Mental Health Adult and Older Adult Residential Facilities: The community feedback period for this idea began on 2/25/2019 and ended on 4/26/2019. *STATUS UPDATE*

What is the problem that needs to be addressed? Please describe how it is related to mental health.
California Behavioral Health Planning Council – ARF paper dated March 1, 2018 focused on “The need for increasing access to appropriately staffed and maintained Adult Residential Facilities (ARFs) in California for adults (including seniors) with mental illness.
In California in the early 1970’s, the residential care system was established to provide non-institutional home-based services to dependent care groups such as the elderly and adult mentally disordered. Due to ARF closures and lack of new facilities and adequate supportive housing options, many individuals with mental illness are not able to obtain sustainable community housing options within the appropriate level of care following stays in acute in-patient treatment programs, hospitals, Short-Term Crisis Residential or Transitional Residential Treatment Programs and/or correctional institutions. This results in a “revolving door scenario” where people are discharged or released from one of the above and then are unable to find appropriate residential care or housing. Thus, another mental health crisis ensues, resulting in a return to high-level crisis programs, facilities, hospitals, jails/prisons or homelessness”


Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
The California Behavioral Planning Councils ARF paper’s findings included in California, at least 22 counties out of the total 59 counties that participated, reported a need for at least 907 ARF beds. With a loss of at least 100 beds, Orange County is #3. As of 2017, Riverside County needs up to 300 ARF beds. The is a shortage of options and a great need for housing for adults with mental illness at the lowest level of care possible.


What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is, it working; why or why not?
Currently this population are either homeless, incarcerated, or residing in crises care units, acute hospitals or skilled nursing facilities.
“No Place Like Home” An Innovation project, designed to address the needs of the chronic homeless people is having difficulties getting off the ground.
According to the US Department of Housing and Urban Development’s Annual Homeless Assessment Report of 2018, nationwide there were around 553,000 homeless. Homelessness has increased for the second year in a row. California has 134,278 homeless people and is second in the nation at 33%. New York has the largest percentage of homeless people at 46%.
The top 5 cities that make up the 68% of the nations unsheltered homeless, are in California. In order they are as follows; Fresno/Madera, Los Angeles, San Jose/ Santa Clara, Oakland and finally the list rounds out with Long Beach.
The LA Times reported in March of 2018, “California plans to spend $700 million on homelessness in 2019. Nationwide the budget is $1.5 billion. The State of California plan to implement a new permanent supportive housing program for homeless people, called the “No Place Like Home” program, has been stalled by a lawsuit challenging the legality of the funding arrangements. The program, created in 2016, intended to issue $2 billion in bonds to develop new permanent supportive housing for homeless people.”
Per Open Minds news report May 20, 2018

Click to access Yes-on-Prop-2_No-Place-Like-Home_Advocates-FAQ-091218.pdf

“counties do not have adequate resources to do this on their own: No. The magnitude of the investment envisioned under No Place Like Home could not be done county by county, in three-year planning spurts.
A recent State Audit found counties had amassed $231 million in MHSA funds that should have reverted to the state because they were not spent in the timeline laid out by statute. In addition, the auditors found that the state had failed to guide counties in how much to hold as a “prudent” reserve for mental health spending, resulting in excessive unspent funds of as much as $274 million.”
Criminal Justice System
In 2016, Department of Health and Human Service’s Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that about 10.4 million adults in the United States suffered from a serious mental illness, conditions such as schizophrenia and bipolar disorder. As of May 27, 2017, Federal Bureau of Prisons (BOP) estimates 45% of federal prisoners have serious mental illness and behavioral problems, 30.5 % have been identified as Chronic Suicide Risk.
BOP tracks costs associated with mental health care services system-wide, for fiscal year 2016, BOP spent about $72 million on psychology services, $5.6 million on psychotropic drugs and $4.1 million on mental health care in residential reentry centers.
Unfortunately, federal prisons have a shortage of psychologists, psychiatrists, and other mental health professionals. This shortage results in most inmates do not received mental or behavioral health counseling while in federal prison. The inmates who were able to receive services said that they did not find it helpful and noted that the counselors themselves did not seem experienced, or that a sense of confidentiality and trust was never sufficiently established to foster a therapeutic relationship.

Medical System:
According to 2016 National Survey on Drug Use and Health(NSDUH) by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States, 44.7 million adults live with mental illness, of that, 10.4 million adults have serious mental illness. The CDC noted that 5.7 million adults visited the Emergency Department as a result of their serious mental illness. U.S. Agency for Healthcare Research and Quality (AHRQ), between 2006-2013 saw a 55% increase in visit to the ED due to serious mental illness.
During the last 20 years, there has been a steady increase in the volume of patients seeking mental health services in hospital emergency departments (EDs), the point that these patients represent the most rapidly growing component of ED treatment. EDs have become the first line of treatment for many patients seeking mental health services.
The brunt of the initial treatment responsibility defaults to emergency departments (ED). While some individuals who are assessed and stabilized in an ED may be discharged to receive outpatient follow-up, others require an inpatient level of care. For these individuals, a bed that meets their needs must be located.

