Assisted living communities and nursing homes are seeing more residents with opioid use disorder (OUD), chronic mental health issues, and traumatic brain injuries. These special populations require clinicians, direct care staff, and others to look at care, communication, and team coordination in new ways. The results will yield an array of benefits, including better outcomes and more-engaged, satisfied staff.

Opioid Use Disorder

OUD affects more than two million people nationwide, and as many as ten million people misuse opioids on some level. According to the U.S. Centers for Disease Control and Prevention (CDC), drug overdose deaths in the United States, including those from synthetic opioids such as fentanyl, have spiked in recent years. The CDC also states that between 2021 and 2022, the greatest increase in overdose deaths were in adults over age 65. At the same time, Centers for Medicare & Medicaid Services (CMS) has “greatly expanded its expectations for nursing homes regarding treatment of residents with substance use disorders, including OUD,” said Sabine von Preyss-Friedman, MD, CMD, chief medical officer at Avalon Healthcare and Caldera Care. All this suggests that nursing homes need to be prepared to care for individuals with OUD.

There is an array of interventions facilities are expected to take for residents with OUD. According to the CMS State Operations Manual Interpretive Guidelines, they include providing a supportive, person-centered environment; understanding resident history and prior level of functioning, as well as customary routines, interests, and preferences; providing communication that supports well-being; and offering meaningful activities. In addition, there are two measures that are especially significant for residents with OUD: understanding if there is a need for visitor restrictions, voluntary inspections, and drug testing if there is suspicion or evidence of drugs being brought into the facility, and knowing when to make law enforcement referrals.

Providers also must be aware that the Americans with Disabilities Act (ADA) covers substance use disorders, and many private facilities, including nursing homes and assisted living communities, must comply with this law.
 There are some highly effective medical treatments for opioid use disorders available. Among them is buprenorphine, a partial opioid agonist used in OUD and chronic pain. This is a longer-acting medication that is generally well tolerated and has a low risk of overdose. It also is beneficial for residents with respiratory concerns, as it has a lower risk of respiratory suppression.

Methadone is often used to treat OUD. However, it doesn’t come without challenges. Long term care facilities cannot dispense methadone, “so you have to be associated with a treatment program,” von Preyss-Friedman said.
She added, “Staff often are not prepared for this, and there often isn’t guidance on how to approach
patients on methadone or buprenorphine maintenance therapy who are in pain and come into our buildings after a hospital stay.”

This is significant because facilities often see patients who are on medical treatment for substance use disorders, but the facility may not be adequately prepared to meet all their needs. Methadone maintenance treatment is very specific regarding how methadone can be prescribed and dispensed, and clinicians in the building may not know how to meet those requirements.

As OUD is considered a protected disability under the ADA, patients shouldn’t be asked to change their OUD therapy to receive long term care services, and they can’t be denied admission strictly because they are receiving methadone treatment. Moreover, methadone can’t be transitioned to a chronic pain medication if the individual is being treated for OUD. These complexities can be confusing, but, von Preyss-Friedman observed, “opioid authorities in your state are available to assist, and they want to reduce discrimination for these individuals.”
Caroline Garvey, PharmD, BCGP, manager of clinical operations at PharMerica, noted that staff need to know the signs and symptoms of opioid intoxication and overdose, as well as understand possible interventions for OUD, and the facility should have a clearly defined and communicated naloxone policy for when there is a suspected overdose.  

Chronic Mental Illness

Chronic mental illnesses—such as bipolar disorder, schizophrenia, and anxiety disorders—are not uncommon in older adults. When residents come into a facility with these conditions, diagnoses on admission are key to ensuring they get the care and treatment they need. When people have a history of mental health issues, this may get lost in the shuffle as they age and develop comorbidities such as heart disease, chronic obstructive pulmonary disease, arthritis, and even dementia.

