Mental Health Services in Nursing Homes
Models of Mental Health
Services in Nursing Homes:
A Review of the Literature
Stephen J. Bartels, M.D.
Gary S. Moak, M.D.
Aricca R. Dums, B.A.
Objective: The authors review the research literature on models and
outcomes of extrinsic mental health services in nursing homes and summarize the data on current practices in this area. Extrinsic mental
health services are those delivered in the nursing home by specialists
who are not full-time staff of the nursing home. Methods: English-language articles providing descriptive and research reports on models
and outcomes of extrinsic mental health services in nursing homes were
identified through a comprehensive search of peer-reviewed journals,
using MEDLINE and psychological literature databases. The research
methods of the reports were also noted. Results: Three primary models
of mental health service delivery were identified: psychiatrist-centered,
nurse-centered, and multidisciplinary team models. Uncontrolled observational studies suggested that mental health services may result in
improved clinical outcomes and less use of acute services. However, few
well-designed controlled intervention studies have been conducted. Education and training appeared to improve staff members’ knowledge
and performance and to decrease turnover. The least effective model
involoved traditional consultation-liaison service in which a lone clinician provided a one-time, written consultation on an as-needed basis.
Multidisciplinary team approaches were favored as preferred service
models. Conclusions: Few studies using an experimental design have examined the outcomes of mental health services in nursing homes. Program descriptions and uncontrolled outcome studies suggest that preferred practice includes the routine presence of qualified mental health
clinicians in the nursing home, that optimal services are interdisciplinary and multidimensional, and that the most effective interventions
blend innovative approaches to training and education with consultation and feedback on clinical practices. (Psychiatric Services
53:1390–1396, 2002)
Dr. Bartels is director of the aging services division of the New Hampshire–Dartmouth
Psychiatric Research Center and associate professor of psychiatry at Dartmouth Medical
School in Hanover, New Hampshire. Dr. Moak is associate professor of clinical psychiatry at the University of Massachusetts Medical School in Worcester. Ms. Dums is a research assistant in the aging services division of the New Hampshire–Dartmouth Psychiatric Research Center. Send correspondence to Dr. Bartels, New Hampshire–Dartmouth
Psychiatric Research Center, 2 Whipple Place, Suite 202, Lebanon, New Hampshire
03766 (e-mail, stephen.j.bartels@dartmouth.edu). This study was presented in part at the
long-term care consensus conference of the American Association for Geriatric Psychiatry held June 22–24, 2000, in Washington, D.C. This article is part of a special section on
mental health services in long-term care facilities.
1390
PSYCHIATRIC SERVICES
D
espite the high prevalence of
psychiatric and behavioral
problems among nursing
home residents, most of those residents who need mental health services do not receive them. About 80 percent of nursing home residents have
diagnosable psychiatric disorders,
with dementia being the most prevalent condition (1–3). However, fewer
than a fifth of them receive treatment
from a mental health clinician (4,5).
Nursing home staff have identified a
lack of access to high-quality mental
health services and a lack of appropriate reimbursement as major barriers
to providing needed consultation
services to nursing home residents
(6). Nursing home administrators
have estimated that two-fifths of
nursing home residents need psychiatric services, yet half of nursing
homes do not have access to adequate
psychiatric consultation, and threequarters are unable to obtain consultation and educational services for behavioral interventions (6). In general,
there are not enough mental health
clinicians with specialized training in
geriatric psychiatry who are willing
and able to provide mental health
services in nursing homes (7).
Effective models of mental health
service delivery in nursing homes will
be critical in meeting the needs of the
growing numbers of individuals who
will be entering long-term-care facilities over the coming decades. In this
report we provide an overview of the
treatment research literature on extrinsic mental health services in nursing homes and summarize data on
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
current practice in this area. Extrinsic
mental health services are those provided on-site by specialists who are
not full-time staff of the nursing
home.
Three questions will be addressed.
First, what is known about psychiatric
practice in nursing homes? Second,
what models of mental health services provided to nursing homes are described in the research literature? Finally, what outcomes of mental health
services in nursing homes are reported in the literature?
