Transforming Long-Term Care: Addressing Risky Admissions

The long-term care landscape is undergoing a dramatic transformation, placing unprecedented pressure on administrators and frontline staff. As facilities grapple with fluctuating census and evolving patient needs, a concerning trend has emerged: the increasing admission of younger, more complex individuals whose care requirements often exceed the capabilities of traditional long-term care models. These "risky admissions," encompassing individuals with severe psychiatric disorders, opioid addictions, histories of incarceration, and unstable housing situations, present a multitude of challenges that demand proactive solutions.

Before delving into the complexities and risks, it's crucial to acknowledge the long-standing commitment of the long-term care industry to serving diverse populations. Our facilities have significantly adapted to accommodate a more clinically complex post-acute population, and we have a history of providing care to individuals with mental health issues and addiction. However, we must never compromise the safety and well-being of our existing residents. This is why careful consideration, robust protocols, and a focus on resident safety are paramount. Our commitment is to providing compassionate care to all while ensuring a safe and secure environment for the vulnerable elderly population entrusted to our care. The changing landscape is putting that commitment to the test, however, as we see an increase in "risky admissions", those with severe psychiatric disorders, opioid addictions, those recently released from jail, and homeless individuals with psychiatric or non-compliant behaviors.

This shift forces us to confront profound ethical dilemmas. While we are not unsympathetic to the needs of these individuals – who deserve compassion, care, and comprehensive support – the skilled nursing or long-term care setting was often not designed to meet their unique requirements. They may need intensive psychiatric services, specialized addiction treatment programs, or stable housing solutions, all of which fall outside the traditional purview of the nursing home. This raises the crucial question: are we truly serving these individuals by admitting them into a setting that is ill-equipped to address their core needs? Moreover, at what cost does this trend come to our existing residents, our vulnerable elderly population who rely on a safe and predictable environment?

Given these ethical considerations, let's examine the specific concerns these admissions create, starting with the most critical: resident safety.

I. Resident Safety: The Primary Concern

Our foremost responsibility is to ensure the safety and well-being of the vulnerable elderly population entrusted to our care. Risky admissions can directly compromise this core mission in several ways:

• Increased Risk of Incidents: Disruptive or unsafe behaviors from residents with severe psychiatric disorders, addiction issues, or a history of violence can create a climate of fear and anxiety for other residents. This increases the risk of altercations, assaults, and other incidents that directly threaten their safety and well-being. While long-term care facilities often have established resources for managing behavioral issues associated with dementia, including secure memory care units designed to provide specialized support and a safe environment, these resources are typically not appropriate or available for individuals with severe psychiatric disorders, addiction issues, or a history of violence who do not have a primary diagnosis of dementia. This creates a significant challenge in finding appropriate and effective interventions for this complex population.

• Compromised Quality of Life: The introduction of individuals with significant behavioral challenges can disrupt the peaceful and predictable environment that many long-term care residents depend on for their quality of life. Noise, disruptions, and safety concerns can lead to increased stress, anxiety, and social isolation for other residents.

• Illicit Substance Use and its Consequences: The risk of residents with addiction secretly obtaining and using illicit substances within the facility creates a direct threat to their own health and safety, and potentially a risk to other residents. This can lead to dangerous medication interactions, adverse effects, and medical emergencies that require immediate intervention and can strain the facility's resources.

II. Regulatory Compliance: Navigating the Minefield

Beyond the immediate safety concerns, these risky admissions create a breeding ground for regulatory non-compliance not necessarily due to neglect or inadequate care on the part of the facility, but because of the inherent challenges these individuals present.

• Survey Deficiencies and Financial Penalties: The inherent challenges in managing residents who are often non-compliant with their prescribed plan of care, who create their own risk by introducing illicit or non-prescribed medications, and whose complex behaviors drain valuable staff time and resources can all lead to situations that trigger citations, penalties, and even civil monetary penalties (CMPs), quickly eroding any revenue gained from the initial admission. A significant driver of these surveys is the increase in complaint surveys. Non-compliant behaviors and/or interventions required to safely manage the care of these individuals can trigger complaints from residents, families, or even staff, drawing survey agencies into the building.

• Safe Discharge Complexities: While we're legally obligated to ensure safe discharges back into the community, a particularly difficult challenge arises when admitting housing-insecure individuals for short-term rehabilitation. Even when these individuals complete their rehabilitation goals, they often lack a safe and stable place to which to discharge, leaving the facility in a precarious position as we are charged with ensuring a safe discharge. The long-term care system is mandated to ensure safe discharges back into the community, yet how can we fulfill this obligation when adequate community resources are woefully lacking? This lack of appropriate discharge options creates a significant burden and potential liability, and can potentially lead to regulatory scrutiny.

• Impact on Quality Measures: The use of psychiatric medications to manage complex behaviors can negatively impact our facility's quality measures, ultimately affecting our star ratings and reputation. This, in turn, can affect referral sources and drive down occupancy in the long run. We are charged with the judicious and careful use of psychotropic medications. However, we are increasingly admitting a population group whose complex needs often necessitate these very medications, putting us at greater risk of scrutiny and potential deficiencies despite our best efforts to prescribe them responsibly. Thus, we must ask ourselves again, are we inadvertently placing our facilities at increased risk of regulatory scrutiny by attempting to manage complex psychiatric or behavioral symptoms stemming from years of trauma, addiction, homelessness, and other challenges, even when our interventions are undertaken with the utmost care, clinical justification, and a sincere desire to help these individuals?