According to the National Council on Aging, two-thirds of older adults with mental health issues don’t receive the treatment they need, and despite growing awareness of the importance of mental health in this population, mental illness continues to be underdiagnosed and undertreated in older adults.

One way to effectively address mental health care is “really getting to know the resident,” said Anna Fisher, nurse and educator in long term care. This needs to start on admission.

She noted, “We need to acquire as much information as possible and know everything we can about their history and background. We then can better identify a diagnosis and detail what treatment and care are most likely to be appropriate and effective.”

Specialists such as psychiatrists and psychologists may be helpful or necessary team members in providing care for these residents. However, it can be challenging to get them into the facility and nearly impossible to get residents out to them. Fortunately, telemedicine has made this easier. Following the COVID-19 pandemic, CMS implemented several permanent changes to telemedicine services, such as the ability to receive in-home telemedicine services for behavioral and mental health care. Most of the time, staff are more comfortable with this technology, and reimbursement is available for these services.

Many residents with chronic mental illness take prescription medications for the condition. While there is much evidence to support the benefits of pharmacotherapy for various mental illnesses, medications should be reviewed and reassessed over time to determine if dosages can be reduced, the drug can be eliminated from the person’s regimen, or side effects might suggest an alternative as a better choice.  

The scrutiny of antipsychotics can be challenging when you’re dealing with residents who have chronic mental illnesses. “The drugs are appropriate for some diagnoses. We can’t throw the baby out with the bathwater,” said David Smith, MD, CMD, president of Texas-based Geriatric Consultants. Instead, it’s important to make sure diagnoses are clear in the chart.

Traumatic Brain Injury

According to the CDC, more than 80,000 older adults experience a traumatic brain injury (TBI) every year, often from falls. About 75 percent of these result in hospitalization. Older adults who experience a TBI are at higher risk for complications such as the development of major depression or other mental health disorders. There also may be a link between TBI and dementia, and even repeated mild traumatic brain injury can increase the dementia risk.

People may come into a facility because of a TBI and its negative impact on their life, behavior and cognition, and ability to function independently and perform activities of daily living (ADLs). Most commonly, Smith explained, they enter a long term care facility because of behavioral issues or incontinence.

There are signs that staff can watch for during admission and over time to determine if a resident has an undiagnosed TBI. For instance, the person is exhibiting unusual behavior, is suddenly combative or irritable, has bruises or has reported a recent fall, complains of headaches, and stops social activities. If staff or caregivers notice any of these signs, they should report them to a clinician, which should trigger an assessment and diagnosis.
Therapy matters in TBI. In the first three months after the injury, the brain has a neuroplasticity—an ability to rewire and repair itself. This generally requires a team approach involving such professionals as speech therapists, physical therapists, occupational therapists, and psychotherapists. To ensure adequate reimbursement for these services, the physician should order them and create a care plan as soon as possible after admission.

Neurologists are a valuable part of the care team for residents with TBI. However, Smith observed that it’s usually difficult to get a neurologist to come to the nursing home. This makes it more important to have a strong care team in the facility.

While antipsychotic medications may be useful to manage some issues in TBI, any prescription for these drugs should have an appropriate diagnosis, be ordered for the shortest possible time and in the lowest possible dose, and be monitored and reviewed over time. While providers are aware of the need to limit the use of antipsychotics, some other prescribers, especially those outside of geriatrics and long term care, may need to be reminded of this.

People with TBIs often exhibit challenging behaviors, or their personalities may change. For example, a spouse may leave the house for 20 minutes, and when they return, the person with a TBI may scream and ask why they were gone for two hours. People with a TBI may revert to childlike behaviors, such as grabbing the last cookie or throwing a tantrum if they don’t get their way. Staff, as well as family caregivers, will benefit from training on how to deal with these behaviors and personality changes. Some dementia care training may be helpful, such as on how to divert attention, how to de-escalate anger or agitation, and how not to argue, for example when someone is confused about the day or time.