Methods
We used MEDLINE and psychological literature databases to conduct a
comprehensive search for Englishlanguage descriptive and research reports published through May 2000 on
models of mental health services in
nursing homes. We used a variety of
search terms, including psychiatry,
geriatric psychiatry, mental disorders,
long-term care, homes for the aged,
nursing homes, and residential facilities. We also conducted a manual
search of references from relevant literature. Our searches were restricted
to articles in peer-reviewed journals
reporting on models and outcomes of
extrinsic mental health services as
well as on hybrid services involving
external psychiatric clinicians who
work closely with nursing home psychiatric nurse specialists or social
workers. Given our aim of describing
the roles, models, and outcomes of
mental health services provided by
psychiatrists and other external clinicians, we excluded reports on mental
health services provided by full-time
nursing home staff or descriptions of
special-care units or dementia-care
units staffed by nursing home professionals. We also excluded non–nursing home settings, such as assisted living facilities and residential care
homes, because the literature on
these settings is poorly defined and
their patient population and treatment and regulatory environment are
different from those of nursing
homes. Research methods were also
noted, including narrative program
descriptions, reports of outcome data,
and studies using an experimental design. The sources reviewed included
detailed descriptions of service modPSYCHIATRIC SERVICES
els that lacked outcome data, observational outcome studies, and randomized controlled studies of mental
health service interventions.
Results
Psychiatric practice
in nursing homes
A recent survey of practitioners suggested that psychiatric services in
nursing homes, if they are available,
are most commonly provided by a
psychiatric consultant who works
alone, comes only when called to see
a specific patient, and does not provide subsequent care unless specifi-
The
vast majority of
psychiatric practice
in nursing homes is
provided by a minority
of clinicians who devote
at least a fifth of
their practice to
geriatrics.
cally called back (8). This survey of
clinicians, as well as a multistate survey of nursing home administrators
(6), concluded that traditional, “asneeded” consultation models are inadequate to address the many needs
of nursing home residents and staff.
Available data on nursing home practices by mental health clinicians are
largely limited to the results of surveys of general psychiatrists (9) and
psychiatrists who specialize in geriatric psychiatry (10).
An annual practice survey of a randomly selected sample of general psychiatrists in the United States conducted from 1982 to 1996 has shown
a gradual increase in the proportion
of American psychiatrists who have a
substantial geriatric practice (9). The
proportion of psychiatrists for whom
elderly patients constitute at least 20
percent of their caseload increased
from 7.3 percent in 1982 to 14.5 percent in 1988 and then to 18.1 percent
in 1996. This group of psychiatrists
devoted 7 percent of their professional time to practice in nursing homes.
Moreover, 14.9 percent had board
certification with additional qualifications in geriatric psychiatry. In contrast, psychiatrists for whom elderly
patients made up less than 20 percent
of their caseload were unlikely to devote much time to nursing home
practice, spending on average of only
.5 percent of their time in nursing
homes. These data suggest that despite trends showing an increase in
the proportion of psychiatrists who
treat older people, the vast majority
of psychiatric practice in nursing
homes is provided by a minority of
clinicians who devote at least a fifth of
their practice to geriatrics.
Not surprisingly, most psychiatrists
who have a subspecialty in geriatrics
routinely provided mental health
services in nursing homes. Data from
surveys conducted in 1997 by the
Canadian Academy of Geriatric Psychiatry (10) and in 1998 by the American Association for Geriatric Psychiatry (8) have shown that more than
three-quarters of geriatric psychiatrists saw patients in nursing homes.
The Canadian survey revealed that 78
percent of respondents worked in
nursing homes and that they provided
services for an average of 5.8 institutions (10). Canadian geriatric psychiatrists reported that they spent, on average, 7.5 hours a week in nursing
homes, which accounted for about a
fifth of their professional time. Sixtyfive percent reported that they
worked within an interdisciplinary
team structure.
The 1998 survey conducted by the
American Association for Geriatric
Psychiatry found that geriatric psychiatrists in the United States visited six
nursing homes on average (8), nearly
the same proportion as their Canadian counterparts. At these facilities,
they covered an average of 678 beds.
