In This Issue

• Psychosis in Nursing Facility Residents
• Nursing Facility Guidance- Facility Assessment
• Better Mental Well Being Podcast - Implementing Substance Use Recovery Support in Nursing Facilities
• Subject Matter Expert Article: Integrated Behavioral Healthcare Models in the Nursing Facility Setting
• Office Hours
  • Managing Substance Use Disorders in Nursing Facilities
• COE-NF Resources
  • Behavioral and Emotional Status Critical Element Pathway
  • Comfort Menu
  • Understanding Psychotic Disorders in Nursing Facility Residents
• Did You Know?
  • Substance Induced Psychosis
• Save the Date: Join our Upcoming Virtual Education Events
• You Matter
  •  Self-Care Assessment

Residents in nursing facilities experience complex health challenges, including cognitive decline, sensory impairments, and social isolation. Many may also experience symptoms of psychosis.

Psychosis refers to a condition where an individual may have trouble differentiating between what is real and what is not. Symptoms of psychosis can include:

• Hallucinations (seeing or hearing things that others do not)
• Delusions (false beliefs)
• Confused speech 
• Behavior that is inappropriate for the situation

Warning Signs
Changes in behavior may occur before psychosis develops. Behavioral warning signs for psychosis include:

• Suspiciousness, paranoid ideas, or uneasiness with others
• Trouble thinking clearly and logically
• Withdrawing socially and spending a lot more time alone
• Unusual or overly intense ideas, strange feelings, or a lack of feelings
• Decline in self-care or personal hygiene
• Disruption of sleep, including difficulty falling asleep and reduced sleep time
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating
• Sudden drop in job performance

What causes psychosis?
Psychosis does not have a single cause; instead, it can arise from a combination of different conditions and contributing factors. Psychosis can be a symptom of various mental health disorders, including schizophrenia, schizoaffective disorder, bipolar disorder, and severe depression. It may also be triggered by certain medications or substance use. In older adults, psychosis can develop later in life and may be associated with Dementia, Parkinson’s disease and Alzheimer's disease.

Additional contributing factors may include sleep deprivation, side effects from prescription medications, alcohol or drug misuse, and a genetic predisposition.  

Treatment of psychosis
Management of psychosis can include pharmacological, nonpharmacological, and psychosocial interventions. Ruling out underlying causes, such as substance use, medication side effects, or underlying medical conditions, is an important first step. 

Pharmacological treatment should be an interdisciplinary approach, and careful consideration should be given to side effects, measuring risks vs the benefits.  

What can you do today to support residents with psychosis?

• Observe early warning signs - Watch for subtle changes in behavior or thinking that may indicate the onset of delusions or hallucinations and communicate findings to the interdisciplinary care team.
• Provide reassurance - Let the resident know that support is available and that what they’re experiencing can be addressed. 
• Provide education - Educate residents and their families about psychosis.
• Address and eliminate underlying causes -  Assess for contributing factors such as substance use, medication side effects, or underlying medical conditions.
• Implement person-centered interventions and care planning -  Use individualized, strengths-based non-pharmacological strategies to support safety, reduce emotional distress, and improve quality of life.
• Coordinate psychotherapy - Refer residents to therapeutic behavioral health support such as cognitive behavioral therapy or other relevant modalities to address symptoms and promote recovery.

Understanding psychosis is key to providing effective, compassionate care. Facilities that invest in staff education and evidence-based strategies are better prepared to support resident recovery, reduce distress, and create a more stable, person-centered environment. 

CLICK HERE to access free training on managing psychosis in nursing home settings, submit a request to the Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF).

Reference:National Institute of Mental Health. Understanding Psychosis. 

 

Facility Assessment Reminder: Ensure Compliance and Preparedness

The Centers for Medicare & Medicaid Services (CMS) requires all nursing facilities to conduct and document a facility-wide assessment at least annually. This assessment must be reviewed and updated as necessary, particularly when there are changes in resident populations, facility operations, or available resources.

If your facility completed its assessment early in the year, mid-year is an ideal time to review and revise it to ensure it remains accurate and comprehensive. For facilities that are due for an assessment, now is the time to begin. These assessments can be time-intensive, so starting early is essential to ensuring thoroughness and regulatory compliance.