Anna Fisher suggested also watching the tone and cadence of your voice and not moving in ways that the person might consider threatening or aggressive. These actions, many of which may seem inconsequential, can make working with these individuals and assisting with ADLs, such as bathing, toileting, and eating, easier for staff.

Not Just Another In-service

Staff, especially those who provide direct care, need specific education and training to work with special populations. For instance, staff should be encouraged to use words that inspire healing and avoid judgmental words, von Preyss-Friedman said.

Garvey at PharMerica explained, “Staff need to be trained on the stigmas associated with issues such as OUD. They also need to understand that drug-seeking behaviors are very different than a patient in pain who needed treatment and interventions such as physical therapy.”

She stressed, “We don’t want to discriminate against someone who, for example, just went through a very painful motor vehicle accident and is in your facility for rehab.”

Often with these conditions, patients may benefit from nonpharmacological interventions, as well as medications. The consultant pharmacist can help assess residents’ medication regimens to make sure they are treated appropriately.

Prescribers and other clinicians will need special knowledge, as well. Von Preyss-Friedman noted that, for example, the medical director should clarify the ADA adherence and have an education plan, and every attending physician must be knowledgeable on how to prescribe buprenorphine.

Nurses also may need special training regarding medications. For example, nurses must also understand how and when to administer buprenorphine. The consultant pharmacist can help ensure that anyone who handles medications understands how to do so safely and follow all security and other protocols.

Skilled nursing facility practitioners and staff must understand the regulations related to mental illness and substance use disorders. Von Preyss-Friedman noted, “CMS has identified a need to improve guidance related to meeting the unique health needs of residents with mental health needs and substance use disorder.” Specifically:

• When facilities care for residents with these conditions, their policies and practices must not conflict with resident rights or other requirements of participation.
• The facility staff should have knowledge of signs and symptoms of possible substance use and be prepared to address emergencies (e.g., an overdose) by increasing monitoring, administering naloxone, initiating cardiopulmonary resuscitation as appropriate, and contacting emergency medical services.
• CMS also provided resources and nonpharmacological interventions specific to residents living with mental disorders or substance use disorders to assist providers in identifying alternative approaches to care to support this population.

Practitioners and staff need to be familiar with F-tag 740: Behavioral Health Services, which mandates that people with mental disorders be appropriately assessed, diagnosed, and provided with the necessary care and services to maximize their quality of life.
There also are associated F-tags that surveyors will be looking at with these patients:

• F-tag 838: Facility assessment
• F-tag 644: Preadmission Screening and Resident Review (PASRR) mental health and intellectual disability service needs
• F-tag 557: Dignity and respect
• F-tag 679: Meaningful activities
• F-tag 622: Transfer and discharge
• F-tag 636: Resident assessment
• F-tag 689: Accidents

Staff must know what and how to document information starting with diagnoses on admission. This should involve the PASRR, a federal requirement to make sure someone is appropriately being admitted to a nursing home or would be more appropriate for another setting. It evaluates people for senior mental illness and intellectual disabilities.

PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.”

Survey Prep

Falls, behaviors that result in an accident or injury, or other risks for residents with OUD, chronic mental illness, and TBIs will attract attention and scrutiny on the part of surveyors. Facilities should be prepared to show through detailed documentation how they’ve worked to protect the safety of and provide quality care for their residents.

“We have to make sure that we document everything carefully, not only in terms of what we do for patients when they exhibit some behaviors with dangerous or potentially dangerous consequences, but also efforts to reevaluate and revise—as necessary—the care plan,” Smith said. “If a resident hits another resident, and you have a care-plan meeting but don’t make any changes, you’re going to be in trouble with the surveyor.”

Residents with these conditions can be challenging to care for. However, when staff have adequate training and experience, the team communicates consistently, and the organization has a culture that encourages and enables excellent and collaborative care, these residents can enjoy a safe, purpose-driven life, despite their illnesses.

Joanne Kaldy is a freelance writer and communications consultant based in New Orleans.​