At the primary nursing home where
they worked, they spent an average of
four hours per visit and saw nine res-
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
1391
Table 1
Studies describing models of mental health service delivery in nursing homes
Characteristics of models
Services provided
Model type and study
Psychiatrist-centered models
Goldman and Klugman (13)
Liptzin (14)
Bienenfeld and Wheeler (15)
Grossberg et al. (16)
Sakauye and Camp (17)
Hay et al. (18)
Streim and Katz (19),
Streim et al. (20)
Gupta and Goldstein (21)
Multidisciplinary team models
Hader (22)
Herst and Moulton (23)
Cohn and Smyer (24)
DeRyke et al. (25)
Loebel et al. (26)
Rabins et al. (27)
Joseph et al. (28)
Lantz and Kennedy (29)
Psychiatric nurse-centered
models
Smith et al. (30,31)
Pajarillo et al. (32)
Discipline of primary clinicians
Clinical
consultation
Psychiatrist
Psychiatrist
Psychiatrist
Psychiatrist
Psychiatrist
Psychiatrist
Psychiatrist
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Psychiatrist
Yes
Yes
Psychiatrist, social worker
Psychiatrist, nurse, social worker,
psychologist
Psychiatrist, psychiatric nurse, social
worker, psychologist
Psychologist, nurse, social worker,
psychiatrist, other clinicians
Psychiatrist, nurse, other clinicians
Psychiatrist, social worker
Psychiatrist, psychiatric nurse, social
worker, psychologist
Psychiatrist, other clinicians
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Psychiatric nurse
Psychiatric nurse
idents for an average of 26 minutes
per resident. Sixty-seven percent
worked within a team consisting primarily of nurses (76 percent), social
workers (62 percent), or psychologists
(36 percent). This finding is comparable to the 65 percent of Canadian
geriatric psychiatrists who reported
working as part of a team. The most
common treatment recommendations by geriatric psychiatrists in the
U.S. survey included psychiatric
medications (84 percent), changes in
the general medical regimen (55 percent), staff support interventions (46
percent), medical diagnostic testing
(37 percent), behavioral interventions
(35 percent), staff training (30 percent), individual or group psychotherapy (20 percent), and family psychotherapy (13 percent). These data
suggest that geriatric psychiatrists
tend not to rely solely on pharmacotherapy, instead recommending a
more diverse range of treatment in1392
terventions, as suggested by the treatment literature (11,12). This approach contrasted with the more typical pattern of exclusive reliance on
pharmacotherapy that nursing home
staff perceive to be inadequate (6).
Models of mental health services
Table 1 summarizes the characteristics of three models of mental health
services in nursing homes—psychiatrist-centered models, multidisciplinary team models, and nurse-centered models. Psychiatrist-centered
models emphasize the role of the psychiatrist as the primary and often the
sole provider of direct consultation
and clinical services (13–21). In this
respect, the psychiatrist-centered
model is an adaptation of the traditional hospital-based consultation-liaison model. In general, the psychiatrist responded to a request to provide clinical evaluation and treatment
recommendations for a specific resi-
PSYCHIATRIC SERVICES
Direct
treatment
Administrative
consultation
Training and
education
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
dent. Only a minority of the reports
on this type of model included a description of administrative or program consultation provided to the
nursing home managers, and only
half explicitly described staff training
and education.
