The first meeting of the subcommittee for Redefining Nursing Home Criteria and Build Capacity met on July 17 in Pierre. This study resulted from the 2018 Summer Study on Mental Health Access for Services.

The resolution put forth this past session established five areas of study resulting from the earlier study. In the early discussions on mental health access for services at HSC it was learned that two units had been closed due to inability to fill staffing positions. Those units focused on treating individuals with acute mental health crises and short-term treatment with transition to community based mental health services once the individual was stabilized and safe to return to their community.

Patients in the geriatric nursing home have long-term stays and staffing for that unit is priority. Therefore, the greatest flexibility to move staff to fill unfilled positions in the nursing home is to use those staff that are assigned to the acute mental health units. The flexibility to maintain the staff requirements in the nursing home is provided by limiting access to acute beds by closing units if necessary. The result is that there is a shortage of acute mental health beds at HSC. This impacts the citizens of South Dakota that need those services. Individuals are directed to other behavioral programs in the state, maybe in other health care facilities waiting for an opened bed, in jail or in the community and at risk of hurting self or others.

The question raised was: Are there other options for long-term geriatric mental health care within the state so that reducing the size of the unit would allow for a workforce that could support the opening of the closed units at HSC to meet the acute care mental health needs? Therefore, this committee’s scope of study is to redefine HSC nursing home admission criteria and build mental health nursing home capacity for persons with organic brain damage. There is no intent or desire to close HSC but rather to build capacity for a segment of the population that is needs acute mental health services.

The deputy secretary of Social Services provided the history for the nursing home operations at HSC. In 1976, the program began for the geriatric nursing home. In 1978, it became licensed as a Medicaid facility for 119 beds, and in 1996, moved into the current building with 91 beds. Today they have 69 beds in the nursing home.

A question was raised as to why the decrease in bed numbers. The decline resulted because of the addition of the adolescent unit in 1998 replacing some of the geriatric beds. The average length of stay in FY18 for geriatric patients was 752 days. The operating budget for the geriatric unit is approximately $6 million. Medicaid pays 22% of the days with 78% of the days non-Medicaid days. Medicaid estimated FY19 revenue was $1.3 million and non-Medicaid revenue $700,000.

Information was provided for definition of involuntary admission, criteria for admission and explanation of path to admission to HSC Geriatric Program. Diagnosis categories for residents were presented for FY19. The majority were attributed to a dementia type of disorder. Behavioral changes related to dementia were explained and how currently providers of long-term care are unable to manage these patients because of staffing shortages and training for their care.

The department also presented information regarding guardianship. Areas of challenges were identified with obtaining guardianship by providers of long-term care on the subcommittee.

A case manger from RCR presented an overview of the difficulty in placement of individuals at HSC due to closed units. She also indicated that long-term care facilities in her region do not take patients with behavioral issues due to staff needs and training of staff.

Finally, a presentation of Delivery of Geropsychiatric Institutional and Community-based settings was provided by a consultant doing work in Virginia and Tennessee. The intent was to get a perspective as to what is occurring in other states for care of their geriatric mental health population.

Providers on the committee identified two areas of concern for taking those patients into their facilities. One was immediate access to a mental health crisis team that could provide direction and support when there is a behavioral health crisis for one of their residents. Having that immediate assistance may prevent them from having to transfer the resident to HSC. Second is security at facilities for patients that have behavioral health challenges — how to respond and protect the resident and/or other residents in the facility when there is an acute episode. Finally, training of staff in care of patients with behavioral disorders was identified.

Another major challenge for long-term care is the regulations that nursing homes operate under for Medicare and Medicaid certification. Sometimes the regulations make it very difficult to provide care to this special population.

At the conclusion of the day, more information was being sought on the topics discussed. There was public testimony by the lobbyist for the South Dakota Health Care Association regarding the lack of options for behavioral challenged patients in long-term care if HSC is unable to take these patients.

The committee is requesting more in-depth information on the issues presented, looking to other states for their models of care for geriatric behavioral health challenged patients, and admission criteria other states have for these patients. They are also requesting the DOH to explain the regulatory impact for long-term care with behavioral health patients and county commission association to discuss involuntary committals and payment for services at HSC.

The next meeting will be at HSC on Oct. 1-2. This is an opportunity for members of the committee that have not been at HSC to tour the facility and see the operations of the geriatric unit. Again, public testimony will be available at the meeting.

If there are questions/concerns, please contact me: Jean.Hunhoff@sdlegislature.gov or 660-5619.

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