Homes For Young Adults With Mental Illness - A year ago, a nursing home in Kirkland, Washington became an early battleground for the US coronavirus outbreak. Since then, the disease has ravaged nursing home residents, with more than a third of all covid-19 deaths in the US involving nursing home residents and staff. What followed was virtually unnoticed: in some homes for the elderly, there was a change in the type of resident, one of the reasons being Covid-19.
As an aging population dies from the pandemic and more families choose to keep elderly relatives at home, some of these facilities are accepting more younger patients, including some with drug addictions and mental illnesses. Some patients have schizophrenia. Some have psychosis. These changes in clientele can have a dramatic impact on the day-to-day operations of nursing homes, and administrators and staff may be reluctant to act.
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As a neuropsychologist with more than 25 years of experience working in nursing care settings, I have seen this transition first hand. The migration of psychiatric patients to these institutions began in the 1950s, and then accelerated in the 1980s, when state psychiatric hospitals began to rapidly close. Currently, about 95 percent of these hospitals are closed. Those that are still open have a total of around 37,000 beds, of which almost 90,000 are missing.
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Mainly due to the deaths caused by the pandemic, many nursing homes have many empty beds. And frankly, they need money to survive. The National Healthcare Association and the National Helpline Center estimate that the U.S. long-term care industry will experience a 16 percent decline in revenue and approximately 1,670 percent closings or mergers in 2021. In some states, nursing homes can be penalized with cuts in Medicaid funding if their occupancy drops too low.
Even many high-end nursing homes, once the preserve of wealthy residents, have taken on younger patients, some in their 30s and 40s, most of whom are Medicaid only.
These younger patients often have co-existing conditions: substance use problems and psychiatric illnesses. Some have lost contact with their families. Some have no income; others are disabled. They often have nowhere to go. Even for those who receive help from their families, the cost of extended care is unaffordable and families cannot provide care on their own. Although estimates vary widely, the best estimate is that more than 125,000 young and middle-aged adults, most with mental illness, were living in nursing homes before the pandemic.
Although federal law requires alternatives to this type of institutionalization for younger patients who spend several years in a nursing home, implementation of these laws varies from state to state. Insurance companies often favor nursing homes as more cost-effective options than home care or supervised care, especially for people with severe mental illness. But placing psychiatric patients near an elderly and sick population can cause problems. Active addicts may seek drugs, especially opiates. Active psychotics can be volatile, even violent. These patients can live in nursing homes for years and eventually saturate the facility with a significant number of psychiatric patients.
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The staff of these homes often do not know how to care for this type of patient. They require similar training to psychiatric hospitals. Instead, they can become overwhelmed. They deal with behavioral problems, including aggression. Behavioral nurses have the highest turnover among nursing specialties. A third of them leave within two years.
For nursing home administrators, this is just another problem they face. Covid-19 was a devastating experience for them. The virus ravaged their premises. One caretaker told me that she had lost almost one-third of her population to the disease. I can say that over 100 of my patients have died from covid-19 in the last year.
Of course, death is always present in a nursing home. But the death toll from the pandemic alone is staggering. Death, grief and fear are not a good psychological cocktail. The emotional burden on employees is high, and the already high employee turnover rate has increased with covid-19. Three administrators told me that more than a quarter of their employees quit. Many are paramedics who earn barely above minimum wage and rightly fear the possibility of contracting the virus, which can be fatal. These assistants are often the only ones holding the hands of dying patients.
The staff of these homes often do not know how to care for this type of patient. They require similar training to psychiatric hospitals.
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Residents who survived the pandemic endured enormous hardships. Being stuck in your room for a year, mostly alone, can be very depressing. Friends die and are taken in the middle of the night. Those who remain, some with dementia, may feel abandoned by friends and family. Residents who test positive for Covid-19 are usually moved to another part of the house, causing anxiety and increasing confusion and mood swings.
Finding housing solutions that would benefit both psychiatric patients and the elderly is a long-standing issue. Money is one answer; The National Alliance on Mental Illness lobbied Congress for more. In particular, funding is needed for group homes where residents with mental illness can eventually return to the community. The Department of Housing and Urban Development offers programs to help seniors and people with disabilities obtain safe and decent housing. Typically, a person must be enrolled in Medicaid to qualify for these services, and demand for any of these alternatives far exceeds availability.
At least the near future looks better for many nursing homes. Many of my patients are vaccinated. Mortality rates are significantly lower. The facilities now allow family visits, albeit under strict protocols. Soon the residents will be able to socialize with each other again. However, the pandemic's toll on residents, families and workers will continue for years. 2020 traumatized many of us, including me.
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There is no reliable statewide data on the decline in housing that serves this particular population. But since 2012, San Francisco has lost more than a third of its licensed residential properties serving people under 60 and more than a quarter of those serving an elderly clientele. Much of the reduction has occurred in small, cozy facilities like Palarca's, which provide assistance with food, laundry and medication and are more likely to take in low-income mentally ill people. Los Angeles, which has much of the state's administration and care, has lost more than 200 beds for people with low incomes and serious mental illnesses in the past year. Advocates say the state needs to collect better data and significantly increase reimbursement rates if it hopes to save the remaining facilities. "If lawmakers don't get this, we're in big trouble," said Lisa Codmur, who worked with Los Angeles County on the issue. "We're going to see more homelessness, more incarceration, more institutionalization, more people living on the streets."
The housing crisis has put those who care for nursing homes and the mentally ill in an unusual position: many are now defending facilities they say are of poor quality and outdated. That's because the alternatives they see—homelessness, prison, long-term placement in nursing homes or locked rooms—are worse. "Our inventory is so terrible that now we're trying to save an industry that's not attractive," said Adriana Ruelas, director of legislative affairs at the Steinberg Institute, which advocates for better mental health policy. Sacramento Mayor Darrell Steinberg is a former state Senate leader who founded the institute and was recently appointed by Gov. Gavin Newsom to lead a new commission on homelessness and supportive housing. He calls the closure "catastrophic." "They're not a perfect solution for everyone," he said. "But the perspective here: This is a real shelter with care. The losses here just make an already terrible problem worse. Money is the root of the problem. Many facilities are closing because
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