In contrast, multidisciplinary team
models included a variety of mental
health clinicians with different roles
and responsibilities (22–29). Teams
varied in size from two individuals—
for example, a psychiatrist and a social worker or another clinician—to
as many as five clinicians, including a
psychiatrist, a psychiatric nurse, a social worker, a psychologist, and other
types of service providers. Most reports on these models described direct clinical consultation services to
individual nursing home residents,
and half described training and educational activities. Multidisciplinary
team models emphasized the complementary contributions of different
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
Table 2
Outcomes of mental health service interventions and models in nursing homes
Outcome variable and study
Residents’ symptoms and
functioning
Goldberg et al. (33)
Ames (35)
Santmyer and Roca (11)
Samter et al. (12)
Swartz et al. (34)
Staff compliance with
treatment recommendations
Ames (35)
Snowden and
Roy-Byrne (36)
Study methods and
intervention model
Psychiatrist-centered;
psychiatric nurse-centered
Psychogeriatric consultation
team
Nurse-centered, psychiatristcentered
Nurse-centered, psychiatristcentered
Psychiatrist-centered
Psychogeriatric consultation
team
Preadmission screening and
mental health treatment
written recommendations
provided to the
nursing home
Nursing home staff functioning
Sbordone and Sterman (37)
Administrative consultation
and staff education
Smyer et al. (38)
Education and job redesign
for nursing assistants
Smith et al. (30)
Nurse-centered, train-thetrainer model
Physician prescribing practices
Avorn et al. (39)
Ray et al. (40)
Residents’ use of acute hospital
and emergency services
Dawson and English (41)
Tourigny-Rivard and
Drury (42)
Residents’ mortality
Castle and Shea (43)
PSYCHIATRIC SERVICES
Number of subjects
Findings
Uncontrolled descriptive study;
N=40
Randomized controlled trial using
ratings of depression and
activities of daily living; N=93
Uncontrolled descriptive study;
N=100
Uncontrolled descriptive study;
N=108
Uncontrolled study using clinical
ratings; N=32
78 percent of patients
improved
No difference between intervention and comparison
group
68 percent of patients
improved
51 percent of patients
improved
51 percent of patients
improved
Randomized controlled trial using
ratings of depression and
activities of daily living; N=93
Retrospective review of mandated
level I preadmission screening
and annual resident review
(PASSAR) records and
Medicaid records; N=523
33 percent compliance with
treatment recommendations
29 percent compliance with
recommendations for
alternative placement;
35 percent compliance
with recommendations for
new mental health services
Uncontrolled descriptive study
of 12-week consultation and
training program
Uncontrolled descriptive study
of nurse training and job redesign program
Uncontrolled descriptive study
Staff turnover reduced from
74 percent to 34 percent
Improved staff knowledge
Improved staff knowledge
and performance
Academic detailing consisting of Randomized controlled trial of
one-on-one education and
educational program for
feedback to the physician on
physicians in 12 nursing homes
prescribing practices
with six-month follow-up;
N=823
Antipsychotics discontinued
for 32 percent of patients
in homes with intervention
versus 14 percent in comparison homes; psychoactive drug use decreased
by 27 percent versus 8
percent
Education in behavioral
techniques and a protocol
for antipsychotic
withdrawal
Nonrandomized controlled trial of
an educational program for
physicians and nursing staff
four nursing homes;
N=378
Antipsychotic use decreased
72 percent in homes
with intervention
versus 13 percent in comparison home
Multidisciplinary team;
weekly consultation by
psychiatric nurse, biweekly
consultation by psychiatrist
Geriatric teaching
and consulting service
Uncontrolled descriptive study
involving a total of 350 beds
Four hospitalizations over six
months before intervention
versus one over 4.5 years
during intervention
No emergency service use
over 18-month study
period (no base rate
reported)
Evaluated effectiveness
of receipt of mental
health services
Uncontrolled descriptive study
of consultation and educational
intervention in a 50-bed
nursing home
1987 National Nursing Home
Mortality 26 percent lower
Survey, a descriptive, two-year
for patients with schizostudy of mortality among subjects
phrenia and other psywith psychiatric disorders who
choses and with anxiety
received or did not receive mendisorders who received
tal health services; N=4,646
mental health services
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
1393
disciplines (24). For example, the psychiatric nurse specialist may be more
effective in directly relating to the
nursing staff and in developing treatment plans, and the psychiatrist may
be most influential in relating to the
medical director and physician staff
and providing recommendations for
differential diagnosis and pharmacological interventions. Psychologists
may offer specific expertise in behavioral programming and neuropsychological assessment, whereas social
workers may have superior skills in
addressing family and social support
concerns.
Finally, two reports described
nurse-centered models of mental
health service delivery that are distinguished by the presence of a geropsychiatric nurse specialist who coordinates the service of other extrinsic
mental health clinicians while providing training to develop the skills and
abilities of the intrinsic nursing staff.
