Are nursing homes appropriate for older adults with severe mental illness? Conflicting consumer and clinician views and implications for the Olmstead decision

OBJECTIVES: In response to the recent Olmstead decision, to compare consumer and clinician perspectives on the appropriateness of nursing home settings for older adults with severe mental illness (SMI) in relation to clinical characteristics and care needs. DESIGN: Cross-sectional, descriptive, correlational study. SETTING: Ten community mental health centers and two state-funded nursing homes specializing in long-term care for older persons with SMI. PARTICIPANTS: Consumers of mental health services in the community (n=115) and in nursing homes (n=106), aged 60 and older, with SMI. Sixty-four clinicians (51% registered nurses, 29% masters-level clinicians, and 20% certified social workers) conducted ratings. MEASUREMENTS: Consumers and their clinicians were independently asked to determine the most appropriate care setting for each consumer based on care needs from three alternatives: nursing home, congregate (group) living setting, or individual apartment/home. Clinical characteristics of participants with SMI were rated using the Mini-Mental State Examination, Brief Psychiatric Rating Scale, Specific Level of Function Scale, Cumulative Illness Rating Scale for Geriatrics, a modified memory and orientation subscale from the Clinical Dementia Rating Scale, and an item from the Minimum Data Set related to reasoning. RESULTS: Of nursing home residents with SMI who did not have severe cognitive impairment, 40% (n=42) and 51% (n=54) were considered by consumers or by their clinician, respectively, to be more appropriate for a community-based setting, but there was a low level of agreement (only 27.6%; no better than chance) between consumers and clinicians on which nursing home residents were most appropriate for living in the community. Determinations by clinicians were associated with clinical need (diagnosis and less-severe behavioral problems), whereas there was no association between clinical needs and level of care determinations by consumers. Finally, clinicians considered a group home necessary for 93.7% of nursing home residents judged to be more appropri-ate for a community-based setting, whereas 90.5% of con-sumers stated that an apartment or individual home was indicated. CONCLUSION: State implementation of the Olmstead decision will need to consider major differences in perspectives between clinicians and consumers on the most appropriate long-term care setting for older persons with SMI.