Due to the decrease in the number of acute psychiatric beds from 2004 to 2013, the emergency department staff call skilled nursing facility after skilled nursing facility only to find no available bed which results in more and more patients being “boarded” or left to languish in an ER while in a mental health crisis. This often leads to a worsening of an individual’s condition because their mental health needs are not being met for either hours or sometimes even days. This kind of delay in crisis services isn’t experienced with such frequency by any other patient population or diagnosis.

According to NAMI, Serious mental illness costs America $193.2 Billion per year. Suicide is now the 10th leading cause of death in the US, and the 2nd leading cause of death for people age 10-34, 90% of people who die by suicide show symptoms of mental illness.
American Journal of Geriatric Psychiatry, online February 28, 2018. Examined 3.7 million admissions to 15,600 SNF nationwide and residents with serious mental illness were 55% less likely to be admitted to a five-star facility.
While severe behavioral problems have long been linked to slim chances of admission to a high-quality nursing home, the current study offers fresh evidence that even people with common and comparatively easy to manage mental illnesses like depression and anxiety may be rejected by top facilities.


What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Traditionally RCFE’s and ARF’s are owned and operated by individuals with no experience and staffed completely different than a Skilled Nursing Facility, with individuals who have never worked with the elderly or adult mentally ill.
What is new and different about this project, is, it would be an Assisted Living Facility for adult mentally ill individuals, that is staffed with licensed nurses and all staff are trained and educated on therapeutic interventions when interacting with adults with mental illness. The Activities Program would be structured with variety of therapeutic groups specifically for this population. Also, a psychiatrist and psychologist would be contracted for regular monthly services for the residents and would provide training to the staff. Individuals with mental illness, and mild medical issues such as, insulin dependent diabetics are normally denied admission to lower levels of care i.e. Board and Cares or Assisted Living Facilities. However, with LVN’s staffed around the clock, they would be admitted and cared for. As operator, I bring over 20 years’ experience as a licensed skilled nursing home administrator of a Five Star Facility, and 18 years specializing in treating 18 – 100-year old’s with chronic mental illness. Also, I am a Certified NCI (Non-Violent Crises Intervention) Trainer and would conduct the initial training and mandatory annual retraining.

What is the project idea? Please describe how this project will operate.

The goal of the project is to save county mental health agencies money and provide the lowest level of care possible for this underserved population.

Placing and paying for residents at IMD’s/MHRCs comes from the counties budget and residents with certain medical issues or “too medically declined”are denied placement.

Placing those residents at a SNF level of care and counties paying a patch for those residents, allows the resident to have a little more freedom, but staff usually do not have the skills nor training or activities to address the behaviors. Residents are frequently denied placement.

Placing the residents in an Assisted Living/RCFE/ARF/Board & Care is difficult, if not impossible, due to lack of staff training and experience working with this population and no licensed nursing staff to monitor medial needs and treat minor medical conditions.

As a Licensed Nursing Home Administrator with numerous years of experience with this population I have existing relationships with 20 different county mental health agencies requesting a “board & care” type placement that has licensed nurses, trained staff, structured activity program, readily available psychiatrists and psychologists and an administrator familiar with county mental health practices, policies & procedures and overall operational requirements.

An LVN/Program manager would oversee the LVNs and “care givers”. CNAs are the daily “care givers”, who can really assist residents with ADLs. who can really provide assistance with ADLs. One LVN would be staffed on each shift, who can do Accu-checks and insulin shots, pain management, and quickly assess resident behaviors and intervein, by administering PRN medication for the behaviors when appropriate. By staffing LVNs, who have the training of when to call the psychiatrist and how to relay information to the doctors allows for more timely interventions and the contracted psychiatrist also can use Telemedicine to assess residents in an “emergency” thus decreasing the need to send the resident out for evaluation.

Experienced Activity Director will provide groups that will actively engage the residents, encouraging them to use their coping techniques thus reducing “acting out” behaviors.

A Licensed NHA/RCFE/ARF, overseeing the entire facility, ensuring care plans are appropriate and followed, and documentation in the resident’s medical record is relevant and meets the needs of county mental health. The facility will have contracts with a Dentist, Podiatrist, psychiatrist, and psychologist, who will come to the facility monthly and as needed, to meet the resident’s needs.
Residents would have the ability to attend church activities specific to their faith, Adult Education to possibly obtain their GED, and Senior Centers to increase socialization. Residents would have the opportunity to explore any other activities in their community that they would not be able to do if placed in an IMD, MHRC, SNF or State hospital.