These nurse-centered models (30–32)
emphasize routine administrative consultation to nursing home personnel
and training of intrinsic direct care staff
to provide mental health interventions
within the nursing home. These models
included a “train-the-trainer” approach
in which an extrinsic geropsychiatric
nurse specialist provides ongoing training and consultation to a nursing home
staff nurse who becomes the internal
“expert” responsible for training others.
Common themes among these models include an emphasis on the limitations of traditional consultation services provided on an as-needed or emergency basis. The reports emphasized
the value of a team approach for providing ongoing routine services within
the nursing home, ideally in the context of a formal contract for clinical, administrative, and training services.
Effectiveness of mental
health services
Few studies of the outcomes of mental health services in nursing homes
have been conducted, and most have
substantial methodological limitations. For example, a majority were
observational studies that did not include a comparison group, and, in
most studies, outcomes were rated
by clinicians.
The findings of data-based studies
1394
are summarized in Table 2, with emphasis on four overall categories of
outcomes: residents’ symptoms and
functioning, residents’ use of acute
services, functioning of the nursing
home staff, and physicians’ prescribing practices. The outcomes of mental health services on residents’ symptoms and functioning have been reported in four uncontrolled descriptive studies with samples ranging
from 32 to 108 persons. These studies
found that mental health services
were associated with improvement in
Mental
health services
in nursing homes
may be associated
with better outcomes,
including lower rates
of hospitalization
and lower use of
emergency
services.
symptoms and functioning among 51
to 78 percent of residents who received services (11,12,33,34). In contrast, the only randomized controlled
study that examined these outcomes
found no difference between nursing
home residents who received psychogeriatric consultation services and
a comparison group that received
usual care (35). This study of 93 residents included ratings of depression
and functional outcomes. Although
no difference in outcomes was found
for the group that received psychiatric consultation services, only a
third (27 of 81) of the treatments recommended in the consultation intervention were implemented. The failure of nursing home staff to adopt the
PSYCHIATRIC SERVICES
written treatment recommendations
of external consultants and reviewers
was also noted in a study that examined compliance with mandated
preadmission screening and annual
residence reviews (36). This review of
the records of 523 nursing home residents found that only 35 percent of
recommendations for new mental
health services were followed.
Several studies have suggested that
targeted educational interventions
may be successful in changing clinicians’ treatment practices. Three uncontrolled descriptive studies of specific training and educational programs found that the programs were
associated with lower staff turnover
(37) and improved knowledge and
performance by nursing home staff
(30,38). These studies emphasized
the importance of focusing training
on the staff members who have the
greatest direct contact with residents,
such as certified nursing assistants.
Two different educational interventions have also been shown to be effective in changing the prescribing
practices of physicians in nursing
homes. In the first, a decrease in the
use of antipsychotics and other psychotropic medications was found in a
randomized trial of academic detailing consisting of one-on-one physician education and feedback on prescribing behavior (39). In the second,
lower use of antipsychotics was
achieved in a nonrandomized study of
nursing staff and physician education
in the use of behavioral techniques
combined with a protocol for gradual
withdrawal from antipsychotic medications (40).
Several observational studies have
reported that mental health services
in nursing homes may be associated
with better outcomes, including lower rates of hospitalization (41) and
lower use of emergency services (42).
However, none of these studies reported baseline rates of service use
for an equivalent period before the
intervention. Caution is also warranted in interpreting these results because these studies did not report the
methods for determining service use.
Finally, an analysis of nursing home
survey data suggested that mental
health services may be associated
with lower mortality rates among
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
nursing home residents with specific
psychiatric diagnoses (43). This descriptive two-year follow-up study of
1987 national nursing home survey
data on 4,646 residents reported that
among residents with psychiatric disorders, the mortality rate for those
who received psychiatric services was
26 percent lower than the rate for
those who did not. Notably, this difference was found only for residents
with schizophrenia, other psychotic
disorders, and anxiety disorders.
There were no differences between
the groups for other diagnoses, such
as depression, after the effects of resident and facility characteristics were
controlled for (44).
