Federal authorities are investigating whether mentally ill patients in Illinois have been inappropriately placed in geriatric nursing homes after two young patients from one nursing home were charged with murder. Meanwhile, on a national level, two recent reports from the Office of Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS) faulted several states for not adequately identifying, screening or treating younger (aged 22 years old to 64 years old) mentally ill Medicaid beneficiaries who reside in nursing homes.
In Illinois, HHS has temporarily halted Medicaid or Medicare funding for any new patients at the Hillcrest Healthcare Center nursing home, according to reports in the Chicago Tribune. The federal action came after Illinois' Department of Public Health recommended federal financial sanctions be imposed on Hillcrest for not properly supervising its mentally ill patients; two of its patients (aged 23 years old and 27 years old) were charged with killing a man in March after they signed themselves out of the nursing home for the day.
If the problems at the nursing home remain unresolved by September, federal funding will be terminated permanently, Charles Bennett, Illinois branch manager of HHS' division of survey and certification, told the Tribune.
After visiting the nursing home, federal investigators stated that the facility was not equipped to handle mentally ill patients with violent backgrounds. But the investigators were equally critical of the Illinois Department of Public Aid and questioned why the department had classified Hillcrest as a nursing home rather than an institution for mental diseases (IMD).
Well over half of the nursing home's patients are being treated primarily for mental illnesses, a Hillcrest spokesperson told the Tribune, and federal inspectors estimated the number at close to 80%. Inspectors added that probably more than two dozen facilities across the state are similarly misclassified.
By classifying Hillcrest as a nursing home, the Tribune pointed out, the state is able to shift part of the facility's funding burden to the federal government. Medicaid pays for the care of individuals with mental illness in nursing facilities when residents with mental illness fill 50% or less of the facility's beds. If the percentage climbs above 50%, federal law requires the facility to be designated as an IMD. In IMDs, the state mental health authorities are responsible for funding the care.
Bennett also told the Tribune that the federal government is interested in assessing whether traditional nursing home patients have been neglected or put at risk because mental patients are filling more beds at places like Hillcrest.
This is not the first time that Illinois has been under scrutiny. A three-part investigative series by the Tribune in 1998 showed that, to receive federal Medicaid funds, the Illinois Department of Public Aid improperly transferred thousands of mentally ill people into nursing homes designed for older patients. The state, subsequently acknowledging that several of the nursing homes should be reclassified as psychiatric facilities, withdrew 17 nursing homes from the federal Medicaid program. In 1999, the Illinois legislature passed a bill to tighten standards for treating the mentally ill in nursing homes. The law requires the Department of Public Health to provide mentally ill nursing home residents with appropriate services and to provide training for nursing home personnel regarding the assessment, care planning and care for patients with a mental illness or developmental disability.
Problems that surfaced in Illinois also have surfaced across the country. Issued by HHS' OIG, the report "Younger Nursing Facility Residents with Mental Illness: An Unidentified Population" (2001a) sought to determine how many younger individuals with a primary or secondary diagnosis of a severe and persistent mental illness reside in nursing homes and how much Medicaid spends on their care. One of the report's key findings is that the number of younger individuals with mental illness who reside in nursing facilities cannot be conclusively determined.
Emily Melnick, program analyst with the OIG's Office of Evaluations and Inspections and one of the report's authors, explained to Psychiatric Times that they could not establish an overall percentage. For example, the federal government's Minimum Data Set (MDS), used to aid in the administration of the survey and certification of Medicare/Medicaid long-term care facilities, found that the number of younger residents with mental illness represents an average of 1.6% of the states' nursing facility population. However, a state survey (20 states reporting) conducted by the OIG found that these younger residents represent on average 20% of the nursing facility populations.
Moreover, the federal government's own data sets differ: the Medicaid Statistical Information System (MSIS), which collects claims and eligibility data for medical services, shows that in 39 states there are 5,745 Medicaid beneficiaries aged 64 years and under with a primary diagnosis of mental illness who reside in nursing facilities. However, the MDS data for those same states show that 17,919 younger patients with any diagnosis of mental illness reside in nursing homes.
Besides the numerical inconsistencies, the OIG report found that Medicaid expenditures for that population could not be validated. For example, a nursing facility's claim for per diem might not identify an individual with a serious mental illness if it was not the individual's primary diagnosis. Consequently, the state and federal expenditures for this population are underestimated. The report also found that many states do not know where younger individuals with mental illness are receiving long-term care, whether it is in IMDs, state psychiatric hospitals, community-based facilities, hospital psychiatric wards or nursing homes.
The unsuccessful attempt by the OIG to identify the younger mentally ill population in nursing homes is indicative of a larger problem with federal data sources, the OIG report authors said.