III. Financial Implications: Beyond the "Head in the Bed"

While the initial increase in census may seem tempting to operators, the financial realities of these "risky admissions" often paint a very different picture:

• The High Cost of Regulatory Non-Compliance: As outlined above, survey deficiencies, citations, and CMPs can quickly erase any revenue gained from the initial admission, turning a seemingly profitable decision into a significant financial loss.

• The Repetitive Cycle of Deficiencies: The facility can become trapped in a cycle of regulatory non-compliance, making it harder to attract new residents and retain existing staff.

• Staffing Strain and Turnover: Traditional long-term care staffing models are not designed to adequately manage individuals with severe psychiatric disorders, addiction issues, or a history of incarceration. This leads to staff burnout, increased turnover, and the need for additional training and resources, all of which contribute to increased costs.

• Reputational Damage and Lost Referrals: Reputational risks also loom large. Incidents arising from disruptive or unsafe behaviors can quickly become public knowledge, leading to negative press, complaints from other residents and their families, and a general erosion of trust in the facility. This reputational damage can severely impact referral streams and community partnerships, undermining the facility's long-term sustainability despite the facility's commitment to providing quality care.

• Increased Management Time and Resources: Beyond the direct cost of penalties, the additional time spent managing behaviors, de-escalating situations, and diligently monitoring these residents represents a significant hidden financial burden on the facility and highlights the inadequacy of current funding models to address these complex needs.

Given these significant risks, proactive strategies are essential to protect the facility, its staff, and its residents. These "risky admissions" require careful consideration and robust protocols before admission. Behaviors, non-compliant tendencies, and the availability of adequate resources must be thoroughly evaluated. To that end, proactive risk management strategies are crucial.

Elevating care planning is paramount. We must move beyond standard assessments and delve deeply into the resident's history, triggers, and specific needs, creating truly individualized care plans. Addressing illicit drug use proactively is a critical component of this process. For those with a history of illicit drug use, develop specific care plan interventions and clearly document conversations about the facility's policies and expectations. Collaboration with medical leadership is essential. Develop clear protocols with your Medical Director on medication management, particularly for opioid addiction and withdrawal. Ensure early psychiatric and psychological intervention by partnering closely with psychiatrists and psychologists to evaluate new admissions promptly, document their history thoroughly, and develop appropriate interventions immediately.

Comprehensive documentation is your shield during surveys. Meticulously document all care planning efforts, interventions, and communication with the resident, family, and other healthcare providers.

Strengthen admission agreements to ensure clear language on community rules, particularly as they pertain to illegal substances. Obtain a signed acknowledgment of these rules upon admission. You should also review your policy on visitation and consider language in the admission agreement stating that anyone bringing illegal substances onto the premises will be asked to leave or will only be permitted supervised visitation. Also, consult with your legal team to ensure all policies, procedures, and admission agreements are compliant with all applicable federal, state, and local laws.

Prioritize risk management and brainstorm with your team to identify potential risks associated with these admissions and implement proactive solutions. This includes staff training, de-escalation techniques, emergency response protocols, conducting frequent mock surveys to identify vulnerabilities, and implementing robust incident reporting systems. Regular updates to your Facility Assessment and Staffing Plan are a must; the assessment should accurately reflect the population you are serving, and your staffing plan must be adequate to meet their needs.

Equally important is fostering a supportive and empowering environment for your staff. The long-term care industry has already adapted significantly to accommodate a more clinically complex post-acute population. However, while we have a long history of providing care to individuals with mental health issues and addiction, we must ensure that at all times, we are only admitting residents who will not pose a threat of harm of any kind to our existing resident population or our staff. Therefore, it's crucial to foster a culture where staff feel safe and supported in raising concerns about resident care, especially when dealing with complex admissions. This involves enhanced training on managing complex behaviors, establishing clear reporting channels for voicing concerns, fostering a collaborative team-based approach to care, providing readily available supervisory support, focusing on prevention, conducting incident debriefings, and reinforcing facility safety protocols.

In the face of these complex challenges, administrators and leaders have a profound responsibility. We must protect our licenses, protect our teams, ensure the long-term viability of our facilities, and, most importantly, uphold our ethical obligations to provide quality care to the vulnerable elderly population we serve. It is imperative that we advocate for these individuals. Remember why you are there!

We cannot resolve this crisis alone. We did not create the homeless crisis, the mental health crisis, or the opioid epidemic. But we can be powerful voices for change. Talk to your legislators, demanding increased funding for community mental health services, addiction treatment programs, and supportive housing. Advocate for alternative housing programs and explore partnerships with organizations that provide specialized housing for individuals with complex needs. Demand realistic expectations and push back on mandates that place unrealistic expectations on long-term care facilities without providing the necessary resources to carry out those mandates given the complexities of the populations we are serving.

The influx of complex residents into long-term care facilities presents profound ethical, financial, and regulatory challenges. We must resist the pressure to prioritize census over ethical care and responsible risk management. We must prioritize proactive planning, investing in our teams, implementing robust risk management protocols, empowering our staff, and, most importantly, advocating for systemic change. The integrity of long-term care, the well-being of our most vulnerable residents, and the future of our profession depend on it. We must act decisively and with unwavering conviction. The time for action is now. Are you willing to lead the change?