In summary, the data on the effectiveness of mental health services in
nursing homes are promising but
have substantial methodological limitations. Uncontrolled observational
studies have reported that one-half to
three-quarters of residents who received mental health services improved and that mental health services may be associated with lower rates
of hospitalization and lower use of
emergency services. However, welldesigned controlled studies are needed to confirm the effectiveness of
mental health services in improving
clinical outcomes and reducing use of
acute services in nursing homes. Education and training appear to improve staff knowledge and performance and to decrease staff turnover.
Innovative educational models are effective in changing physicians’ prescribing behavior when ongoing monitoring and direct feedback are provided.
The literature suggests a general
consensus that the least effective
model consists of traditional consultation-liaison services in which a clinician provides written treatment recommendations on an as-needed basis.
This approach appears to be ineffective because of poor treatment implementation, a lack of adherence to
written recommendations, and a failure to provide additional services, including ongoing training, administrative consultation, program development, and discipline-specific support.
In contrast, multidisciplinary treatment team approaches appear to be
favored in descriptions of preferred
PSYCHIATRIC SERVICES
service models. However, these studies did not assess the cost-effectiveness of this model. Although researchers have argued that the combined use of physician and nonphysician services, including follow-up,
may result in more efficient and effective services, data are lacking. In
addition, evidence-based guidelines
are needed to ensure that services are
provided by qualified clinicians, are
medically necessary, and have the appropriate intensity. The lack of costeffectiveness data is particularly unfortunate in view of the recent controversial findings of the Office of Inspector General of the Department
of Health and Human Services,
which concluded that 27 percent of
mental health services in nursing
homes are medically unnecessary
(44). Despite problems in the methods and interpretations of such regulatory studies, they underscore the
urgent need to provide empirical support for recommended treatments
and service models. Finally, some of
the most promising models have focused on improving the behavioral
management skills and treatment behaviors of the nursing home staff
though training and discipline-specific interventions.
Discussion
What conclusions can be drawn about
the characteristics and effectiveness
of optimal models of mental health
service delivery in nursing homes?
First, the available research literature
is marked by a paucity of well-designed studies that use a sufficient
test of effectiveness. Many reports
describe programs but lack outcome
measures. With few exceptions, the
studies that used outcome measures
did not use a controlled design with a
comparison group. Overall, we were
able to identify only two randomized
controlled studies of service interventions. One study tested the effectiveness of psychogeriatric consultation
in a small sample and found inadequate implementation of treatment
recommendations (35). The other focused on physicians’ prescribing practices and reported that a targeted educational and feedback intervention
provided significant benefits (39).
Despite substantial limitations in
the current research literature, a
clear convergence on several points
can be discerned in the descriptions
of service models and the findings of
outcome studies. First, these reports
recommend the routine presence of
qualified mental health clinicians in
the nursing home. A regular presence
allows mental health clinicians to provide ongoing consultation and followup during episodes of acute illness
and to provide an intensity of services
dictated by medical necessity. Other
elements of good care may include
routine subsequent visits by mental
health clinicians for management of
maintenance treatment and for administrative and programmatic consultation to the facility and its staff.
The most appropriate intensity of
services is still unclear. Variations in
the intensity of services are likely to
be driven by factors such as practice
structure, demand for services, patterns of reimbursement, and geography in addition to medical necessity.
Second, optimal services are interdisciplinary and multidimensional,
addressing neuropsychiatric, medical,
psychosocial, environmental, and
staff issues. Most of the models described in the literature are team
models, and a majority of geriatric
psychiatrists who are members of the
Canadian and American associations
of geriatric psychiatrists practice
within a team structure. However, the
ideal composition of the team is not
well defined, and it is not clear
whether the interdisciplinary team
must be formally organized or
whether it can function through collaboration between extrinsic consultants and specially trained on-site
nursing home staff.
Third, among the most effective interventions are those that blend consultation with training and educational interventions. Training and education should focus on frontline nursing
staff who provide basic care to residents as well as on nursing home
physicians who are responsible for
prescribing psychotropic medications
and behavioral interventions.
