eat or drink despite no obvious medical problems, and displays of acute or chronic psychosis including paranoia, hallucinations, and personality changes.
Outlining expectations for a psychiatric consultant is important, Dr. Burl said. For example, agree whether you'll notify the consultant by phone, fax, or e-mail. What processes do you have for regularly communicating with the consultant? What's your expected turnaround time for such communications?
It's also essential to delineate how recommendations from the consulting psychiatrist will be transmitted to an attending physician and to devise a procedure for addressing the consultant's recommendations when the attending isn't available or refuses the recommendations.
Dr. Burl reminded his audience that as stated in the Centers for Medicare and Medicaid Services' F-tag 150 language, medical directors are ultimately responsible for coordination of care and implementation of resident-care policies and procedures. They might need to intervene to make sure that all consultants to a nursing home are meeting expectations.
After all, he said: “Our cases are getting more complex. This is our challenge.”
Dr. Burl said that he had no relevant conflicts to disclose.
Up to 70% of residents in nursing homes have dementia or a dementia-related diagnosis. DR. BURL