Additional Information:
Respondent skipped this question


February 7, 2019


Some historical perspective is required to support this idea. The Diagnostic and Statistical Manual (DSM) – the handbook of Psychiatric Diagnoses – was first published in 1952. People born in 1952 would be 67 years old in this year, 2019. We are living in the first generation of people living with mental illness under the DSM. That generation was subjected to institutionalization, suing for peonage back pay, deinstitutionalization, homelessness, job applications requiring disclosure of excessive work gaps to screen out people who experienced mental illness/imprisonment, playing the game of matching job application disclosures to what was expected to be found in a background check etc. Thus that generation did not amass the Medicare / Social Security credits that qualify a person for Medicare and Social Security – both programs are insolvent anyways and thus resources will likely be rationed to the “productive” people who were “responsible” with “earned income.” The current education, work, retirement, and end of life system wasn’t designed for people with mental illness to be included.

Aging into this system is just cruel. Previous NIH leadership cite a life expectancy disparity/inequity for people experiencing mental illness at about 40-60 years of life (compared with 70 to 80 years for the general population). Thus it is expected with the current system that people experiencing mental illness/homelessness will die prior to needing elder care.

Expect a savvy lawyer to link up with the survivors of this system to sue for whatever they can get. Expect a frustrated physician to prescribe to the reported pain of a patient – pain is whatever the patient says it is – likely with large amounts of oxycontin.

Aaron, thank you for your comments.

Aswome idea the population of mental illness is big & having the supportive system that Deborah has to offer is beyond.Ive worked with this project for 10 years & to learn the importance of mental illnesses.This project will differently make a change & balance the population.Lets make a change & Debbie has the commitment & tools I’m all for it well excited to make a difference in the IMD setting.Lets put the puzzles back together for this population:)

Jermani, I greatly appreciate your kind words and support!

Is the innovative component of this idea the combination of differing elements within a facility including: training and educating all staff in working with those living with a mental illness; clinical staff conducting therapeutic groups; and staffing a facility with Licensed Vocational Nurses in order to accept those needing medical assistance? This combination has not been offered to this population within other facilities?

Correct. I am suggesting that all care giving staff be CNA’s with experience working with adults with mental health issues, and all staff , housekeeping, laundry, dietary, receive specific training, during orientation and continuing throughout the year, regarding working with adults with mental health issues. Staff conducting groups/activities would have a BA or be an LVN or CNA.
Current practice at assisted living facilities under 59 beds, the staff do not have to have experience or degrees or be an LVN. Most activity programs conducted consist of current event groups, Bingo, cards or shopping at Target.
Staff do not receive training regarding therapeutic interventions with adults with mental illness.
Most assisted living facilities do not admit residents with mental health diagnoses.

My experiences with my mom as you know have not always been the best as far as the care she receives. I have moved her 3 times now, first she had broken her pelvis and needed to be in rehab. She walked again after that but to see her for some time after her fall she was almost a vegetable and that was caused by the heavy medications she no longer needed. I intervened and she came back to her sweet self. Another time she contracted a UTI which can alter the behavior of the elderly. I was on vacation when I came back she was a mess. I went to the hospital her hand were tied etc. She was out of her normal state she was combative etc. I asked if they had tested her for UTI. They had not. The UTI test was requested and done, she received the proper medication and again was her sweet self. So much more. This is the result of the medical staff not being trained on working with the elderly. I had been told the would make her comfortable as her dementia has changed. This was not the case and I knew it. Having a staff trained to work with these problems would be a blessing! I think this would be the best change in health care ever.

Pamela, It means a lot to have your support! Thank you so very much

These services are necessary. Current mental health resources are very limited.

Thank you so much Nancy for your words of support, I truly
appreciate it.

Moving an older adult away from their long-standing home and family may not be the best choice. As people age they are not able to form memories as easily as when they are younger. Thus moving a person into a different facility – especially after a dementia diagnosis – sets an elderly person up for failure.

Thank you for your idea submission. Upon review and discussion, it was determined that this idea can continue moving forward at this time for further consideration and development.The Innovation team is currently exploring options for a community planning and engagement meeting where potentially viable ideas can be further discussed with local community members. Status updates will be posted as they become available.

I am a CPA who has been specializing in the long term care field for over 20 years. This includes ICF-dd’s, IMD’s and Skilled Nursing facilities that are part of the OC DMH program.

In my experience, Mental health care is ignored nearly as much as actual mental illness is stigmatized. Society seems to wish that both mental illness, and the services needed to care for it, would just go away. But, unfortunately, mental illness is getting more prevalent, not less.
Some mental illness statistics. Globally, more women die due to mental illness than childbirth-related causes, yet far more money and attention goes towards improving maternal health than mental health. And as horrible as the morality rate is for women with mental illness, 30% to 40% more men die of mental illness than women.

The author of this program has a great reputation in the long term care community. Her experience, connections in the field, and her drive for success makes her one of a few unique people who not only have the vision, but the drive to make this program work.

More of our government’s attention needs to be focused on mental health. The Mental Health Adult and Older Adult Residential Facilities program described above, will not only save the county money, but provide much better care for Orange County’s mental health population. The money saved by this program could then be used to fund other programs.

Kevin, Thank you so much for your support, I truly
appreciate it!

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