In recent years, CMS has updated its SOM - Appendix PP  to include enhanced surveyor guidance on facility assessments. A major focus of these updates is the expectation that facilities identify and address residents’ behavioral health needs. This includes ensuring that staff are adequately trained and possess the necessary skills and competencies to support residents with:

• Mental health disorders
• Psychosocial disorders
• Substance use disorders
• Trauma histories and/or Post-Traumatic Stress Disorder (PTSD)

The facility assessment must reflect these needs and demonstrate that staff training and competencies are aligned accordingly.

Taking time now to assess your facility’s readiness helps ensure not only regulatory compliance but also high-quality, person-centered care for all residents.

What can you do TODAY?

Identify: 

• The facility’s resident population, including the number of residents and the facility’s capacity. 
• The care required by the resident population. This includes the behavioral health needs of the residents. 
• The staff competencies and skillsets necessary to provide the level of care needed for the residents. 
• The facility’s resources, including buildings, equipment, services provided (including behavioral health), and personnel, including nursing staff.  

Partner with the COE-NF's Regional Behavioral Specialists  to assess your facility’s current behavioral health needs. They can help you develop action plans and enhance your facility’s ability to care for residents with behavioral health challenges – all while supporting your facility assessment process. 

Reference: State Operations Manual

Special guest Molly Hedgpeth, director of dementia and behavioral health programs at SLP Operations, LLC, shares the processes and strategies involved in implementing recovery supports for nursing facility residents actively using substances. She will also share how to provide continued support throughout their recovery journey while residing in the facility. CLICK HERE  to watch the episode.

CLICK HERE  to listen to this episode and any others you may have missed. 

Behavioral health (BH) conditions, such as depression, agitation, and substance use disorders, are very common in nursing facility (NF) residents. Despite this, BH conditions often go undetected or inadequately treated in this patient population.

NF residents with poorly treated BH conditions are at elevated risk of negative clinical outcomes, including reduced adherence to treatment for comorbid physical health conditions, worse functioning, greater utilization of healthcare services, and increased risk of rehospitalization and death (1). Two key reasons that NFs have been unable to adequately address the BH needs of residents include the lack of necessary staff training and inadequate access to BH providers (2). 

Integrated care models (ICMs) have been developed in response to the need for greater access to BH services. In these models of care, physical health providers, typically primary care providers (PCPs), work together with BH providers to varying degrees, as described below. These models aim to address the needs of the whole person across the lifespan, including chronic pain, common BH conditions (e.g., depression and anxiety), insomnia, health-related behaviors (e.g., treatment non-adherence, physical inactivity, and smoking), social determinants of health (e.g., food insecurity), and substance use disorders. While ICMs emerged from outpatient primary care settings, they can be adapted and tailored to meet the needs of NFs and their residents.

The first ICM is known as coordinated care. In this model, patients are routinely screened for common BH condition(s). Upon a positive screening score, patients are referred for BH services at another treatment facility. In order to be effective, this model requires that each facility identify which BH condition(s) to screen for; identify corresponding BH screening tools; train staff to use these tools; develop workflows to alert PCPs to positive screens; identify referral sources; and then communicate the results of positive screening tools in BH referrals. 

In the second model, the collocated care model, a BH provider (e.g., psychiatric nurse practitioner) works in the same facility as the PCP. The goal of the proximity of the BH provider and PCP is to facilitate sign-outs between providers and expedite referrals to BH providers knowledgeable with both the facility and its patient population. Patient communication also tends to be enhanced due to provider use of the same electronic health record (EHR). 

In the third model, the behavioral health-primary care model (BH-PC) model, a behavioral health consultant (BHC) provides evidence-based, time-limited psychotherapy services for a particular clinical concern that has been identified by the PCP. The BHC is typically equipped to provide brief psychotherapeutic interventions for a wide range of BH conditions. Use of the same EHR, direct sign-out between PCPs and BHCs, and the possibility for same-day access to the BHC are the strengths of this model. 

