Psychiatric Services in Nursing Homes in Israel: Should the American Legislation Be Adopted?
Barak, Yoram, Davidson, Michael, Luxenberg, Jay S., Aizenberg, Dov, The Israel Journal of Psychiatry and Related Sciences
Abstract: Background: Nursing homes provide care for the elderly who require medical, nursing or rehabilitation services. Legislation for the public health model of mental health care for nursing home residents in the USA was enacted in 1987. Objective: To determine whether the USA act regulating psychiatric care for nursing homes may be applied in Israel. Methods: Publications analyzing the outcome of the USA regulations demonstrate improved care as reflected by decrease in restraints and better use of psychotropic compounds. The shortcomings as well as benefits of the USA legislation are tested as to their relevance to the specific economic, environmental and medical issues in Israel. Conclusions: The adoption of USA legal acts regulating nursing home residents' psychiatric care may not be feasible in Israel. However, quality of care in nursing homes can be significantly improved if such regulations were "tailored" to Israel's unique structure of nursing homes.
Nursing homes provide care for the elderly who require medical, nursing or rehabilitation services. However, the high frequency of psychiatric disorders among nursing home residents is still underestimated despite ongoing research and publicity (1, 2).
The psychiatric morbidity in nursing homes is not without serious medical and ethical consequences. Excessive and inappropriate use of psychotropic medication is found in numerous studies (for review: 3), adverse events related to drugs and drug withdrawal are reported (4), physical restraints are widely used (5, 6), and substandard care as well as low-care cases may be over represented in nursing home residents with psychiatric co-morbidity (7, 8). In addition, underdiagnosis and undertreatment of psychiatric disorders in general and in nursing home residents is a well recognized problem also contributing to adverse outcome.
Several options have been suggested as to the improvement in the care and management of nursing home residents with psychiatric morbidity. Consumer organizations offer, on the internet and in their leaflets ready-to-use questionnaires that focus on assessing a long-term care facility (9). Insurance programs such as the Medicare or Medicaid require that the minimum-data-set for nursing home resident assessment and care screening be submitted to the appropriate federal agencies so as to create a national database with high reliability (10). Professional associations such as the American Psychiatric Association publish official actions publicizing and emphasizing the need for "...unrestrained access to appropriate psychiatric consultation and treatment" as part of their position statement on psychiatric services for the elderly (11).
As the knowledge and awareness of long-term care within nursing homes became apparent, the USA legislators enacted in 1987 the Nursing Home Reform Act of the Omnibus Budget Reconciliation Act, known as the OBRA '87 (12). This act deals specifically with the psychiatric aspects of long-term care. One section of the act mandates pre-admission screening of potential nursing home residents and screening of nursing homes to ensure that patients with mental illness are not admitted solely as a result of their psychiatric disorder to long-term care facilities. Patients cannot be admitted unless they require the level of services provided by nursing facilities and do not require "active treatment" for their psychiatric illness that would not be available in the nursing home. Other sections of the act provide federal standards for the quality of care in nursing homes. sections specifically relevant for psychiatry include those concerned with the use of restraints, psychopharmacological treatment and quality of life. The regulations enacted in the USA state: "The resident has the right to be free and the facility must ensure freedom from physical restraints imposed or drugs administrated for the purpose of discipline and convenience. …