This examination questions the use of Federal data sources to accurately yield important demographic, utilization, and expenditures information upon which to base policy. Without reliable information that enables us to identify populations of individuals requiring particular types of services, we cannot assess appropriateness, access and quality of care, nor determine the effectiveness of Federal Medicaid and nursing facility policy.
The OIG also produced a companion report, "Younger Nursing Home Residents with Mental Illness: Pre-Admission Screening and Resident Review (PASRR) Implementation and Oversight" (2001b) ( Table ). It evaluates the safeguards for monitoring the admission and mental health treatment of younger nursing facility residents with serious mental illness.
According to the report, from the 1950s through 1985 state mental health hospitals began reducing their resident populations and transferring many patients to nursing facilities and other residential facilities. Thus, in 1987, the Omnibus Budget Reconciliation Act mandated preadmission screening to ensure that only individuals with serious mental illness in need of nursing facility care would be admitted to nursing facilities, that their need for specialized services would be determined and that the facilities would provide patients with mental health treatment.
All nursing home applicants, regardless of whether they are private- or public-pay, are required to be given preadmission screening, referred to as Level I PASRR. The federal government defines a patient as having a serious mental illness if they have a major mental illness diagnosis, not including dementia or organic brain disorders; a functional limitation within the past three to six months; and psychiatric treatment more intensive than outpatient care within the past two years. States can design their own PASRR forms and may choose more inclusive criteria for identifying a serious mental illness.
Individuals who meet the aforementioned requirements are supposed to undergo an independent physical and mental evaluation, a Level II PASRR, in part to determine whether they require specialized services. If they do, state mental health authorities must provide such services or arrange for them. Mental health services of "lesser intensity than specialized services" must be provided by the nursing home facilities.
For their report, the OIG team collected information and data from Medicaid programs, surveys of state officials involved in mental health services and nursing home care. They also made on-site visits to 19 nursing facilities in five states--California, Florida, Kansas, Minnesota and Pennsylvania.
The OIG staff found that only 47% of the nursing home residents sampled in five states had received a Level 1 PASRR screen, and, of those who did, 17% of the screens were completed after the patient was admitted to the facility. "If [PASRR screens] are not being done, there is no way of insuring whether someone has a psychiatric illness or not," Melnick told PT.
Additionally, there was little evidence that initial Level II PASRRs or reassessments were conducted.
"Of those people that the nursing home did identify as having a severe mental illness," Melnick further explained, "only 41% actually had a mental health evaluation."
Another major problem identified in the report was that states might violate the intent of the federal requirement to provide mental health services.
"Four of the 5 states we visited and 15 of the states responding to our survey define 'specialized services' as 24-hour psychiatric treatment. Under this definition, a nursing facility is not a 24-hour psychiatric treatment facility and residents in nursing facilities are excluded from receiving 'specialized services,'" the report authors wrote. "Limiting the definition in this way excludes the provision of certain mental health services to individuals in nursing facilities and relieves states of their responsibility to provide this care."
Of equal concern, the report authors found that most state mental health authorities in the five states that were studied did not consider it their responsibility to monitor or provide treatment for residents of nursing facilities with mental illness.
William C. Moran, regional inspector general of the Office of Evaluations and Inspections who directed preparation of both OIG reports, told PT that both the Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration have generally concurred with OIG's report findings and have laid out plans of action that are particularly important in light of the U.S. Supreme Court's Olmstead decision.
The 1999 Olmstead v L.C. Supreme Court decision said that continued institutionalization might violate the rights of an individual with mental illness or mental retardation under Title II of the Americans with Disabilities Act. The HHS has interpreted the decision to mean that no person should have to live in a nursing home or other institution if they can live in their community. In June, President George W. Bush signed an executive order directing designated federal agencies to help states find community-based housing alternatives for such individuals. The HHS is providing $70 million in grants to help states improve their community-based services.
"The Center for Medicare & Medicaid Services as well as the Office of Civil Rights are very involved with the actions of the states in implementation of the Olmstead decision," Moran told PT. "A lot of actions are being taken, both specifically regarding the recommendations of the reports, as well as addressing the broader issue of ensuring that [people] with mental illness are receiving appropriate care in the least restrictive setting."
1. Office of Inspector General (2001a), Younger Nursing Facility Residents with Mental Illness: An Unidentified Population. Available at: http://oig.hhs.gov/oei/reports/a507.pdf. Accessed July 27.
2. Office of Inspector General (2001b), Younger Nursing Facility Residents with Mental Illness: Preadmission Screening and Resident Review (PASRR) Implementation and Oversight. Available at: http://oig.hhs.gov/oei/reports/a506.pdf. Accessed July 27.