Conclusions
Well-designed intervention and services research studies are needed to
determine which psychiatric treat-
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11
1395
ments are most effective in the nursing home, which disciplines should
provide such treatments, what competencies are crucial for nursing
home staff, and which interventions
are the most cost-effective. These
findings will form the basis of changes
in regulatory and reimbursement
policies to support more effective and
efficient mental health services in
long-term care. ♦
References
1. Rovner BW, German PS, Brodhead J, et al:
The prevalence and management of dementia and other psychiatric disorders in
nursing homes. International Psychogeriatrics 2:13–24, 1990
2. Tariot PN, Podgorski CA, Blazina L, et al:
Mental disorders in the nursing home: another perspective. American Journal of Psychiatry 150:1063–1069, 1993
3. Krauss NA, Freiman MP, Rhoades JA, et al:
Medical Expenditure Panel Survey, Nursing Home Update, 1996, AHCPR publication 97-0036. Rockville, Md, Agency for
Health Care Policy and Research, 1997
4. Shea DG, Streit A, Smyer MA: Determinants of the use of specialist mental health
services by nursing home residents. Health
Services Research 29:169–185, 1994
5. Smyer MA, Shea DG, Streit A: The provision and use of mental health services in
nursing homes: results from the National
Medical Expenditure Survey. American
Journal of Public Health 84:284–287, 1994
6. Reichman WE, Coyne AC, Borson S, et al:
Psychiatric consultation in the nursing
home: a survey of six states. American Journal of Geriatric Psychiatry 6:320–327, 1998
7. Lombardo NE, Sherwood S: The 1992 National Telephone Survey of Nursing Home
Administrators and Directors of Nursing.
Boston, Research and Training Institute,
Hebrew Rehabilitation Center for Aged,
1992
8. Moak GS, Borson S, Jackson J: The AAGP
Long Term Care Survey. Paper presented
at the long-term care consensus conference
of the American Association for Geriatric
Psychiatry, Washington, DC, June 22–24,
2000
9. Colenda CC, Pincus H, Tanielian TL, et al:
Update of geriatric psychiatry practices
among American psychiatrists. American
Journal of Geriatric Psychiatry 7:279–288,
1999
10. Conn D, Silver I: The psychiatrist’s role in
long-term care. Canadian Nursing Home
9:22–24, 1998
11. Santmyer KS, Roca RP: Geropsychiatry in
long-term care: a nurse-centered approach.
Journal of the American Geriatrics Society
39:156–159, 1991
12. Samter J, Braun JV, Culpepper WJ, et al:
Description of a program for psychiatric
consultations in the nursing home. American Journal of Geriatric Psychiatry
1396
View publication stats
2:144–156, 1994
13. Goldman LS, Klugman A: Psychiatric consultation in a teaching nursing home. Psychosomatics 31:277–281, 1990
14. Liptzin B: The geriatric psychiatrist’s role
as consultant. Journal of Geriatric Psychiatry 16:103–112, 1983
15. Bienenfeld D, Wheeler BG: Psychiatric
services to nursing homes: a liaison model.
Hospital and Community Psychiatry
40:793–794, 1989
16. Grossberg GT, Hassan R, Szwabo PA, et al:
Psychiatric problems in the nursing home.
Journal of the American Geriatrics Society
38:907–917, 1990
17. Sakauye KM, Camp CJ: Introducing psychiatric care into nursing homes. Gerontologist 32:849–852, 1992
18. Hay DP, Hay L, Howell T, et al: Geriatric
psychiatry consultation for nursing homes.
Nursing Home Medicine 4:178–184, 1994
19. Streim JE, Katz IR: The psychiatrist in the
nursing home: II. consultation, primary
care, and leadership. Psychiatric Services
46:339–341, 1995
20. Streim JE, Oslin D, Katz IR, et al: Lessons
from geriatric psychiatry in the long-term
care setting. Psychiatric Quarterly 68:281–
307, 1997
21. Gupta S, Goldstein MZ: Psychiatric consultation to nursing homes. Psychiatric Services 50:1547–1550, 1999
22. Hader M: The psychiatrist as consultant to
the social worker in a home for the aged.
