The Nursing Home Reform Actopens in new window of 1987 led to major improvements in the quality of long-term care in the United States by emphasizing patient rights and beefing up federal standards, inspections and enforcement. Now, new regulations issued by the Centers for Medicare and Medicaid Services in 2017 go a step further in boosting care by emphasizing the need for facility staff to learn more about who residents are as people, provide greater support for resident preferences and give residents increased control and choice.
The new regulations also require increased attention to the mental health and behavioral needs of residents, among other changes.
Psychologists are playing an important role in realizing these reforms, both in creating new care models that better serve both residents and staff and in implementing these ideas on the ground, says geropsychologist Kelly O’Shea Carney, PhD, co-author with Margaret P. Norris, PhD, of "Transforming Long-Term Care: Expanded Roles for Mental Health Professionals" (APA, 2017).
"Mental health professionals are uniquely equipped to assist, support and perhaps even lead the evolution in care that is taking place across the long-term-care continuum," says Carney, of Acts Retirement-Life Communitiesopens in new window, a nonprofit serving 10,000 older adults at 23 locations in nine states.
Carney has developed one of the approaches that is leading to better care: the Eldercare Method, which fosters well-being among long-term-care residents by teaching interdisciplinary professional staff—administrators, aides, nurses, social workers and others—to incorporate knowledge of residents into their services. For example, staff might discover that a resident enjoys eating ice cream before dinner, and they’ll make sure to supply that. Or, they may find out a resident grew up on a horse farm and bring in a picture book with horses. "It all has to do with changing the external triggers to a challenging behavior and increasing the chances of more desirable behavior with the ultimate goal of enhancing quality of life and well-being for each resident," Carney says.
Studies show that the model improves outcomes for both residents and caregivers. Among residents, it reduces falls, the use of psychotropic medications and challenging behaviors. For staff, it decreases injuries and turnover.
Increasingly, psychologists are essential to such person-centered programs—as well as to the evaluation of their effectiveness and the development of interprofessional teams to implement and assess them.
Finding more joy
A similar program aimed at promoting the ideals of person-centered, homelike care is the Montessori-Based Dementia Programming method, developed by applied geropsychologist Cameron Camp, PhD. It applies principles of the Montessori education method and behavioral psychology to help people with Alzheimer’s disease develop more agency in their daily lives, connect with others and find joy in living.
At the Veterans Health Administration’s Community Living Centers, or nursing homes, staff psychologists are among those implementing the STAR-VA program, which uses interdisciplinary behavioral approaches to manage dementia-related behaviors. These include identifying and resolving behavioral problems using "ABC" (antecedents, behaviors and consequences) methodology; building in events that residents find pleasurable—such as going for a car ride, listening to music or discussing past events, depending on the individual; promoting effective communication between staff and older adults; and fostering realistic expectations of what residents are capable of. In a study examining the uptake and effectiveness of this program in 17 centers, VA psychologist Michele J. Karel, PhD, and colleagues found that veterans in these nursing homes were significantly less depressed, anxious and agitated at the end of a six-month staff training period than they were at the start ( The Gerontologistopens in new window , Vol. 56, No. 1, 2016).
Psychologists are implementing these ideas at the individual and system levels in a range of other long-term-care settings, adds Carney’s co-author Norris, an independent practitioner and past-president of Psychologists in Long-Term Care (PLTC), a national nonprofit organization. Individual interventions with residents continue to be a powerful approach to improving both resident and staff well-being, she says. "Residents get better, their roommates get better, the aides caring for them get better, and their families become more relaxed," Norris says. "It snowballs in a very positive way."
Systems-level interventions can provide additional dramatic results, Carney adds. In that capacity, psychologists train staff in behavioral principles and encourage them to treat residents as human beings rather than as "the hip in room 303," as Carney puts it, and to foster agency and communication among team members, which may include administrators, social workers, nurses, aides, rehab and recreation workers, kitchen staff and housekeeping personnel.
This communication creates an atmosphere in which team members feel free to discuss what works and what doesn’t. "The interdisciplinary team process becomes a forum for learning among staff members, as well as for care planning," Carney says. "People in all of these disciplines encounter residents with dementia, as well as other psychological needs and issues, so they can all benefit from the learning."
Remaining barriers
Yet despite those and other benefits, many psychologists continue to face reimbursement challenges in these settings. Medicare regulations, for example, still don’t require facilities to provide psychological services as they do the services of social workers, recreational therapists and rehabilitation therapists, says long-term-care consultant Eleanor Feldman Barbera, PhD, author of " The Savvy Resident’s Guideopens in new window " (Psychology Insights Press, 2012), a guide for residents starting out in nursing homes. And while Medicare reimburses physicians for conducting staff training and care-plan meetings, it doesn’t do the same for psychologists, meaning psychologists often work as consultants in these capacities, Barbera says.
On a more positive note, nursing homes are now more willing to pay such consulting fees to psychologists, and Medicare reimbursement for long-term-therapy services has improved and stabilized in the last several years, says Norris.
That’s largely due to advocacy by APA and other organizations, which helped to gradually reduce all Medicare Part B mental health co-payments from 50 percent in 2008 to 20 percent starting in 2014, including those involving long-term care.
What’s more, a greater number of young psychologists are entering geropsychology thanks to expanding opportunities in health-care settings, says PLTC President Craig H. Schweon, PhD. Training in the area is improving, too: A survey of 100 graduates of geropsychology doctoral and postdoctoral training programs by the VA’s Karel and colleagues found that most graduates of these programs reported receiving strong training for providing geropsychology services, though they wanted more training and practice in supervisory roles ( Training and Education in Professional Psychologyopens in new window , Vol. 10, No. 1, 2016).
Those who do work in these health and long-term-care settings say they’re an option more psychologists should consider, offering an up-close look at residents’ relationships with staff, roommates and family members. Cultural differences are also part of the mix. "It’s unbelievably fascinating," Barbera says.
She recalls a woman who initially resisted being in a nursing home but adjusted thanks in part to Barbera’s help in making the experience more like home. Barbera connected the woman with other residents who were sewing a quilt for Haitian refugees, and she had the woman’s family bring beloved objects from home, including her electronic piano.
"She’d play it, and staff and residents would gather around her door to listen," says Barbera. "And she said to me, ‘I know people say terrible things about these places—but I’m having a ball here.’"