The collaborative care model (CCM) works by screening all patients at set intervals of time with a battery of BH screening tools. Positive results flags a BH case manager (CM) to evaluate the patient. Typically, a therapist by training, the BH-CM closely works with a BH provider to develop an individualized treatment plan for the patient. The BH-CM and PCP then carry out this treatment plan in collaboration with a psychiatric consultant. The BH-CM meets with the BH provider during weekly case staffings and modify the treatment plan accordingly. Unlike the other models, the BH provider does not typically meet with patients directly. However, this model drastically increases the number of patients that each BH provider can serve, while also enhancing PCP’s comfort and ability to manage common BH concerns. Of all of the ICMs, CCM has the strongest evidence base to support its effectiveness.

In conclusion, NFs may choose to close the treatment gap between physical health and BH conditions by implementing an ICM. In addition, ICMs hold the potential to enhance the quality and safety of NF care, reduce staff burnout, increase staff satisfaction, and reduce overall treatment costs. When deciding which ICM to use, it is recommended that each NF take into consideration the merits of each model, the needs of its patient population, available resources, and the impact on staff’s training needs and clinical workflows.

While policy changes have enhanced reimbursement of ICM services, an evaluation of the financial viability of ICM is also critical (1). In order for ICMs to be both clinically and financially effective, it is imperative that clinicians, NF administrators, healthcare payers, policy advisors, and healthcare quality experts work together to support the utilization of ICMs in NF settings. 
 
References: 

1. Let’s Integrate! The Case for Bringing Behavioral Health to Nursing Home–Based Post-Acute and Subacute Care. Evan Plys PhD , Cari R. Levy MD, PhD, Lisa A. Brenner PhD , Ana-Maria Vranceanu PhD
2. Providing Behavioral Health Services in Nursing Homes Is Difficult: Findings From a National Survey. Jessica Orth, Yue Ki, Adam Simning and Helena Temkin-Greener. Orth et al. J Am Geriatr Soc. 2019 Aug;67(8):1713-1717.

Dr. Sarah McCutcheon, MD, FAPA is the regional medical director for Comagine Health and is based in Anchorage, Alaska.

Managing Substance Use Disorders in Nursing Facilities

Interested in receiving expert answers to substance use challenges you are facing in your nursing facility? Join Dr. Jen Azen and Dr. Swati Gaur, subject matter experts, as they answer questions related to your complex cases. No question is too big or too small!   
  
Join our monthly office hours on the third Friday of each month from 1-1:30 p.m. ET to get answers directly from the experts working in nursing facilities!  
  
Audience: Appropriate for clinicians, nurses, administrators, and social workers. 

Use these resources created by the COE-NF to promote understanding and learning about behavioral health in your facility.

Behavioral and Emotional Status Critical Element Pathway 

This is the pathway used by surveyors to determine if a nursing facility is providing necessary behavioral, mental and/or emotional health care and services to residents. Nursing facilities can use this to help evaluate their compliance with regulations and to assist in survey preparation.  Download Resource

Comfort Menu

Identify ways to reduce anxiety, discomfort and pain without using medications. Download Resource

Understanding Psychotic Disorders In Nursing Facility Residents

Psychotic disorder is an umbrella term used to describe a group of mental health disorders characterized by delusions and/or hallucinations, often resulting in a loss of contact with reality. Download Resource

Substances, including marijuana, cocaine, amphetamines, hallucinogens, alcohol and benzodiazepines, have been linked to psychosis. These substances can cause drug-induced psychotic episodes during or within a month of intoxication.

Drug-induced psychosis, also known as substance-induced psychosis, refers to transient delusions, hallucinations, or both that occur due to the effects of drugs or from intoxication or withdrawal from certain substances. CLICK HERE to learn more. 

Reference:Substance-induced psychosis: Symptoms, causes, and treatment. American Addiction Centers. (2025, April 17). 

Self-care comes in many forms, from physical activities like regular exercise to spiritual practices such as quiet reflection.

Taking time to consider which areas of self-care may need more attention in your life can be a powerful first step toward greater well-being. Complete this brief  Self-Care Assessment to check in with yourself.

As you complete the assessment, note any areas you'd like to focus on for the day, the week, or the month.

Reference: Center to Advance Palliative Care. Health care professional well-being. 

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