Journal of the American Geriatrics Society
14:407–413, 1966
23. Herst L, Moulton P: Psychiatry in the nursing home. Psychiatric Clinics of North
America 8:551–561, 1985
24. Cohn MD, Smyer MA: Mental health consultation: process, professions, and models,
in Mental Health Consultation in Nursing
Homes. Edited by Smyer MA, Cohn MD,
Brannon D. New York, New York University Press, 1988
25. DeRyke SC, Wieland D, Wendland CJ, et
al: Psychologists serving elderly in longterm care facilities. Clinical Gerontologist
10:35–49, 1991
26. Loebel JP, Borson S, Hyde T, et al: Relationships between requests for psychiatric
consultation and psychiatric diagnoses in
long-term-care facilities. American Journal
of Psychiatry 148:898–903, 1991
27. Rabins P, Storer D, Lawrence MP: Psychiatric consultation to a continuing care retirement community. Gerontologist 32:
126–128, 1992
28. Joseph C, Goldsmith S, Rooney A, et al: An
interdisciplinary mental health consultation
team in a nursing home. Gerontologist
35:836–839, 1995
Archives of Psychiatric Nursing 8:272–279,
1994
31. Smith M, Mitchell S, Buckwalter KC:
Nurses helping nurses: development of internal specialists in long-term care. Journal
of Psychosocial Nursing and Mental Health
Services 33:38–42, 1995
32. Pajarillo EJ, Sers AJ, Ryan RM, et al: Consultation-liaison psychiatric nursing in longterm care. Journal of Psychosocial Nursing
and Mental Health Services 35:24–30, 1997
33. Goldberg HL, Latif J, Abrams S: Psychiatric
consultation: a strategic service to nursing
home staffs. Gerontologist 10:221–224, 1970
34. Swartz M, Martin T, Martin M, et al: Outcome of psychogeriatric intervention in an
old-age home: a 3 year follow-up study. Annals of Clinical Psychiatry 11:109–112,
1999
35. Ames D: Depression among elderly residents of local-authority residential homes:
its nature and the efficacy of intervention.
British Journal of Psychiatry 156:667–675,
1990
36. Snowden M, Roy-Byrne P: Mental illness
and nursing home reform: OBRA-87 ten
years later. Psychiatric Services 49:229–
233, 1998
37. Sbordone RJ, Sterman LT: The psychologist as a consultant in a nursing home: effect on staff morale and turnover. Professional Psychology: Research and Practice
14:240–250, 1983
38. Smyer M, Brannon D, Cohn M: Improving
nursing home care through training and job
redesign. Gerontologist 33:327–333, 1992
39. Avorn J, Soumerai SB, Everitt DE, et al: A
randomized trial of a program to reduce the
use of psychoactive drugs in nursing
homes. New England Journal of Medicine
327:168–173, 1992
40. Ray WA, Taylor JA, Meador KG, et al: Reducing antipsychotic drug use in nursing
homes: a controlled trial of provider education. Archives of Internal Medicine 153:
713–721, 1993
41. Dawson D, English C: Psychiatric consultation and teaching in a home for the aged.
Hospital and Community Psychiatry 26:
509–511, 1975
42. Tourigny-Rivard MF, Drury M: The effects
of monthly psychiatric consultation in a
nursing home. Gerontologist 27:363–366,
1987
43. Castle NG, Shea DG: Mental health services and the mortality of nursing home residents. Journal of Aging and Health
9:498–513, 1997
44. Medicare Payments for Psychiatric Services in Nursing Homes: A Follow-Up.
Publication OIE-02-99-00140. Rockville,
Md, Office of the Inspector General, Department of Health and Human Services,
2001
29. Lantz MS, Kennedy GJ: The psychiatrist in
the nursing home: I. collaborative roles.
Psychiatric Services 46:15–16, 1995
30. Smith M, Mitchell S, Buckwalter KC, et al:
Geropsychiatric nursing consultation: a
valuable resource in rural long-term care.
PSYCHIATRIC SERVICES
♦ http://psychservices.psychiatryonline.org ♦ November 2002 Vol. 53 No. 11